From Emory University and Children's Healthcare of Atlanta, Atlanta, GA, USA.
From Emory University and Children's Healthcare of Atlanta, Atlanta, GA, USA.
J Pediatr Urol. 2021 Aug;17(4):547.e1-547.e6. doi: 10.1016/j.jpurol.2021.05.029. Epub 2021 Jun 9.
Endoscopic injection (EI) has been considered a minimally invasive option with high success rates. However, in clinical settings where EI has failed, and after repeat injections or worsening clinical presentation, different treatment modalities may be offered. Open ureteral reimplantation has emerged as a safe option in patients who have failed EI for VUR treatment. Currently there is limited literature describing success of complex robot-assisted laparoscopic ureteral reimplantation (RALUR) following primary EI for vesicoureteral reflux (VUR).
We aim to describe our surgical technique and outcomes using RALUR approach following failed EI for VUR. We hypothesize RALUR can be a safe, salvage option in patients who have failed EI for VUR in the setting of recurrent VUR or ureterovesical junction obstruction (UVJO).
A single site, retrospective study using electronic medical records of all patients who underwent RALUR between 2013 and 2019 following history of previous ipsilateral EI using dextranomer/hyaluronic acid (DHA) for diagnosis of vesicoureteral reflux (VUR) was conducted. Primary outcomes were radiographic resolution and/or clinical resolution.
A total of 17 RALUR procedures were reviewed in 16 patients. There were 14 females (87.5%) and 2 males (12.5%). Seven patients had two prior EI. Median (range) age at time of RALUR was 10.1 (5.7-17.9) years, and the average time between EI and RALUR was 5.9 years [1-13]. The average VUR recurrence grade after failed EI was 3 (ranges 2-4) on preoperative VCUG. History of bilateral EI using dextranomer/hyaluronic acid (DHA), was observed in 14 patients. Surgical diagnosis at time of RALUR included persistent VUR (N = 10) or symptomatic ureterovesical junction obstruction (UVJO, N = 6). Mean console times were 102 min (range 70-240 min) for RALUR vs 128 min (range 70-180 min) for cases requiring ureteral tailoring. Six complications occurred in 16 patients (37.6%): Using the Clavien-Dindo classification scale, four patients (25%) were grade I, one (6.3%) grade II, and one (6.3%) was grade IIIb, which required additional procedures for ureteral obstruction.
RALUR after failed EI should be considered a reasonably safe and effective surgical approach in older children with persistent VUR or acquired UVJO.
内镜下注射（EI）被认为是一种微创治疗方法，成功率较高。然而，在 EI 治疗失败的临床环境中，以及在重复注射或临床症状恶化后，可能会提供不同的治疗方法。对于因 VUR 而接受 EI 治疗失败的患者，开放式输尿管再植术已成为一种安全的选择。目前，关于初次 EI 后行复杂机器人辅助腹腔镜输尿管再植术（RALUR）治疗 VUR 的成功率的文献有限。
我们旨在描述我们在 VUR 初次 EI 治疗失败后采用 RALUR 治疗的手术技术和结果。我们假设 RALUR 可以作为一种安全的挽救方法，适用于 VUR 复发或输尿管-膀胱交界处梗阻（UVJO）的患者。
对 2013 年至 2019 年间因 VUR 行单侧 Dextranomer/hyaluronic acid（DHA）EI 治疗且既往有同侧 EI 史的患者，采用电子病历进行了一项回顾性单中心研究，所有患者均行 RALUR 治疗。主要结局为影像学缓解和/或临床缓解。
共回顾了 16 例患者的 17 例 RALUR 手术。其中女性 14 例（87.5%），男性 2 例（12.5%）。7 例患者有 2 次 EI 治疗史。RALUR 时的中位（范围）年龄为 10.1（5.7-17.9）岁，EI 与 RALUR 之间的平均时间为 5.9 年[1-13]。初次 EI 治疗失败后 VUR 复发的平均分级为 3 级（术前 VCUG 范围为 2-4 级）。14 例患者双侧 EI 采用 DHA。RALUR 时的手术诊断包括持续性 VUR（N=10）或有症状的输尿管-膀胱交界处梗阻（UVJO，N=6）。RALUR 的平均控制台时间为 102 分钟（范围 70-240 分钟），而需要输尿管裁剪的病例平均控制台时间为 128 分钟（范围 70-180 分钟）。16 例患者中有 6 例（37.6%）发生了并发症：根据 Clavien-Dindo 分类量表，4 例（25%）为 I 级，1 例（6.3%）为 II 级，1 例（6.3%）为 IIIb 级，需要额外手术治疗输尿管梗阻。
对于持续性 VUR 或获得性 UVJO 的大龄儿童，初次 EI 治疗失败后行 RALUR 应被视为一种相对安全且有效的手术方法。
