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awatchai Mankongsrisuk, M.D.*, Jad A. Degheili, M.D.**, Bansithi Chaiyaprasithi, M.D.*
*Division of Urology, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, ailand, **Division of Pediatric
Urology, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada.
Intraoperative Problems and Solutions in
Pneumovesicum Laparoscopic Cross-trigonal
Ureteral Reimplantation in Children by a Beginner
Surgeon
ABSTRACT
Objective: Many beginner surgeons feel anxious when rst doing the procedure. Some may encounter many
intraoperative diculties or problems, resulting in abandoning the technique. We will demonstrate our methods
and the solutions to major intraoperative problems.
Materials and Methods: A beginner surgeon performed the operation on 13 children with VUR (20 ureters) who
met the indications for surgery between October 2016 and August 2017. Age ranged from 2 to 7 years. Each operation
comprised 2 main steps: anchoring the urinary bladder wall to the anterior abdominal wall under cystoscopic
vision, followed by a cross-trigonal ureteral reimplantation under pneumovesicum laparoscopy. e intraoperative
problems, postoperative care, and follow-up periods were recorded to identify surgical outcomes.
Results: Most signicant, intraoperative problems were air leakage, bleeding, tear of the bladder mucosa above the
tunnel, and inability to insert a tube into the ureter pre- and post-reimplantation. Most problems could be managed.
Only one case had to be converted to open reimplantation due to uncontrolled air leakage. Postoperatively, 2 patients
had hydroureteronephrosis at 4 weeks, but it eventually spontaneously regressed. One patient had cystitis, treated
with oral antibiotics. Between the 1-year and 4-year follow-up, no patients had hydroureteronephrosis or urinary
tract infections (UTI).
Conclusion: Pneumovesicum laparoscopic ureteral reimplantation is a feasible technique for beginner surgeons.
Although many intraoperative problems may be encountered, most can be managed, resulting in the completion
of the laparoscopic procedure.
Keywords: (Siriraj Med J 2021; 73: 758-762)
Corresponding author: awatchai Mankongsrisuk
E-mail: thawatchai.man@mahidol.ac.th
Received 21 May 2021 Revised 1 October 2021 Accepted 5 October 2021
ORCID ID: https://orcid.org/0000-0001-9459-0870
http://dx.doi.org/10.33192/Smj.2021.98
INTRODUCTION
Although many of the patients diagnosed with
vesicoureteral reux (VUR) may recover spontaneously
with conservative treatment, a large number meet the
indications for anti-reux interventions. Injection therapy
is now more popular because of its endoscopic approach
that can be done in an outpatient setting and is more
cost-eective than open ureteral reimplantation, especially
for low-grade VURs.
1,2
In contrast, for high-grade VURs,
ureteral reimplantation is considered a suitable option due
to the lower success rate of injection therapy.
3
In many
countries, including ailand, no injection materials are
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used due to high cost. Consequently, ureteral reimplantation
remains the option of choice for VUR treatment.
Like many other operations, ureteral reimplantation
can be performed using open and/or laparoscopic methods.
Based on our experience, laparoscopic surgery, in general,
is associated with less pain, shorter lengths of hospital stay,
rapid recovery, and better cosmesis than open approach.
e same applies to the ureteral reimplantation procedure.
Laparoscopic ureteral reimplantation employs 2 techniques:
an extravesical and an intravesical approach. Because
of concerns about postoperative voiding dysfunction,
extravesical ureteral reimplantation is considered inferior
to the intravesical technique, especially for bilateral
reimplantation. A novel technique, transvesicoscopic
Cohen ureteral reimplantation under carbon dioxide
bladder insuation, was rst reported by Yeung et al.
in 2005.
4
ey demonstrated a high success rate for this
method (96%), which is comparable with the conventional
open intravesical Cohen cross-trigonal technique. is
technique is currently in widespread use and is still
employed to treat VUR.
For young pediatric urologists, laparoscopic
procedures in children are hard to perform and require
more learning than those for adults. is is not only
because of the very small working space available in a
little body, but also due to relatively few cases. Many
beginner surgeons therefore face a steep learning curve.
Compared to a pneumoperitoneum, a pneumovesicum
has much less working space, resulting in more diculty
in performing a vesicoscopic ureteral reimplantation.
is paper describes the experience gained in performing
this operation by a beginner surgeon, the intraoperative
problems encountered, and the solutions developed.
e content should enable other beginner surgeons to
undertake this operation with a degree of condence
and encourage them to perform further laparoscopic
surgeries in children.
MATERIALS AND METHODS
Patients
From October 2016 to August 2017, a urologist,
who recently nished his residency training in June
2016, carried out pneumovesicum laparoscopic ureteral
reimplantation in 20 ureters of 13 patients with VUR.
eir ages ranged from 2 to 7 years at the time of surgery.
ey all were followed until mid-2021.
Surgical technique
Cystoscopy. Aer general anesthesia was administered,
each patient was placed in the lithotomy position. e
abdomen and external genitalia were prepared and
draped in a sterile fashion. Transurethral cystoscopy
with a 30-degree lens and normal saline irrigation was
performed. e bladder was carefully inspected, and
both sides of the ureteral orices were identied before
the bladder capacity was measured. Normal saline was
lled in the bladder again until maximum anesthetic
capacity was reached.
Bladder wall anchoring and ports placement. e next step
was to anchor the bladder wall to the anterior abdominal
wall. is procedure prevented bladder collapse during
the operation. Under cystoscopic vision, two, 24-gauge,
Medi-Cut needles were passed into the bladder at the
midline of the suprapubic site, which corresponded
to the most anterior part of the bladder wall that had
been observed from the cystoscopy. In this step, there
is a need to be aware of the peritoneal recess, which
may go down to cover the superior part of the anterior
bladder wall. Number 1 nylon was rst inserted into one
Medi-Cut needle. Grasping forceps for cystoscopy were
subsequently inserted into the other needle in order to
grasp the end of the nylon, pull it up, and tie both ends of
the nylon together, thereby anchoring the bladder wall.
Using the same technique, two other anchoring stitches
were sequentially placed on the Langer’s at Langer line,
just lateral to the site where the working ports would be
placed. A 5-mm camera port was placed below the midline
anchoring stitch using an open technique. Another two,
5-mm working ports were placed under laparoscopic
vision on the Langer line (Fig 1). Placing the working
ports on the Langer’s line facilitated the later dissection
of the ureter and creation of the submucosal tunnel. e
bladder was then drained and insuated with carbon
dioxide at a pressure of 10–12 mmHg via a camera port
at the bladder dome.
Ureteral dissection and tunnel creation. A size 5 to 6 Fr
feeding tube was inserted into the ureteral orice. is
tube facilitated the visualization of the ureter’s contour
and its serosa. e medial side of the ureteral orice was
hung with 4–0 chromic catgut or Vicryl. Dissection of
the ureter was performed with the hook. Blood vessels
on the serosa of the ureter were clearly visualized under
the laparoscope. When the ureter was freely dissected,
a cross-trigonal submucosal tunnel was created with
sharp scissors. e ureter was mobilized through the
tunnel and xed into position with 4–0 Vicryl. e gap
of the muscular layer at the ureteral hiatus was sutured
to prevent the future formation of a diverticulum. e
ureter serosa was xed to the hiatus before the bladder
mucosa was closed. e feeding tube was placed in the
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(range: 200 to 450 mL). e mean operative time (from
cystoscopy to wound closure) was 176 minutes (range:
140 to 205 minutes) for the unilateral reimplantations and
240 minutes (range: 180 to 371 minutes) for the bilateral
reimplantations. Table 1 details the demographic data
and operative times of all 13 cases. In our experience,
the intraoperative problems were air leakage (4 cases),
bleeding (3 cases), tear of the bladder mucosa over the
tunnel (2 cases), and inability to insert the ureteral stent
(1 case). e whole operation managed to be performed
for almost all of the patients. e procedure for only
one patient (who was the youngest, aged 1 year and 10
months) had to be converted to an open reimplantation
because of uncontrolled air leakage into the extravesical
space and severe bladder collapse.
No patient had signicant postoperative complications.
ey occasionally had gross hematuria for only a few
days. ey could start ambulating on postoperative day
1. Bladder spasm was minimal with no anti-muscarinic
administration. e ureteral stent was le in the reimplanted
ureter for 7 days. e urethral catheter was removed
one day aer the ureteral catheter removal, following
which the patients were discharged home. A follow-up
was conducted 4 weeks later. A urinalysis and kidney
ultrasonography were carried out on all patients. If both
tests were normal and the patients had no abnormal
symptoms, they were scheduled for a further follow-up
3 months postoperatively. One patient was found to have
dysuria, frequent urination, and pyuria at the initial two
follow-ups. She received oral antibiotics and recovered
fully during the following 2 weeks. Two patients with
grade 5 VUR were found to have hydronephrosis in the
rst follow-up. However, the degree of hydronephrosis
had improved by the next 4-week follow-up. Between
the 1-year and 4-year follow-up visits, none of the 13
patients exhibited a dilated ureter or hydronephrosis in
an ultrasound examination, and there were no signs or
symptoms of urinary tract infections.
DISCUSSION
A minimally invasive technique for intravesical
cross-trigonal ureteral reimplantation was reported by
Gill et al. in 2001.
5
ey used a transurethral endoscope,
and 2 working balloon-ports were placed at the suprapubic
area. However, this technique had some limitations,
such as not being suitable for bilateral reimplantations
and problems with the original ureteral hiatus. In 2005,
Yeung et al. reported the rst series of transvesicoscopic
Cohen ureteral reimplantations; these had a high success
rate that was comparable with that achieved with open
cross-trigonal ureteral reimplantations.
4
ey placed
Fig 1. Position of all ports
ureter to enable splinting via the working port. e
working port was removed, but the feeding tube was
le and xed to the skin with Number 3 nylon. A Foley
catheter was placed. e camera port was removed, and
cystoplasty was performed using an absorbable suture.
e anchoring stitches were removed, and the abdominal
sheath and skin were closed.
Postoperative care and follow-up. General routine
postoperative care was conducted. A ureteral stent was
used for about 6 to 7 days, and the Foley catheter was
removed 1 day aer the ureteral stent removal. Without
any catheter, the patient could then be discharged from
the hospital. e patient was scheduled for a urinalysis and
kidney-bladder sonography at 4 weeks postoperatively.
If no abnormal symptoms or ndings were found at
that time, the patient was rescheduled to see us every
3 months postoperatively in the rst year and every year
with ultrasound aerwards. Voiding cystourethrography
would be repeated in case of persistent hydronephrosis
or febrile UTI. Prophylactic antibiotics was discontinued
at 6 months aer surgery if the patient had improved
hydronephrosis and no febrile UTI.
RESULTS
e mean age of the patients was 4 years 6 months
(range: 1 year 10 months to 6 years 5 months). Six patients
had unilateral VUR, while seven had bilateral VUR; a total
of 20 ureters were reimplanted without tapering of the
ureters. e mean bladder anesthetic capacity was 302 mL
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a camera port at the dome of the bladder instead of using
transurethral endoscopy, resulting in a better forward
intravesical view. Moreover, they used carbon dioxide
to distend the bladder instead of glycine, which resulted
in much better intravesical vision. e largest series of
this technique was reported by Valla et al. in 2009.
6
eir
success rate was 92%–95%, and the conversion rate was
6%. e cause of the conversions was an inability to
maintain pneumovesicum, which mostly occurred in
patients aged under 2 years.
From our series and experience, there are four main
problems which occur during the operation. e methods
to solve or to prevent those problems are described below.
Air leakage and port problem. is is an important
problem that forces surgeons to convert to open surgery.
Air from the inated bladder may leak through to the
urethra, the ureteral hiatus, or the port sites. e Foley
catheter placement and traction can prevent air leakage
through the urethra. Air leakage through the hiatus aer
the ureteral dissection can be solved by the immediate
suturing of the defect aer the ureteral dissection, and by
the subsequent insertion of a small feeding tube into the
prevesical space beside the ports to release the air. From
the series of Mohan et al., another method to solve air
leakage from the hiatus is to reduce the pressure.
7
ey
reduced the intravesical pressure from 14 to 8 mmHg,
and air leakage did not recur. Air leakage through the
port sites into the extravesical space can be prevented
by anchoring the bladder to the abdominal wall and by
assuring the stability of the working ports by xing them
the skin with suture material or using a balloon port
instead. We observed that younger patients had a port
problem more than older patients. Port displacement
is also an important problem that is associated with air
leakage. One patient in our series had to be converted
because of severe bladder collapse from uncontrolled air
leakage into the extravesical space. According to the series
from Yeung et al.,
3
out of 16 patients had this problem,
and 1 patient had to be converted to open surgery.
4
Canon et al. also reported a port problem.
8
One out of
52 patients in their series had to be converted to open
surgery due to poor port placement and an equipment
malfunction. ey also reported air leakage into the
peritoneal cavity, which caused pneumoperitoneum.
However, transumbilical Veress needle placement was
used to release the air in the abdominal cavity. In our
series, no pneumoperitoneum occurred. is may be the
result of using a dierent technique for the placement
of the camera port at the dome of bladder. We used the
open technique, whereas Canon et al. placed the camera
port under cystoscopy. Port placement with the open
technique can denitely avoid entering the peritoneum
TABLE 1. Demographic data and operative times.
Gender Age Side Grade of VUR Bladder capacity (mL) Operative-time
(Lt/Rt) (mL) (minutes)
Male 5 yr. 2 mo. Left 4 350 193
Female 5 yr. 10 mo. Both 3/3 350 190
Female 5 yr. 3 mo. Both 5/1 260 371
Male 2 yr. 4 mo. Left 4 200 205
Male 6 yr. 1 mo. Left 4 350 140
Female 5 yr. 7 mo. Left 3 320 180
Female 6 yr. 5 mo. Left 3 300 180
Male 4 yr. 3 mo. Both 5 300 270
Male 3 yr. 1 mo. Both 5/4 250 205
Female 4 yr. 5 mo. Left 3 450 160
Female 3 yr. 9 mo. Both 3/4 300 275
Male 4 yr. 11 mo. Both 4/5 300 180
Male 1 yr. 10 mo. Both 4/4 200 190
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via the peritoneal recess. In Valla’s study, 4 out of 72
patients had to be converted owing to a port placement
problem, and 6 patients had pneumoperitoneum, which
could be corrected using a Veress needle.
6
Bleeding. e laparoscopic approach resulted in a
higher chance of serosal blood vessel preservation than
the open reimplantation technique because of better
visualization. However, it is possible to have a bleeding
from the detrusor muscle or the serosa of the ureter
during a ureteral dissection. Although bleeding in this
operation is usually minimal, it will cause diculty with
the visualization of the plane between the ureter and the
bladder muscle. is problem can be solved by careful
electrocoagulation at the bleeding point. However, extensive
electrocoagulation may cause long term complications,
such as ureteral stricture due to ischemia or heat eect.
Tear of bladder mucosa over the tunnel. If this
problem occurs, it can be easily corrected by suturing
the tear mucosa. is problem mainly stems from an
inappropriate scissor curve and working-port angle. e
working ports should be placed on the Langer’s line. We
observed that the ureteral orices and the interureteric bar
are usually underneath the Langer’s line. Consequently,
we can create a submucosal tunnel in a direction that will
not cause a mucosal tear. In addition, we recommend
placing the working ports laterally as far as possible
to make the angle of the port more parallel with the
posterior bladder wall. However, one should be aware
of the injury to the iliac and inferior epigastric vessels.
To prevent inferior epigastric vessel injury during the
working-port placement, which may result in abdominal
wall bleeding or hematoma, the light from the cystoscopy
shining through the abdominal wall greatly facilitates
the identication of the position of these vessels.
Inability to insert the feeding tube. e feeding
tube in the ureter allows us to clearly identify the contour
of the ureter and the plane between the ureter and the
detrusor muscle. An inability to insert the feeding tube
may be caused by 2 factors: either the tube is too big, or
the angulation of the ureterovesical junction is dicult.
e later can be solved by inserting the guidewire rst,
followed by railroading the feeding tube over the guidewire.
Alternatively, a smaller tube can be chosen for insertion
into the ureter.
From our series, the average operative time was
longer than the series of Yeung et al., Canon et al.,
and Valla for both the unilateral and bilateral ureteral
reimplantations.
4,6,8
is may reect the level of experience
of the surgeon with laparoscopic surgery. Moreover, we
found that the operative time is inversely associated with
bladder capacity, with no statistical signicance (Pearson
correlation coecient: -0.347; p-value: 0.25). erefore,
it would be easier for beginner surgeons to perform this
operation on patients with a large bladder capacity.
CONCLUSION
Ureteral reimplantation is still a crucial operation
for pediatric urologists. Pneumovesicum laparoscopic
cross-trigonal ureteral reimplantation is a better option
than open technique for reducing postoperative pain, the
incidence of bladder spasms, and the lengths of hospital
stay, and for achieving better cosmesis. Because of the
many problems that may occur during the operation,
this procedure may be hard to perform, but it is not
impossible to learn and acquire the necessary skills.
Despite there being a steep learning curve, we rmly
believe that every beginner surgeon is able to carry it
out eectively and safely with good outcomes.
ACKNOWLEDGEMENTS
I express my sincere gratitude to my advisor,
Dr. Kittipong Phinthusophon, for continuously supporting
my work and related research, and for his patience,
motivation, and immense knowledge. His guidance
helped me throughout the research and operations.
I also thank Ms. Jitsiri Chaiyatho for her kind help with
the proofreading and publishing of this paper.
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Mankongsrisuk et al.
