PEDIATRIC UROLOGY

Nerve sparing robotic extravesical ureteral reimplantation
Casale P, Patel RP, Kolon TF
Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
J Urol. 2008; 179: 1987-9; discussion 1990

• Purpose: Laparoscopic transvesical ureteral reimplantation with or without robot assisted surgical devices is being developed as an alternative to open surgery. We sought to review our experience with an extravesical robotic technique, to determine whether postoperative voiding dysfunction might be avoided with pelvic plexus visualization and to evaluate the overall feasibility of this approach to ureteral surgery.
• Materials and Methods: A total of 41 patients underwent robotic extravesical reimplantation for bilateral vesicoureteral reflux. The patients were divided into groups based on bladder capacity as measured by voiding cystourethrogram. The operation was performed via a transperitoneal approach with robotic assistance using the da Vinci Surgical System.
• Results: Operative success rates were 97.6%. There were no complications. There were no episodes of urinary retention documented by bladder scanning.
• Conclusions: Robotic extravesical reimplantation is in its infancy, and visualization of the pelvic plexus appears to be paramount in avoiding postoperative voiding complications. This approach appears to be a feasible and reasonable option for vesicoureteral reflux correction.
  
  
• Editorial Comment
  Forty-one patients underwent retrospective chart review after robotic extravesical reimplantation for vesicoureteral reflux grades III-V regardless of duplication anomalies. Indication for surgery was breakthrough pyelonephritis despite prophylactic antibiotics. Voiding diaries, uroflow, post-void residual measurements and constipation issues were addressed pre-operatively. All patients underwent cystoscopy with ureteral catheters placed in the aid of the dissection. One camera port and two other robotic ports were used. The authors were careful to do a nerve-sparing technique and felt that the robot with its better visualization allowed the nerves to be easily spared. All patients had an overnight catheter. The average operating time was 2.33 hours with an average length of stay of 26.1 hours. Post-void residual urines were checked by bladder scan and all patients voided after the catheter was removed and there was a mean residual of 13 mL of urine in the bladder. One patient had reflux on a three month VCUG and no patients had hydronephrosis on the ultrasound at 3 and 6 months postoperatively.
  The authors should be congratulated on a study well done with good and careful follow up of the pre- and post-op bowel and bladder management. This shows that extravesical nerve-sparing robotic reimplantations can be done safely with excellent results. Always the question for endoscopic procedures in children: “is it an improvement over the open surgical techniques and does it offer patient benefit?” I believe those answers will in time become clear but as yet it remains to be seen.

Dr. Brent W. Snow
Division of Urology
University of Utah Health Sci Ctr
Salt Lake City, Utah, USA
E-mail: brent.snow@hsc.utah.edu