Ureteral reimplantation aligned laparoscopically: Pneumovesicoscopic Politano-Leadbetter reimplantation in children

J Pediatr Urol. 2021 Feb 16;S1477-5131(21)00086-3. doi: 10.1016/j.jpurol.2021.02.007. Online ahead of print.

Abstract

Introduction: Ureteroneocsytostomy is a well-established procedure for correction of certain ureterovesical conditions like vesicoureteral reflux and ureterevesical obstruction. Amazing developments in technology paved the way for minimally invasive surgery and conventional procedures are increasingly being performed minimal invasively during the recent decades. Although Politano-Leadbetter ureteroneocystostomy is an anatomical repair, lost its popularity against Cohen's technique as it is more challenging to perform and requires extravesical dissection which may increase the complication rates.

Objective: In this study, we evaluated our results and feasibility of laparoscopic intravesical (pneumovesicoscopic) repair of certain ureterovesical conditions by Politano-Leadbetter principle in children.

Study design: Twenty one children who underwent pneumovesicoscopic uretero-neocystostomy are enrolled in the study. Surgical procedure is described and surgical duration, complications, conversion rate and success rates are evaluated.

Results: Fourteen (67%) of the patients were girls and 7 were boys (33%). Median age at operation was 6 years (1.5-15 years). Main indications for surgery were vesicoureteral reflux, megaureter and bladder diverticulum. Fourteen of the patients underwent bilateral (67%) intervention while the 5 left (24%) and 2 right (9%). Four patients were converted to open surgery (16%; 4/25). Median surgical duration was 265 min (190-320 min) for bilateral and 180 min (115-260 min) for unilateral procedures. Success rates confirmed by a contrast study were 92% for VUR.

Discussion: It appears that minimally invasive intravesical surgery fails to keep up with the other minimally invasive procedures secondary to restricted working field in the bladder, technically demanding procedures and well-documented high succes rates of open counterpart techniques. Although developing relatively slower, minimally invasive technology offers better vision, better cosmesis, lesser pain and lesser tissue disturbance. Although cross-trigonal reimplantation is the most popular technique, Politano-Leadbetter technique provides an anatomical alignment of ureters and is a good option for caudally located ectopic ureters. In our study, pneumovesicoscopic approach provided anatomical reimplantation, identification and sparing of vas deferens and better cosmesis. Major limitations of our study are the limited number of cases, longer operation times, higher complication rates and short follow up duration which we hope to improve with increasing experience.

Conclusion: Although not brilliant as its open counterpart yet, initial results of pneumovesicoscopic reimplantation with Politano-Leadbetter technique is promising and growing experience would further improve the results and lower the complication and conversion rates.

Keywords: Megaureter; Pneumovesicoscopy; Ureteroneocsytostomy; Vesicoureteral reflux.