When surgical management of vesicoureteral reflux is required, open ureteral reimplantation remains the most commonly-used approach – and a very successful one. But in an effort to reduce patient pain, bleeding and scarring, pediatric urologists have increasingly explored minimally invasive options over the last decade.
A group of studies has shown that while some institutions are using robot-assisted extravesical ureteral reimplantation, success rates remain lower than for open procedures, and complication rates can be higher. A recent study from the Section of Urology at Nationwide Children’s Hospital, however, demonstrates that a different minimally invasive technique can equal the open success rates.
The research, published in the Journal of Pediatric Urology, examines a series of 182 patients who underwent vesicoscopic ureteral reimplantation at Nationwide Children’s from 2004 to 2016. The procedures were performed with two 3mm working ports and a 5mm camera port.
“The beauty of this approach is that you have the exact same result of the operation, the same success rate, but you do not have the same kind of incision as with an open procedure,” says V. Rama Jayanthi, MD, chief of Urology at Nationwide Children’s and the author of the paper. “The kids recover more quickly, they experience less pain, and their families really appreciate the minimally invasive option.”
A total of 165 patients in the series were females and 17 were male. Mean age was 7.03 years; 47 of the patients underwent unilateral repairs (with mean operating time of 169 minutes) and 135 had bilateral repairs (mean operating time 197 minutes).
Success was judged by postoperative voiding cystourethrogram, which was obtained in 100 patients. Seven patients had persistent postoperative reflux, but four of the failures occurred in the first 30 patients. Dr. Jayanthi made adjustments in technique as the series continued, including ultimately using lower power settings on cautery during ureter mobilization.
Only one failure occurred in the last 49 patients, for a 98 percent effective success rate after a learning curve. There were four perioperative complications, all also occurring early in the series.
It’s true that vesicoscopic ureteral reimplantation is a challenging procedure, says Dr. Jayanthi, who is also a clinical professor of Surgery at The Ohio State University College of Medicine. Other institutions may feel that continuing with an open approach is best based on a number of factors, including proven success.
But, “I do feel that if people were to develop this kind of minimally invasive program, they will find that their patients are more comfortable, and their patient families will appreciate this option,” Dr. Jayanthi says.
Jayanthi VR. Vesicoscopic cross-trigonal ureteral reimplantation: High success rate for elimination of primary reflux. Journal of Pediatric Urology. 2018 April 28. [Epub ahead of print]