(From the March 2015 Issue of PediatricsOnline)
Open surgery is the gold standard for resolving severe cases of vesicoureteral reflux, an abnormality causing urine to flow from the bladder back up to the kidneys. But positive reports suggest that a minimally invasive technique called vesicoscopic reimplantation has similar effectiveness and less post-operative pain. As Chief of Urology V. Rama Jayanthi, MD, of Nationwide Children’s Hospital, is among the only surgeons in the country performing this operation regularly, he published a review of his work with vesicoscopic reimplantation (VR) in February.
For many conditions, surgeons have developed minimally invasive approaches in an attempt to reduce pain and scarring. Although laparoscopic approaches are commonplace for kidney operations, they have not yet become routine for bladder operations, such as the correction of vesicoureteral reflux (VUR). This is largely because traditional open surgery works so well, with a greater than 98 percent success rate in in children with primary VUR.
“Traditional open surgery works well and has had a high success rate with minimal morbidity. It’s hard to improve an already good outcome,” says Dr. Jayanthi, senior author on the publication. “But I have promoted vesicoscopic reimplantation for treatment because our data suggests that children have less pain with this approach. Many parents are also more comfortable agreeing to surgery, as they know it is being done in a minimally invasive approach.”
In VR, the surgical ports are placed directly into the bladder, leaving the surgeon with less working space than traditional laparoscopic procedures, for which the working ports are placed into the abdomen. Since that anatomical area is minute in infants and toddlers, Dr. Jayanthi performs the procedure only in children 3-4 years of age and older. He has performed nearly 170 VRs to date.
Among the 96 VR patients who underwent a postoperative voiding cystourethrogram during the course of follow-up reported in the published review, 95 percent showed complete resolution of their reflux. Four of the five patients who did not experience resolution were among the first 30 patients receiving the operation and may be attributable to the technique’s learning curve, Dr. Jayanthi suggests.
VR technique also appears to require a full hour less time than average operation times reported for robot-assisted reimplantation surgery.
“The results so far show that VR success rates are equivalent to standard open repair, which is considered the gold standard,” Dr. Jayanthi says. “But VR also has the advantage of reduced patient pain associated with minimally invasive procedures.”
Dr. Jayanthi will to continue with VR due to his experience and comfort with laparoscopic techniques, although he anticipates that outcomes of robot-assisted reimplantation will improve and operative times will decrease somewhat as the technique gains popularity.
“VR is a hard operation to learn,” he says. “Most surgeons are doing either open surgery or robot-assisted, and ultimately, the choice depends on surgeon preference and experience.”
Dr. Jayanthi continues to prospectively track patients with vesicoureteral reflux at Nationwide Children’s who undergo VR and robot-assisted surgery. His team of surgeons is also planning a larger study to determine which children with VUR do not need surgery and can be managed medically.
Schober MS, Jayanthi VR. Vesicoscopic ureteral reimplant: Is there a role in the age of robotics?Urologic Clinics of North America. 2015 Feb, 42(1):53-9.