Laparoscopic Versus Open Transvesical Ureteric Reimplantation for Correction of Vesico-Ureteral Reflux in Children, A comparative Study

INTRODUCTION

The retrograde flow of urine from the bladder into the upper urinary tract is known as vesicoureteral reflux (VUR). It is the outcome of a number of abnormalities relating to the ureter's functional integrity, bladder dynamics, and the anatomic structure of the ureterovesical junction (UVJ). The clinical manifestation varies, although the majority of patients are asymptomatic (hydronephrosis) or have pyelonephritis. Medical and surgical treatments are the two types of treatment options available. ¹

There are many methods for treating VUR today, including monitoring programmes with or without antibiotic prophylaxis, endoscopy, laparoscopy, and open methods. Surgical correction to eradicate VUR is a critical component of treatment.²

Intravesical or extravesical procedures for the VUR correction were documented with a high rate of success. In terms of the intravesical technique, the Ledbetter-Politano and Cohen procedures are the most prevalent ureteral reimplantation techniques, with a rate of success of 97–99%. ³

In the open surgical treatment of VUR, the Cohen approach has historically been regarded as the "gold standard." This procedure has the natural outcome of putting the ureteric orifice across the midline of the trigon, potentially rendering future accessibility to the ureteric orifice more challenging than if it stayed lateralized.

Because the Glenn-Anderson procedure does not need the ureteric orifice to be placed contralaterally, future ureteric orifice accessibility is unlikely to be complicated.⁴

For a variety of pediatric urological disorders, laparoscopic surgery has largely supplanted open surgery. Minimally invasive surgical methods utilizing such approaches have been demonstrated to be beneficial in the treatment of VUR in children.⁵

In the realm of pediatric urology, transvesicoscopic ureteral reimplantation is rapidly substituting the open extravesical method. Reduced postsurgical bladder spasms, reduced incisional blood loss and pain, and better aesthetics are also significant advantages. In 2005, laparoscopic techniques with CO2 bladder insufflation (pneumovesicum) were launched as minimally invasive treatments.⁶

This work aimed to compare laparoscopic and open transvesical ureteral reimplantation for the correction of VUR in children as regards the mean operative time, hospital stay, incidence of complications, successful rate, and recurrence rate.

PATIENTS AND METHODS

This was a prospective comparative study between laparoscopic and open transvesical ureteric reimplantation for the correction of VUR in pediatric patients. It was done at the Pediatric Surgical Department, Al-Azhar University Hospitals and other government and private hospitals over a duration of two years from December 2019 to December 2021. This research was done on (20) children. All patients had a thorough medical history and physical examination, as well as an ultrasonography, a Voiding cystourethrogram (VCUG), and a nuclear renal DMSA scan.

Inclusion criteria: Primary VUR Grade III, IV or V, both sexes and age from 1 to 18 years.

Exclusion criteria: Grade I & II VUR, secondary VUR and recurrent cases.

Patients divided into two groups (A&B) randomizedly selected by closed enveloped method. Ten patients submitted to Laparoscopic Transvesical Modified Glenn-Anderson Ureteric Reimplantation Group (A) and remaining 10 patients submitted to Modified Open Transvesical Glenn-Anderson Ureteric Reimplantation Group (B).

Patient data:

Ten patients (3 male, 7 female) with mean age 5.10 ± 1.37 years were included in group (A), other 10 patients (6 male, 4 female) with mean age 4.30 ± 1.62 years were included in group (B), as (table 1). Clinical presentation was fever and recurrent UTI in all cases involved in group (A), 8 patients were presented with fever, UTI and 2 patients were diagnosed antenatally by hydroureteronephrosis in group (B). Five cases were bilateral, 3 cases were unilateral right sided, and 2 cases were unilateral left sided in group (A), 2 cases were bilateral, 3 cases were unilateral right sided, and 5 cases were unilateral left sided in group (B), as (table 2). Three cases were grade III, 4 cases were grade IV, and 3 cases were grade V in group (A), 2 cases were grade III, 4 cases were grade IV and 4 cases were grade V in group (B), as (table 3). The mean diameter of the ureter was 18.51 ± 4.32 mm in group (A), and 18.16 ± 4.54 mm in group (B), as (table 4).

Surgical technique:

Group (A): Following general anaesthetic and endotracheal intubation, the patient was positioned in a low lithotomy posture, allowing the surgery to begin with cystoscopy. The camera was positioned near the foot end, while the surgeon stood at the head end for young children as well as on the left side for bigger children. Under cystoscopic supervision, the bladder was filled with saline as well as a suture was introduced percutaneously at the bladder dome above the site of the proposed camera port installation. With saline bladder distension, the first port (for the camera) was put under cystoscopic view. A urethral catheter was placed, and CO2 bladder insufflation (pneumovesicum) was initiated at a pressure of 8 to 10 mm Hg. Under CO2 pneumovesicum, endoscopic visualisation of the bladder's interior has been established. Endoscopically, two 3-to 5-mm functioning ports are subsequently placed at the bladder's lateral walls. A percutaneously passed staying suture was used to attach every port to the bladder as well as the wall of the abdomen and was used to seal the port site when the operative procedure was completed. To aid with ureteral mobilisation and dissection, ureteric orifices have been cannulated with a 4- or 6-Fr feeding tube (Figure 1B). Laparoscopic tools with a diameter of 3 mm are generally employed (Figure 1A). The diathermy hook and laparoscopy scissors were used to mobilize the ureter with sharp and blunt dissection. The ureter was mobilized into the intravesical space for a length of 2 to 3 cm, with extra care made to prevent damaging the ureter's vascularity (Figure 1C). The ureteral hiatus then closed using interrupted 4-0 or 5-0 polydioxanone sutures. Using hook electro cautery, a muscular groove from the hiatus to near the neck of the bladder was prepared (Figure 1D). The site of ureteroneocystostomy is usually chosen to extend to a point above the bladder neck. A mobilised ureter is dragged into the muscular groove, and a ureteroneocystostomy is conducted with a ureteral stent for 4 to 6 weeks (Figure 1E). The stay sutures at the port entrance sites have been knotted to prevent urine extravasation following the ports have been removed, and absorbable skin sutures have been applied. Drainage of the urethra with a catheter has been needed for 24 to 48 hours, (Figure 1F).

Group (B) The patient was positioned in a low lithotomy posture following general anesthesia and endotracheal intubation, allowing cystoscopy to begin. A Pfannenstiel incision was made, and then the bladder was opened to expose the vesicoureteral junction. The opening of the ureter was found and a stent was implanted (Figure 2A). A circumferential incision was made around the opening of the ureter, the distal ureter was dissected proximally, and ureteral mobilization was performed (Figure 2B), and a muscular groove emerged from the original mucosal hiatus and prolonged to a point marked superior to the bladder neck. The muscular groove should be 4 or 5 times as long as the ureter width. Through the groove, the ureter is transferred. The muscular groove then sutured circumferentially with running absorbable sutures, (Figure 2C). Then bladder was closed, (Figure 2D).

Modification of Glenn-Anderson include: One or two interrupted 5/0 absorbable sutures were used to seal the detrusor defect in the ureteral hiatus and the ureter's seromuscular layer. Hook electrocautery was used to create a muscular groove from the hiatus to near the bladder neck. Where necessary, the terminal part of the ureter is resected to a sufficient length. For better fixation, the neoureteral opening's tip was sutured to the groove's end. A 5/0 absorbable running suture was used to seal the mucosal layer above the muscular groove.

Post-operative: The main outcome comparative measurements of this study included the average operating duration in minutes (from the beginning of the skin incision to the conclusion of wound closing), hospital stay in hours, complications, rate of success, recurring rate, and follow-up by ultrasound every 1 month, Voiding cystourethrogram (VCUG) every 3 months, and DMSA scan after 6 months.In both groups, the rate of success was defined as the lack of recorded febrile UTI or the lack of VUR recurrence as objectivized by VCUG.

Ethical Consideration: Al-Azhar University's Ethical Research Committee considered and accepted the protocol for clinical study. The patient and his family have been given a thorough explanation of the study's procedures and goals.  Before being enrolled in the study, written consent was sought. The patient is not denied medical care because his or her family refuses to grant consent.

Statistical Analysis:

SPSS 24.0 for Windows was used to collect, tabulate, and statistically analyze all of the data (SPSS Inc., Chicago, IL, USA). The Shapiro-Walk test was performed to determine if the data had a normal distribution. Frequencies and relative percentages were used to represent qualitative data. To calculate the difference between qualitative variables, the chi-square test (χ2) and Fisher exact were employed. For parametric data, mean ± SD was employed, and for non-parametric data, median and range were used. For parametric and non-parametric variables, the independent T test and Mann-Whitney test were employed to calculate the difference between quantitative variables in two groups. All statistical comparisons have been two-tailed, with a P-value of ≤ 0.05 indicating a significant difference, p < 0.001 indicating a highly significant difference, and P > 0.05 indicating a non-significant difference.

RESULTS

All procedures have been successfully completed. One patient (unilateral left sided) was converted to open surgery because of small bladder capacity. For comparison of Group A and Group B during and after operation (Table 5&6), Operative time of group A was longer than group B (P< .002) on unilateral cases (104.8 ± 3.96 versus 74.38 ± 4.14), and on bilateral cases (170.4 ± 7.96 versus 139 ± 1.41). Intraoperative blood loss was less in group A about (10.57 ± 2.61versus 21.48 ± 5.33), postoperative gross haematuria developed only in one case in group A while the gross haematuria developed in 6 cases in group B (1/10 versus 6/10), regarding the incidence of wound infection, there was no wound infections in group A and one case developed wound infection in group B (0 versus 1/10). Urinary extravasation developed in 2 cases in group B and no cases developed urinary extravasation in group A (0 versus 2/10), regarding the incidence of urinary tract infection there was one case in group B, while there have been no cases in group A (0 versus 1/10), the length of hospital stay after surgery was significantly lower in group A versus group B (3.3 ± 1.06 versus 4.7 ± 1.16). drainage tubes were needed in both groups.

After follow-up by clinical symptoms, ultrasonography and VCUG, there were marked improvement regarding the degrees of hydroureter obtained by US and absent of VUR in postoperative VCUG in group A, while one cases developed recurrence in group B (Table 7), There were no statistically significant differences in follow-up between these 2 groups such as fever, recurrent UTI, grade of VUR and improvement of ureteral diameter.

Table 1: Demographic characteristics between studied groups

We found no significant differences in age, sex, or BMI between the two groups studied.

Table 2: Clinical presentation distribution and Laterality distribution among the two studied groups  

This table reveals that there was no statistically significant difference between the groups studied. This table showed that regarding group A, 50% of the patients were on both right and left and regarding group B, 50% of the patients were on left without statistical significance difference between the two groups.

Table 3: Grade of VUR distribution between the two studied groups

This table reveals that there was no statistically significant difference between the groups studied

Table 4: Ureteral diameter distribution between the two studied groups

 This table reveals that there was no statistically significant difference between the groups studied

Table 5: Operative data between the two studied groups

This table demonstrates that the operative time in group A was much longer than in group B. In comparison to group B, group A's hospital stay was much shorter. However, blood loss was significantly lower in group A compared to group B. All patients in both groups had drainage tube.

Table 6: Cosmetic outcome and Postoperative complication between the two studied groups

In terms of cosmetic outcome, there are no significant differences between the groups. However, 30% of cases in group B were poor, while none were in group A. There is a significant difference between the groups regarding urinary extravasation and growth hematuria. Thus, in comparison to group A, they were significantly more common in group B.

Table 7: Follow-Up and Success rate between the two studied groups

In terms of the rate of success, there is no significant difference between the two groups. There is only conversion of one case in group A and one recurrent case in group

B.

Fig.1: A- Locations of trocars, B&C- A feeding tube was implanted as a stent into the ureter to aid in later ureter mobilisation and dissection. D- Rather than a tunnel, a muscular groove is created from the ureteral hiatus to the trigone, E- Closure of muscular groove over the dissected ureter was done, F- Post operative view.

Fig.2: A&B- A ureteric catheter was placed as a stent into the ureter to aid in later ureter mobilization and dissection, C- Closure of muscular groove over the dissected ureter was done, D- Post operative view.