Pediatric Endourology

Laparoscopic-Assisted Ureteroureterostomyfor Duplication Anomalies in Children

Gwen M. Grimsby, MD,1,2 Zahra Merchant,3 Micah A. Jacobs, MD, MPH,1,2 and Patricio C. Gargollo, MD4

Abstract

Purpose: To describe a novel laparoscopic-assisted technique for ureteroureterostomy for the surgical man-agement of a completely duplicated collecting system with an obstructed and/or ectopic ureter.Patients and Methods: A camera is placed through a 5-mm infraumbilical port and the duplicated uretersidentified and delivered through a small inguinal incision with a laparoscopic Babcock clamp. The ureter-oureterostomy is performed in an open fashion. The mean operative time, length of stay, success, and com-plications of nine patients who underwent this technique were reviewed and compared with a cohort of patientswho underwent open ureteroureterostomy at a single institution. In addition, the existing literature on laparo-scopic and robot-assisted ureteroureterostomy is reviewed.Results: There were no statistically significant differences in operative time (134 vs 133 min, P = 0.950), lengthof stay (0.32 vs 0.33 days, P = 0.929), complications (2 and 2, P = 0.574), or rates of success (95% vs 100%,P = 1.00) between the open and laparoscopic-assisted ureteroureterostomy groups. In addition, the operativetimes and length of stay in our laparoscopic cohort were shorter than a majority of the laparoscopic and roboticcases reported in the literature.Conclusions: Laparoscopic-assisted ureteroureterostomy is a successful technique for the management of anectopic and/or obstructed ureter in a completely duplicated collecting system. This technique combines thespeed and ease of the open technique with the improved cosmesis and visualization of a laparoscopic approachand is thus a useful approach for the pediatric urologist.

Introduction

There are many treatment options for the manage-ment of a completely duplicated collecting system that

may be associated with an ectopic ureter, ureterocele, orvesicoureteral reflux. Although upper pole partial or hemi-nephrectomy can be undertaken for the management of theseconditions when associated with a nonfunctioning moiety, itis possible to leave the upper renal segment in situ and focuson ureteral reconstruction for correction of the obstruction.1–3

Indeed, this is the preferred approach when there is goodupper pole function. In addition, it has been documented thatthere is little infection or tumor risk in leaving poorly func-tioning renal segments in place.4

The novel technique of performing an open ureterour-eterostomy through a small inguinal type or modified Gibsonincision has been previously reported from this institutionwith excellent success and cosmesis.3 A minimally invasivetechnique was desired, however, especially for older chil-

dren. The purpose of this report is to share the technique andoutcomes of a new laparoscopic-assisted ureteroureterostomytechnique for the management of an ectopic or obstructedureter associated with a completely duplicated collectingsystem. In addition, the outcomes of the laparoscopic tech-nique are compared with an open cohort as well as a review ofthe laparoscopic and robotic ureteroureterostomies reportedin the literature to date.

Patients and Methods

After Institutional Review Board approval, a review wasperformed of all patients who underwent ureteroureter-ostomy at Children’s Medical Center from June 2009 toOctober 2013 by six pediatric urologists. Patients who under-went laparoscopic and robotic approaches were kept in aprospective database, and the open cohort was identified byCurrent Procedural Terminology code. Data collected in-cluded diagnosis, concomitant procedures performed at time

1Division of Pediatric Urology, Department of Urology, UT Southwestern Medical Center, Dallas, Texas.2Children’s Medical Center, Dallas, Texas.3UT Southwestern Medical Center, Dallas, Texas.4Texas Children’s Hospital/Baylor College of Medicine, Houston, Texas.

JOURNAL OF ENDOUROLOGYVolume 28, Number 10, October 2014ª Mary Ann Liebert, Inc.Pp. 1173–1177DOI: 10.1089/end.2014.0113

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of the ureteroureterostomy, length of surgery, length of hos-pital stay, complications, and outcome. A successful procedurewas defined as resolution of urinary incontinence (if presentfrom an ectopic ureter), and resolution or improvement ofhydroureteronephrosis of the effected renal moiety as con-firmed on postoperative renal ultrasonography.

Preoperative demographic information as well as intra-operative data and surgical outcomes were compared be-tween the open and laparoscopic-assisted cohorts. Roboticprocedures were not included in the comparison secondary tonumbers too small for statistical analysis. In addition, oper-ations that included a concomitant procedure at the time ofureteroureterostomy, which would affect the overall opera-tive time, were excluded from the comparison. Categoricaldata were compared via Fischer exact test, and continuousvariables were compared via unpaired t tests with Graphpadstatistical software. An alpha of < 0.05 was consideredsignificant.

The open ureteroureterostomy technique was similar tothat described previously.3 The laparoscopic-assisted tech-nique was performed as follows: After a ureteral stent wasplaced into the upper ureter via cystourethroscopy, the patientwas reprepped and draped. With the patient in the supineposition, an umbilical trocar was placed through which acamera was placed to visualize the pelvic structures. Stayingextraperitoneally, a plane was dissected after making a skinincision in the inguinal crease on the appropriate side andtaken down to the duplicated ureters. A Babcock clamp wasused to grasp and deliver the ureters into the inguinal incisionunder laparoscopic visualization.

A Penrose drain was passed underneath the ureters, the5-mm laparoscope removed, and the ureters dissected prox-imally and distally. The stent was identified and removed andthe upper pole ureter transected distally and suture ligatedwith a 3-0 polydioxanone suture. The upper pole ureter wasspatulated proximally, and an ureterotomy made in the lowerpole recipient ureter. The spatulated upper pole ureter wasthen anastomosed to the ureterotomy of the lower pole ureterusing two running 6-0 polydiaxanone sutures, one up eachside. A ureteral stent was placed at the discretion of thetreating surgeon and when placed, removed 4 to 6 weekspostoperatively. Patients were seen in follow-up 3 monthsafter surgery with renal ultrasonography.

Results

A total of 50 ureteroureterostomies were performed—37 open, 9 laparoscopic-assisted, and 7 robot-assisted.After exclusion of 15 open and 3 robotic cases that wereperformed with a concomitant procedure (most commonlyureteral reimplantation), a total of 32 cases were left for re-view (Fig. 1). As noted above, because of the small numberof remaining robot-assisted procedures, statistical analy-sis was only performed between the open and laparoscopic-assisted cohorts.

All procedures were performed for a duplicated collectingsystem with either an ectopic or obstructed ureter. Meanage was 2.73 years (0.23–21.32), and 26 (82%) patientswere female. In the four robot-assisted cases, mean operativetime was 189 minutes, and all patients spent one night in thehospital after the procedure. There were no complicationsand no surgical failures in the robotic group.

In comparing the open and laparoscopic-assisted groups,there were no differences between mean age or sex (Table 1).There was, however, a significant difference in the number ofpatients who received a stent in the laparoscopic group (89%)compared with the open cohort (21%), P = 0.0012. In addi-tion, there was no statistically significant difference in meanoperative time between the open and laparoscopic groups:Open, 134 minutes; laparoscopic, 133 minutes (P = 0.950).There was also no difference in length of stay between thetwo groups because a majority of patients (70%) went homethe same day as the surgery.

There was no statistically significant difference in numberof complications or failures between the two groups (Table1). In the open group, there were two complications: Onehospital readmission for a febrile urinary tract infection(UTI) and one urine leak necessitating percutaneous drain-age. The patient with the urine leak had a ureteral stent placedat the time of the initial procedure. In the laparoscopic group,there were two hospital readmissions after surgery—one foremesis and one for a febrile UTI.

Mean follow-up after surgery was 21 months. Of the 28total patients compared between the open and laparoscopic-assisted groups, there was one failure in a patient who hadundergone an open ureteroureterostomy. This was defined byworsening renal cortical thinning on postoperative ultraso-nography and two febrile UTIs after surgery, both of which

FIG. 1. Breakdown of patients. UU = ureteroureterostomy;lap = laparoscopic.

Table 1. Preoperative, Operative,

and Postoperative Demographics

Open UU(n = 19)

Lap UU(n = 9) P value

Age (y); mean (SD) 1.38 (2.2) 2.19 (2.4) 0.375Female; n (%) 15 (79) 7 (78) 1.000Stent; n (%) 4 (21) 8 (89) 0.0012OR time (min);

mean (SD)134 (43.9) 133 (40.6) 0.950

LOS (d); mean (SD) 0.32 (0.48) 0.33 (0.50) 0.929Complications; n (%) 2 (11) 2 (22) 0.574Success; n (%) 18 (95) 9 (100) 1.000

UU = ureteroureterostomy; lap = laparoscopic; SD = standard de-viation; OR = operative; LOS = length of stay.

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necessitated hospital admission. A postoperative photographof a patient who underwent the laparoscopic technique can beseen in Figure 2.

Discussion

Laparoscopic-assisted ureteroureterostomy is a noveltechnique for the management of an ectopic or obstructedureter in a completely duplicated collecting system withoutreflux. After success with the open technique as reportedpreviously by Prieto and coworkers,3 it was thought that aminimally invasive endoscopic procedure would be valu-able, especially for older children where dissection deep inthe pelvis can be more cumbersome. Initially, a roboticapproach seemed an attractive option for these patients.Despite minimal complications and 100% success, how-ever, the length of stay was 1 day for all patients treatedrobotically whereas a majority of the patients treated withthe open technique were discharged on the same day as the

procedure. In addition, operative times were an averageof 60 minutes longer for the robotic ureteroureterostomiesthan the open technique. Finally, the overall cost of ob-taining and maintaining a robotic platform is high and maynot be available at all centers.

These findings led to the development of the novellaparoscopic-assisted open technique as described above.Because the most challenging part of the case is identificationof the ureter through a small inguinal incision, the laparo-scopic-assisted method allows for direct visualization andretrieval of the ureters, which simplifies this surgical step. Inaddition, the approach provides smaller incisions and thusbetter cosmesis, which is desirable especially for older chil-dren. With the laparoscopic-assisted approaches, these ad-vantages of minimally invasive surgery were maintainedwithout sacrificing operative time or length of stay; the com-parison with the open technique revealed no differences inoperative time, length of stay, complications, or failures.Because this series includes the learning curve of the surgeonwith this procedure, one can hypothesize that surgical timesmay continue to improve with more experience.

A complete ureteral duplication with associated ectopic orobstructed ureter may be managed by a variety of operationsincluding ureteral reimplantation and pyeloureterostomy, orheminephroureterectomy when upper pole function is poor.2

In addition, multiple previous reports have documented thesuccess of a simple ureteroureterostomy for the managementof ectopic ureters, ureteroceles, and vesicoureteral reflux in aduplicated collecting system.1–3 Advantages of this approachinclude preservation of the upper pole moiety, technical ease,improved exposure and visualization, decreased morbiditycompared with a flank or transvesical approach, improvedcosmesis because the procedure may be performed through asmall hernia type incision, avoidance of ureteral tailoring andbulky ureteral reimplantation for associated ureteral dilation,and a high success rate of 94% to 98%.1–3

Multiple authors have also reported the technique and re-sults of minimally invasive approaches to ureteroureter-ostomy including laparoscopic, single site, and robot-assisted

FIG. 2. Laparoscopic ureteroureterostomy incisions.

Table 2. Minimally Invasive UU Literature Review

Author n Operative time (min) LOS (d) Complications Success

Laparoscopic approach- Gonzalez, 20075 6 211 3 (1–7) 2 100%- aLowe, 20076 4 202 3 1 100%- Steyaert, 20097 2 120 5.5 (4–9) 0 100%- Storm, 20118 7 187 2 (1–4) 0 100%- Olguner, 20129 2 Not stated 2 0 100%- bLiem, 201210 9 78 2.6 (1–3) 0 100%

Combined laparoscopic and robotic cohort- Kutikov, 200711 6 186 2.6 (1–3) 1 100%

Robotic approach- cPasserotti, 200812 3 244 3.5 (2–4) 0 100%- Leavitt, 201213 5 225 1.2 (1–2) 0 100%

Total 44 182 2.8 4 (9%) 100%

aUpper urinary tract obstruction in a duplicated system.bSingle trocar laparoscopic approach.cUU performed for midureteral obstructions.UU = ureteroureterostomy; LOS = length of stay.

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approaches for the repair of proximal and distal obstructionin the duplicated system, midureteral pathology, as well asfor the management of reflux and ectopic ureters in a dupli-cated system.5–14 A summary of the existing literature onlaparoscopic and robotic ureteroureterostomy in children isprovided in Table 2. A pooled analysis of all results reveals amean operative time of 182 minutes (78–244 min) and amean length of stay of 2.8 days (1–9 d). Overall, the proce-dure has an excellent success rate with no reported failuresin the literature. Minimal complications included one epi-sode of pyelonephritis that prolonged the initial hospital stay,one hospital readmission for febrile UTI, and two urineleaks,5,6,11

Our report of nine children treated with a minimally in-vasive approach for ureteroureterostomy is comparable insize with the largest reported study by Liem and associates10

who reported the results of nine patients treated with a singleport technique. Our reported success rate and complicationprofile is similar to that reported in other laparoscopic androbotic series. Our mean operative time of 133 minutes,however, is much less than a majority of the series reported,many of which have operative times more than 200 minutes,more than 1 hour longer than in this series. In addition, ouroperative time included stent placement while the fastestreported operative time reported in the literature (78 min) waswithout ureteral stent placement.10 The performing sur-geon recorded his own time to secure the ureter during thelaparoscopic-assisted ureteroureterostomy procedure, whichaveraged 10 minutes (6–15). In addition, 6/9 (67%) of pa-tients in the laparoscopic-assisted group went home the dayof surgery and the remaining three spent one night in thehospital. This, too, is superior to the reported mean of 2.8days (1–9) spent in the hospital by those patients who un-derwent a minimally invasive ureteroureterostomy as re-ported in the literature.

Advantages of the laparoscopic-assisted ureteroureter-ostomy thus include shorter operative times and length ofstay compared with contemporary laparoscopic and robot-assisted techniques in the literature. These times are no dif-ferent when compared with our established cohort of openureteroureterostomies. In addition, we think that the cosmesisof small inguinal and single periumbilical port incisions aresuperior to the three to four port site incisions created with arobotic approach. The laparoscopic-assisted approach pro-vides improved visualization of the ureters and aids in theidentification the affected ureter. The approach also allowsfor the smallest possible inguinal incision because the iden-tification and delivery of the ureters occur laparoscopically.Last, the most difficult and time-consuming portion of a purelaparoscopic case, the ureteral reconstruction, is eliminatedbecause this part is performed rapidly in an open fashionthrough the small inguinal incision.

Finally, a comment should be made on the use of ureteralstent placement because there was a significant difference instents used between the laparoscopic and open cohorts. Thiswas secondary to surgeon preference. Previous reports haveestablished the success of ureteroureterstomy without the useof a ureteral stent.3 Other authors, however, have cham-pioned the use of one or two ureteral stents because the stentoften aids in identification, and thus assists in avoiding in-

advertent injury to the lower pole ureter.1,2 This choiceshould thus be left to the treating surgeon’s preference andcomfort level and if left out from our reported techniquewould only shorten the operative time.

Conclusion

Laparoscopic-assisted ureteroureterostomy is a successfultechnique for the management of an ectopic or obstructedureter in a completely duplicated collecting system. Opera-tive time and length of stay were similar to an establishedopen cohort and shorter than a majority of minimally invasiveprocedures reported in the literature as well as our own ro-botic experience. In addition, this technique has improvedcosmesis and less overall cost compared with a robotic ap-proach. The novel technique combines the speed of the openprocedure with the improved ureteral identification and re-trieval offered with a laparoscopic approach and is thus auseful technique for the pediatric urologist.

Disclosure Statement

No competing financial interests exist.

References

1. Chacko JK, Koyle MA, Mingin GC, Furness PD 3rd. Ip-silateral ureteroureterostomy in the surgical management ofthe severely dilated ureter in ureteral duplication. J Urol2007;178:1689–1692.

2. Lashley DB, McAleer IM, Kaplan GW. Ipsilateral ureter-oureterostomy for the treatment of vesicoureteral reflux orobstruction associated with complete ureteral duplication.J Urol 2001;165:552–554.

3. Prieto J, Ziada A, Baker L, Snodgrass W. Ureteroureter-ostomy via inguinal incision for ectopic ureters and ur-eteroceles without ipsilateral lower pole reflux. J Urol 2009;181:1844–1850.

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10. Liem NT, Dung LA, Viet ND. Single trocar retroperi-toneoscopic assisted ipsilateral ureteroureterostomy forureteral duplication. Pediatr Surg Int 2012;28:1031–1034.

11. Kutikov A, Nguyen M, Guzzo T, et al. Laparoscopic androbotic complex upper-tract reconstruction in childrenwith a duplex collecting system. J Endourol 2007;21:621–624.

12. Passerotti CC, Diamond DA, Borer JG, et al. Robot-assisted laparoscopic ureteroureterostomy: Description oftechnique. J Endourol 2008;22:581–585.

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Address correspondence to:Patricio C. Gargollo, MD

Texas Children’s Hospital/Baylor College of Medicine

6701 Fannin Street, CCC Suite 620Houston, TX 77030

E-mail: pgargollo@gmail.com

Abbreviation UsedUTI¼ urinary tract infection

LAPAROSCOPIC-ASSISTED URETEROURETEROSTOMY IN CHILDREN 1177