Predictors of Failure in 90 Complex Ureters Using Robot-Assisted Laparoscopic Surgery
Robot-assisted laparoscopic ureteral (RALUR) reimplantation has been adopted as an alternative surgical approach to treat children with persistent high-grade vesicoureteral reflux (VUR). The debate continues in regards to the safety, feasibility and standardized technique. We performed a retrospective analysis of perioperative outcomes in patients undergoing RALUR; using our recent technique modifications to identify predictors of surgical failure.
We reviewed a prospectively maintained database of children undergoing RALUR at a single-institution from 2010-2017. Only patients with high-grade VUR at age 5, urinary tract infections, or renal scarring were selected for surgical correction. This series included patients who received the previously reported LUAA technique, which stands for length of detrusor tunnel (L), U stitch (U), ureteral alignment suture (A), and the inclusion of ureteral adventitia (A). Patients with ureterovesical junction obstruction were excluded. Radiographic failure was defined as persistent VUR on postop VCUG. Complications were grade using Clavien-Dindo scale. Logistic regression analysis was used to determine predictors of failure. Significance was set at p
A total of 63 patients (90 ureters) met inclusion criteria. Mean age was 68.41 months (4.32 yrs) and 75.38% were female. Our cohort included patients with complex anatomies, such as duplex ureters, bladder diverticulum, and post-deflux injection. Of the 90 ureters reimplanted 85.56% showed radiographic VUR resolution at 4-months. In our cohort of 63 patients, 10 (15.87%) presented with grade II complications and 1 (1.59%) with grade I. However, none presented grade III, IV or V complications. Out of the 13 ureters that failed surgery, 9 had preoperative high-grade VUR (IV-V) and concomitant complex anatomy features. On univariate analysis, length of the detrusor tunnel was associated with increased odds of radiographic failure after RALUR (p=0.01). (Table 1)
Using the LUAA technique, RAL surgery has shown to improve operative outcomes in children undergoing extravesical ureteral reimplantation for persistent high-grade and complex VUR. We observed that the length of the detrusor tunnel is a critical step to optimize outcomes and prevent complications while doing this operation.