V10-02: Complex Robot-Assisted Laparoscopic Extravesical Ureteral Reimplantation (RALUR) Following Endoscopic Injection Of Dextronamer/Hyaluronic Acid For Vesicoureteral Reflux
Endoscopic management of primary vesicoureteral reflux (VUR) is commonly performed using dextronamer/hyaluronic acid (Deflux) with reported success rates between 50 and 93%. The success for RALUR has been reported to be 72% in one multi-institutional study (J Urol 2015). We have reported clinical and radiographic success of over 94% with RALUR for complex cases (J Ped Urol 2015). We present three cases of complex RALUR performed after endoscopic management with Deflux.
Patients treated with Deflux for primary VUR, who subsequently underwent RALUR were identified. Between ?2013-15, a total of 17 complex RALUR cases were identified of which 3 were selected to highlight useful technical pearls: 1. Evacuation of Deflux when possible, 2. Complete exposure of the ureterovesical junction, 3. Creation of wide detrusor flaps, and 4. Conversion to a dismembered extravesical ureteral reimplantation if ureteral dissection is limited or technically difficult. The use of intraoperative stents may also be useful in complex cases.
All three patients were female, with a mean age of 10.2±6.7 years at the time of robotic surgery. Endoscopic surgery was performed 26.2±6.8 months prior to robotic surgery; mean VUR grade 3±1.4; and mean volume of Deflux injected was 1.2±0.5mL per side. Indications for RALUR included recurrent right grade III VUR in two patients and recurrent UTI and obstruction in one patient. No patient experienced clinical or radiographic failure postoperatively.
Complex RALUR after endoscopic correction of VUR is a potentially challenging procedure that can be performed safely and effectively. We advocate attention to the principles outlined in this video, namely 1. Evacuation of Deflux if possible, 2. Full exposure of the ureterovesical junction, 3. Creation of wide detrusor flaps, and 4. Conversion to a dismembered extravesical ureteral reimplantion if ureteral dissection is limited.