Clinical indications for ureteral reconstruction include strictures, trauma (often iatrogenic), vesicoureteral reflux (VUR), fistulas, and malignancy (1-3). Short ureteral defects can be managed by ureteroureterostomy, or ureteroneocystostomy. Longer defects require complex procedures such as psoas-hitch ureteral reimplantation often combined with a Boari flap. Traditionally, open ureteral reimplantation has been the gold standard for ureteral reconstruction (1,2,4-6). Laparoscopy provides patients the advantages of quicker recovery, low post-operative morbidity, less postoperative pain, less blood loss and better cosmesis (7,8). Successful results using laparoscopic ureteral reimplantations have been reported in the literature to treat ureteral strictures, iatrogenic injuries, VUR, and ureterovaginal fistulas (8,9). It demonstrates that laparoscopic ureteral reimplantation has comparable functional outcomes to open surgery (8). However, in reconstructive surgery early reported success rates can be misleading and the long-term outcomes are important in assessing the efficacy of the procedure. In this study, we review medium-term outcomes of laparoscopic ureteral reimplantation and discuss current developments of this procedure.
Medline and Embase databases were searched using relevant key search terms (laparoscopic, vesico-ureteral, reimplantation). No publication date limits were applied and the final search was performed on August 30, 2016. Literature reviews, individual case reports, exclusively adult studies (age >20 years), and small case series of fewer than three paediatric patients were excluded. Paediatric data from combined adult and paediatric studies were included only if it was possible to select out the paediatric data. The procedure was considered successful if (I) the author reported success and/or (II) there was no alternate or subsequent surgical procedure (open or mininvasive) caused by technical failure 3 or more weeks after the initial procedure.
Criteria of evaluation
Parameters analyzed included operative time, blood loss, analgesic requirement, complications, time to oral intake, hospital stay, and follow-up. Success was defined as no significant dilatation on ultrasonography and good drainage on radiological contrast studies such as IVU and RGP.
Five studies were assessed, overall, 69 laparoscopic extravesical ureteral reimplantation (LEVUR) were performed in children. Despite different surgical technique (10), in all case the technique was respected. Patient demographics, preoperative symptoms, radiological imaging, complications, and postoperative outcomes were analyzed. Median success rate was 96%. Complications were reported in five cases.
The extravesical Lich-Gregoir procedure is used mostly in children to treat high grade VUR and in renal transplant surgery with reported high success rates in the literature (11,12). Lakshmanan and Fung refined the laparoscopic technique and reported 71 cases in children with high grade VUR, and concluded that the laparoscopic technique was comparable to open reimplantation techniques (13). Yohannes et al. and Kamat et al. performed the procedure in adult patients with post-hysterectomy ureterovaginal fistula, and lower ureteral stricture with the additional advantages of a minimal invasive procedure (14,15).
Laparoscopic ureteroneocystostomy was completed in all patients without open conversion. The mean operative time was 241 (range, 131–351) min (Does not include additional procedures. For the two ureteral reimplantations during LRP, the trocar placement and ureteral preparation times are included). The mean estimated blood loss was 300 (range, 50–550) mL. No blood transfusion was required (16).
Open surgery remains the gold standard for ureteral reimplantation with good long-term results (success rates over 90%) (1,2,4,5). An initial laparoscopic case series was first reported in children to treat high grade VUR (8,17). Reddy and Evans reported the first procedure in an adult (18). In recent years, more laparoscopic and robotic ureteral reimplantation cases have been reported with good preliminary results in the literature (15,19).
However, in reconstructive ureteral surgery early reported success can be misleading because recurrent strictures typically develop up to 1 year after surgery (20-22). Selzman et al. observed an 11% stricture rate after 1 year following open ureteral reimplantations for ureteral injury (23). The median follow-up time was 35 months, which represents one of the longest for a laparoscopic ureteral reimplantation series (9,24). The results are comparable to open surgery with the advantages of a minimally invasive procedure.
The laparoscopic ureteral reimplantation in the pelvis and lower abdomen is technically demanding even for experienced surgeons, and each case offers a different challenge based on the etiology and location of the stricture (11,12).
Despite the difficulties of the procedure, the magnification and high definition (HD) visualization allows a clear identification of the ureter and bladder as well as the surrounding tissues and allows careful manipulation during the operation especially for the secondary cases. The authors used a HD wide view camera system (Karl Storz, Tuttlingen, Germany) after our published first series, and we are in opinion that this definitively better visualization with a large angel has added a great value to our technique. More technical advances will facilitate reconstructive procedures in the future (16).
Laparoscopic ureteral reimplantation requires advanced laparoscopic skills and this procedure should preferably be carried out in high-volume specialist centres.
Finally, we are of the opinion that the laparoscopic procedure offers similar efficacy to open surgery, and therefore the procedure may become the gold standard in the future. Further comparisons with open surgery and with increased numbers of cases and longer follow-up are, however, warranted.
Laparoscopic ureteral reimplantation is an efficacious procedure and can be used to correct ureteral pathologies due to many etiologies. Mid-term follow-up results of this procedure are promising. We are convinced that this procedure offers comparable results to open surgery and with evidence from larger series in the future, is likely to become an established procedure.
Conflicts of Interest: The authors have no conflicts of interest to declare.
- Streem SB, Franke JJ, Smith JA. Management of upper urinary tract obstruction. In: Walsh PC, Retik AB, Vaughan ED Jr, et al. editors. Campbell’s urology. 8th edition. Philadelphia: W. B. Saunders Co., 2003:463-512.
- Benson MC, Ring KS, Olsson CA. Ureteral reconstruction and bypass: experience with ileal interposition, the Boari flap-psoas hitch and renal autotransplantation. J Urol 1990;143:20-3. [PubMed]
- Challacombe B, Dasgupta P. Reconstruction of the lower urinary tract by laparoscopic and robotic surgery. Curr Opin Urol 2007;17:390-5. [Crossref] [PubMed]
- Stief CG, Jonas U, Petry KU, et al. Ureteric reconstruction. BJU Int 2003;91:138-42. [Crossref] [PubMed]
- Riedmiller H, Becht E, Hertle L, et al. Psoas-hitch ureteroneocystostomy: experience with 181 cases. Eur Urol 1984;10:145-50. [PubMed]
- Ahn M, Loughlin KR. Psoas hitch ureteral reimplantation in adults--analysis of a modified technique and timing of repair. Urology 2001;58:184-7. [Crossref] [PubMed]
- Stolzenburg JU, Katsakiori PF, Liatsikos EN. Role of laparoscopy for reconstructive urology. Curr Opin Urol 2006;16:413-8. [Crossref] [PubMed]
- Rassweiler JJ, Gözen AS, Erdogru T, et al. Ureteral reimplantation for management of ureteral strictures: a retrospective comparison of laparoscopic and open techniques. Eur Urol 2007;51:512-22; discussion 522-3. [Crossref] [PubMed]
- Modi P, Gupta R, Rizvi SJ. Laparoscopic ureteroneocystostomy and psoas hitch for post-hysterectomy ureterovaginal fistula. J Urol 2008;180:615-7. [Crossref] [PubMed]
- Fugita OE, Dinlenc C, Kavoussi L. The laparoscopic Boari flap. J Urol 2001;166:51-3. [Crossref] [PubMed]
- Heidenreich A, Ozgur E, Becker T, et al. Surgical management of vesicoureteral reflux in pediatric patients. World J Urol 2004;22:96-106. [Crossref] [PubMed]
- Veale JL, Yew J, Gjertson DW, et al. Long-term comparative outcomes between 2 common ureteroneocystostomy techniques for renal transplantation. J Urol 2007;177:632-6. [Crossref] [PubMed]
- Lakshmanan Y, Fung LC. Laparoscopic extravesicular ureteral reimplantation for vesicoureteral reflux: recent technical advances. J Endourol 2000;14:589-93; discussion 593-4. [Crossref] [PubMed]
- Yohannes P, Gershbaum D, Rotariu PE, et al. Management of ureteral stricture disease during laparoscopic ureteroneocystostomy. J Endourol 2001;15:839-43. [Crossref] [PubMed]
- Kamat N, Khandelwal P. Laparoscopic extravesical ureteral reimplantation in adults using intracorporeal freehand suturing: report of two cases. J Endourol 2005;19:486-90. [Crossref] [PubMed]
- Esposito C, Escolino M, Lopez M, et al. Surgical Management of Pediatric Vesicoureteral Reflux: A Comparative Study Between Endoscopic, Laparoscopic, and Open Surgery. J Laparoendosc Adv Surg Tech A 2016;26:574-80. [Crossref] [PubMed]
- Ehrlich RM, Gershman A, Fuchs G. Laparoscopic vesicoureteroplasty in children: initial case reports. Urology 1994;43:255-61. [Crossref] [PubMed]
- Reddy PK, Evans RM. Laparoscopic ureteroneocystostomy. J Urol 1994;152:2057-9. [PubMed]
- Andou M, Yoshioka T, Ikuma K. Laparoscopic ureteroneocystostomy. Obstet Gynecol 2003;102:1183-5. [PubMed]
- Castillo OA, Litvak JP, Kerkebe M, et al. Early experience with the laparoscopic boari flap at a single institution. J Urol 2005;173:862-5. [Crossref] [PubMed]
- Modi P, Goel R, Dodiya S. Laparoscopic ureteroneocystostomy for distal ureteral injuries. Urology 2005;66:751-3. [Crossref] [PubMed]
- Chung H, Jeong BC, Kim HH. Laparoscopic ureteroneocystostomy with vesicopsoas hitch: nonrefluxing ureteral reimplantation using cystoscopy-assisted submucosal tunneling. J Endourol 2006;20:632-8. [Crossref] [PubMed]
- Selzman AA, Spirnak JP. Iatrogenic ureteral injuries: a 20-year experience in treating 165 injuries. J Urol 1996;155:878-81. [Crossref] [PubMed]
- Casale P, Patel RP, Kolon TF. Nerve sparing robotic extravesical ureteral reimplantation. J Urol 2008;179:1987-9; discussion 1990.