JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES

Volume 00, Number 00, 2017 Full Report

ª Mary Ann Liebert, Inc.
DOI: 10.1089/lap.2016.0456

Laparoscopic-Assisted Extravesical Ureteral

Reimplantation and Extracorporeal Ureteral Tapering
Repair for Primary Obstructive Megaureter in Children

Manuel Lopez, MD, PhD, Romy Gander, MD, Gloria Royo, MD,
François Varlet, MD, PhD, and Marino Asensio, MD

Abstract

Background: Open surgery is a preferred treatment for primary obstructive megaureter (POM) in cases where
the conservative treatment fails, with reported success rates of 90%–96%.
Objective: To describe our initial experience in the treatment of POM by laparoscopic-assisted extracorporeal
ureteral tapering repair (EUTR) and laparoscopic ureteral extravesical reimplantation (LUER) by following
Lich Gregoir technique as an alternative to open surgery.
Design, Setting, and Participants: A total of 7 patients with POM underwent laparoscopic-assisted extracor-
poreal ureteral tapering repair and ureteral extravesical reimplantation by following Lich Gregoir technique
between 2011 and 2014. Postoperative follow-up included the following: Renal and bladder ultrasound, voiding
cystourethrogram (VCUG), and mercaptoacetyltriglycine (MAG3) renogram were done at 6 months.
Outcome Measurements and Statistical Analysis: Statistical analysis was performed by using the SPSS
software package (version 15.0; SPSS, Chicago, IL), and P < .05 was considered statistically significant. Paired
tests and Wilcoxon test were performed to compare pre- and post-measures.
Results: LUER and EUTR were completed successfully in all patients without conversion. A postoperative
MAG3 renogram showed nonobstructive pattern in all patients. Statistical analysis revealed significant dif-
ferences before and after surgery in the average time of elimination on the MAG3 renogram (T½ 59.10 minutes
versus 13.57 minutes, P < .0001). After medium-term follow-up, the overall POM resolution was 100%. One
case of vesicoureteral reflux (VUR) was found during VCUG control. A total of 7 patients were asymptomatic
without recurrence of POM.
Conclusion: Laparoscopic-assisted extracorporeal ureteral tapering repair and ureteral extravesical re-
implantation by following Lich Gregoir technique for POM constitutes a safe and good option when the first
line of treatment fails, with a success rate similar to the open procedure. Nevertheless, larger randomized
prospective trials and long-term follow-up are required to validate this technique.

Keywords: obstructed megaureter, laparoscopy, pediatric, urology

Introduction and an increasing dilatation on serial ultrasound (US) scans

are considered suggestive of obstruction.2

P rimary obstructed megaureter (POM) constitutes

approximately 10% of uropathies, with clinical signifi-
cance detected prenatally. The overall incidence of POM is
the range of 1:1500–1:2000.1 Actually, the ureters with ret-
rovesical diameter q7 mm from 30 weeks’ gestation onward
are considered abnormal.
The guidelines of British Association Paediatric Urologists
(BAPU) propose that an initial differential renal function
(DRF) below 40%, or a drop in DRF of 5% on serial scans,
Regarding morphologic appearance of POM, the Pfister-
Hendren classification established three types of mega-
ureters: Type I involved the distal ureter without associated
hydronephrosis; type II extended to both ureter and pelvis;
and type III was associated with severe hydroureterone-
phrosis and ureteric tortuosity.3,4
Around 80% of perinatally detected megaureters are spon-
taneously resolved.5–7 Conservative treatment appears to be
the current option for an initial treatment.2,8 Nevertheless,

Department of Pediatric Surgery and Urology, University Hospital of Vall d’Hebron, Barcelona, Spain.

1
2 LOPEZ ET AL.

Table 1. Patients’ Characteristics

Age
(months)/ DUD P-H Type of Taper Preop MAG3 Postop MAG3 Postoperative
Patients gender Side (mm) type detrusormyotomy tecnhnique DRF (T½ max) DRF (T½ max) complication
01 38/F L 24 II Vertical Hendren 38% (48 minutes) 41% (12 minutes) VUR Grade III
(redo laparoscopy)
02 24/M L 25 II Vertical Hendren 37% (81 minutes) 40% (11 minutes) No
03 17/M L 21 II Vertical Hendren 40% (52 minutes) 42% (13 minutes) No
04 18/F R 17 II Vertical Hendren 51% (65 minutes) 52% (13 minutes) No
05 9/M L 15 II Vertical Hendren 40% (63 minutes) 42% (9 minutes) No
06 14/M L 19 III Vertical Hendren 22% (53 minutes) 20% (8 minutes) No
07 17/M R 15 III Vertical Hendren 38% (45 minutes) 37% (7 minutes) No
DRF, differential renal function; DUD, distal ureter diameter; HUN, hydronephrosis; MAG3, mercaptoacetyltriglycine; P-H, Pfister-
Hendren classification; VUR, vesicoureteral reflux.

when increasing hydronephrosis on a US scan, a decrease of An attempt of balloon dilatation by cystoscopy was per-
renal function, urinary tract infection (UTI), and stone for- formed as a first line of treatment in 14 patients. It was suc-
mation are observed, and surgical correction should be cessfully carried out only in 7 patients.
recommended.8–10 The other 7 patients who were included in this study were 5
The surgical objectives of ureteroneocystostomy are the men and 2 women, and their mean age was 28 months (10–47
same as for nondilated ureters. Distal ureteral tailoring is often months). Five of them were treated on the left side, and 2 of
necessary to achieve an adequate length-to-diameter ratio that them were treated on the right side (Table 1). The mean distal
is required for successful nonrefluxing reimplantation. The ureter diameter was 19.4 mm (15–25 mm). The surgical in-
tailoring of megaureters has been reimplanted with standard dications according to BAPU included an initial DRF < 40%,
cross-trigonal techniques.11–13 Historically, ureteral reimplan- presence of severe hydroureteronephrosis, ureteric tortuosity,
tation and tapering by extravesical or transvesical open sur- and failure of conservative management (breakthrough fe-
gery has been the treatment of choice.14,15 brile UTIs, stone formation, pain, worsening dilatation, and
There are multiple possibilities for minimal invasive treat- deteriorating DRF on serial scans).
ment, including endoscopic, laparoscopic, and robotic ap- All patients underwent laparoscopic-assisted extracorporeal
proaches. The concept of minimal invasive treatment was ureteral tapering repair and ureteral extravesical reimplanta-
introduced by Angulo et al. in 1998, with the use of balloon tion by following Lich Gregoir technique. Detrusor myotomy
dilation of the ureterovesical junction (UVJ) by cystoscopy.11 It was done in vertical fashion, and ureteral tapering repair was
has gained space in the treatment of POM, with goods results performed according to Hendren technique (Table 1).
and advantages of minimal invasiveness.10,12–15 However,
multicenter studies and prospective trials with long-term results Surgical Technique
should be encouraged to provide more definitive evidence on
its benefits.10 Under general anesthesia, the patient was placed in supine
Laparoscopic or robotic repair for POM can be performed position with the legs apart; a urine catheter was inserted at the
transvesically or extravesically. Nevertheless, purely lapa- beginning of the surgery. Three ports were used in all cases:
roscopic reconstructive surgery can be technically challeng- 5 mm-30 for the telescope and two 3 mm trocars. The surgeon
ing, even for the most experienced laparoscopic surgeons.
The first report of laparoscopic repair for POM was de-
scribed by Kutikov et al. in 2006.16 After that, short series and
cases reports have been described by transvesical and extra-
vesical approaches, which have shown a promising technique
that makes laparoscopic or robotic ureteral reimplantation
simpler to perform, with a success rate similar to the open
procedure.16–20
The objective of this study is to describe our initial expe-
rience in the treatment of POM by laparoscopic-assisted ex-
tracorporeal ureteral tapering repair and ureteral extravesical
reimplantation by following Lich Gregoir technique as an al-
ternative to open surgery. When the first line of treatment fails,
and to describe the evolution, we evaluated the results and
benefits of this technique.

Patients and Methods

We retrospectively reviewed the charts of 14 patients, with
prenatal diagnosis of POM and deterioration of renal function
on isotope renography. They were treated by minimal inva-
sive techniques between January 2011 and December 2014. FIG. 1. Trocars and surgeons’ position.
LAPAROSCOPIC EXTRAVESICAL REIMPLANTATION IN OMGU
FIG. 2. The stay sutures are placed through the abdominal wall by percutaneous stitches (arrow) level to the bladder to
expose the ureterovesical junction.
was positioned at the head of the patient, the assistant to the
left, the nurse to the right, and the monitor at the lower end of
the table. The telescope was inserted through a transumbilical
incision, and the other two 3 mm trocars were placed at the left
and right lower abdomen under direct vision (Fig. 1).
Two stay sutures were inserted through the abdominal
wall and placed on each side of the posterior bladder to pull
the anterior wall of the bladder up and to expose the UVJ
(Fig. 2). The retroperitoneum was incised just to identify the
distal ureter that was isolated and dissected toward the UVJ.
The ureter was mobilized to achieve sufficient freedom for a
tension-free reimplantation. Once the stenotic part of the
ureter was completely dissected, the bladder was filled with
CO2. Using the monopolar scissors, the peritoneum was
incised to expose the muscular wall of the bladder and to
create an optimal tunnel with a length that was about four
times the size of the ureter (Paquin law). The detrusor
muscle fibers were cautiously divided with scissors verti-
cally to create a submucosal tunnel, until the mucosa was
exposed (Fig. 3).
The distal ureter was transected at the level of stenosis
and was tapered in all cases. The ureteral tapering technique
FIG. 3. Detrusormyotomy. Exposition of bladder mucosa.
3
used was extracorporeal Hendren technique, with exterior-
ization of the ureter through the ipsilateral port (Fig. 4), and
ureteral tailoring was done by using continuous absorbable
sutures. A stent was placed intraoperatively by laparoscopy.
Vesicoureteral anastomosis was carried out after opening
the bladder mucosa, by two continuous 6/0 PDS sutures.
Extravesical ureteral reimplantation by following Lich
Gregoir technique was done. The ureter was placed in the
new tunnel, and the detrusor muscle was reapproximated
with absorbable sutures (Fig. 5). Neither peritoneal drain
nor bladder catheter was used. The stent was removed at 6
weeks postoperatively.
Postoperative follow-up consisted of a renal and bladder
US scan at 1, 3, 6, and 12 months. Voiding cystourethrogram
(VCUG) and mercaptoacetyltriglycine (MAG3) renogram
were done at the sixth month.
Good results were defined as absence of leakage, anasto-
motic stenosis, vesicoureteral reflux (VUR), and voiding
dysfunction.
Statistical analyses were performed by using the SPSS
software package (version 15.0; SPSS, Chicago IL), and
P < .05 was considered statistically significant. Paired tests
FIG. 4. Extracorporeal ureteral tapering according to
Hendren technique.
4 LOPEZ ET AL.

FIG. 5. Vesicoureteral reimplantation.

and Wilcoxon test were performed to compare measures group and 3.8 months-old in those presenting after birth. All
before and after surgery. infants showed functional and structural urographic im-
provement with a mean follow-up of 2.3 years.21 Keating
Results et al. suggested that the decision to surgical correction was
based on absolute renal function; therefore, the expectant
Laparoscopic-assisted extracorporeal ureteral tapering re-
treatment avoids surgery in a maximum of 87% of patients.5
pair and ureteral extravesical reimplantation by following
Chertin et al. published that renal function < 30%, grade III
Lich Gregoir technique was completed successfully in 7
and IV hydronephrosis, and ureteric diameter >1.33 cm are
patients without conversion. A vertical detrusor myotomy
statistically significant and independent predictive factors for
and extracorporeal ureteral tapering repair by Hendren repair
surgery.22 The BAPU consensus supported initial conserva-
was done in all cases.
tive management and the surgical indications when initial
The definition of success was the absence of obstruction.
DRF < 40%, especially when associated with massive hy-
There were no major intraoperative complications. The
droureteronephrosis and failure of conservative management
mean surgical time was 154 minutes (130–170 minutes).
(breakthrough febrile UTIs, pain, worsening dilatation, or
The postoperative analgesia was managed by acetamino-
deteriorating DRF).2
phen 15 mg/kg/6 h and continuous nubain 1 mg/kg/day. The
The standard open surgery involves excision of the aper-
mean hospital stay was 2.8 days (2–3 days). No urinary
istaltic and/or narrow ureteral segment, reduction of caliber
leakage occurred in the early postoperative period. The
of the distal dilated ureter, and ureteral reimplantation into
mean follow-up period was 28 months (11–47 months).
the bladder in an antireflux fashion, with reported success
None of the patients experienced postoperative voiding
rates of 90%–96%.23 However, complications and morbidity
dysfunction. At 3 months postoperatively, 1 patient pre-
may occur, especially during the first year of life.10 The major
sented a febrile UTI, and a VUR grade III was diagnosed by
short-term complication is urinary leakage, and long-term
VCUG. A redo laparoscopic surgery was done, showing
complications include VUR or persistent obstruction.23
partial disassembling of reimplantation, and then, the tunnel
In our experience, after >150 procedures performed by
was extended to increase the length of antireflux, by fol-
Laparoscopic Extravesical Ureteral Reimplantation by fol-
lowing Lich Gregoir technique with an uneventful course in
lowing Lich Gregoir technique for the correction of VUR, we
a long-term follow-up.
never allow a urethral catheter to be included in bilateral
A postoperative MAG3 renogram showed nonobstructive
cases. Nevertheless, in POM, where vesicoureteral anasto-
pattern in all patients (Table 1). Statistical analysis revealed
mosis is done, and a stent is recomended, it is enough to avoid
significant differences both before and after surgery in the
the urinary leakage.24–26
average time of elimination on the MAG3 renogram (T½
During the past decade, laparoscopy was successfully used
59.10 minutes versus 13.57 minutes, P < .0001). According to
for obliterative and reconstructive management of different
obstruction, the overall success rate of POM resolution was
urological procedures, with high success rates and advantages
100%. After medium-term follow-up, all patients were
of minimum invasiveness. Laparoscopic procedures requir-
asymptomatic without recurrence of POM or VUR.
ing sutures are technically demanding, even for experienced
laparoscopic surgeons. Different techniques of ureteral re-
Discussion
implantation demonstrating feasibility by pneumovesicoscopy,
The management of POM has evolved over the past 20 laparoscopy, and robotic-assisted technique are encouraging
years. In 1989, Peters et al. reported 47 infants < 8 months-old and have been reported to be beneficial in terms of results,
with POM. Forty-two patients (89%) of these with moderate- decreased postoperative pain, allowing shorter hospital stay and
to-severe obstruction underwent open surgical correction. a quicker return to normal activity.17,19,20,24–26,27–30,31 In 2006,
The mean age was 1.8 months-old in the prenatally diagnosis Ansari et al. presented 3 cases of laparoscopic extravesical
LAPAROSCOPIC EXTRAVESICAL REIMPLANTATION IN OMGU
transperitoneal ureteral reimplantation by Lich Gregoir tech-
nique, with extracorporeal tailoring of the ureter by using
Hendren technique. After a 1 year follow-up, no patients pre-
sented VUR and the renal function was preserved in all cases.19
In 2013, Bondarenko reported 10 cases of POM who under-
went laparoscopic extravesical ureteral reimplantation and in-
tracorporeal plication of the ureter by using Starr technique. The
mean follow-up was 13.6 months, and the improvement of the
dilatation of the pelvicalyceal system and the ureters occurred
in all patients.20
Laparoscopic and robotic-assisted techniques by the
transvesical approach have been developed as an alternative
to open surgery, with promising outcomes. Nevertheless,
larger series and prospective randomized trials in pediatric
patients with long-term results are needed.17,27–30,32
The laparoscopic transperitoneal extravesical approach
provides a large operative space for reimplantation and does
not limit the manipulation of the bladder and ureter.20,24–26
The potential complication in open extravesical surgery
has been associated with voiding dysfunction in bilateral
cases, which can be up to 10%.31 However, Palmer published
data on 60 patients from 0.9 to 10.5 years-old (mean age 5.1
years-old), who underwent extravesical ureteral reimplanta-
tion by open surgery, including 36 bilateral procedures. None
of the patients presented voiding dysfunction.33 In our series,
these complications have not been found.
The most popular techniques used for tailoring megaure-
ters are either plication reported by Kalicinski and Starr,34,35
or tapering reported by Hendren.36 Kalicinski et al. described
a folding technique whereby the lateral avascular part of the
ureter was excluded from the lumen by a longitudinal run-
ning suture, and then folded posteriorly before reimplan-
tation.34 Starr modified this procedure, introducing many
interrupted sutures that folded the ureteral wall inwards.35
Hendren advised excisional tapering, whereby a longitudinal
strip of the redundant ureter is excised, and the ureter is su-
tured in two layers.36
In the laparoscopic approach, to reduce ureteral caliber,
some authors have adapted the classic tailoring techniques,
with results comparable to open surgery.17,18
Landa-Juarez et al. decribed a new method without ureteral
taloring for laparoscopic ureterovesical repair for megaureter
treatment, which consisted of incising the stenotic portion of
the ureter longitudinally and maintaining its posterior wall
attached to the bladder; the anterior wall of the ureter was
anastomosed transversally to the bladder mucosa to liberate
the obstruction.32
In our series, Hendren technique was used in 7 patients
with extracorporeal tapering and it is technically easier
than the intracorporeal technique; nevertheless, it is re-
commended to not perform ureteral stenting to avoid post-
operative leakage.36
Balloon dilatation by cystoscopy can be used as the first
line of treatment for the correction of POM. Nevertheless,
when endoscopic management of POM is performed, the
stenotic UVJ is bypassed with a guidewire, but sometimes
cannulation of the urethral meatus is very difficult. Farrugia
et al. reported 16 infants with 19 RU managed by stent in-
sertion at a median age of 24 weeks. Six stents were inserted
endoscopically and 13 (68.4%) were inserted by the open
procedure, after a failed cystoscopic attempt.37 Castagnetti
et al. needed open insertion of the stent in 5 of a total of 10
5
neonates and infants after failure of an attempt of endoscopic
insertion, in patients with POM treated only with the stent.38
In our initial series of 14 patients, a balloon dilatation by
cystoscopy was performed in all cases, as a first line of
treatment, with success only in 7 patients (50%). In the other
7 patients, it was impossible to pass the guidewire through
the UVJ; therefore, LUER and ureteral tapering repair was
performed. Thus, all our 7 patients benefited from the mini-
mal invasiveness.
VUR is one of the most frequent postoperative complica-
tions. Peters et al. published data on 47 infants <8 months-old
with POM. Forty-two patients of these underwent open sur-
gical correction. In a mean follow-up of 2.3 years, VUR was
seen in 8 patients (19%), with spontaneous resolution ob-
served in 3 of them. The 5 remaining patients were followed
and this resulted in redo reimplantation in 3 patients.21 The
presence of VUR after endoscopic balloon dilatation is
controversial, because a VCUG is not systematically per-
formed. Some authors just only perform VCUG in cases of
persistent dilatation or if a UTI occurs.13 Garcı́a-Aparicio
et al. reported 13 patients, 10 men and 3 women, with a mean
age of 7 months-old (4–24) treated by endoscopic balloon
dilation. Postoperative VUR was found in 2 patients (15.3%)
in a systematically postoperative VCUG at 6 months. One
patient with high-grade VUR was treated with open ureteral
reimplantation, and the other was treated conservatively. The
authors concluded that the presence of VUR after this pro-
cedure is greater than after open ureteral reimplantation.
Garcı́a-Aparicio et al. reported that 5 patients needed redo
balloon dilatation when the stent was removed because the
cystoscope was not able to pass the UVJ; therefore, in 8
patients (61%), the endoscopic balloon dilatation was suc-
cessful after the first attempt.15 In 2015, the same author
presented a total of 22 RU who underwent balloon dilation
to treat POM in 15 boys and 5 girls with a mean age of 14
months-old (3–103 months). After endoscopic treatment, 6
RU (27.7%) developed VUR. Four of the RU were managed
surgically and in the other two VUR disappeared in a second
VCUG.39 In our series, 1 patient (14.2%) presented a febrile
UTI at 3 months postoperatively and a unilateral VUR grade
III was diagnosed by VCUG. In this case, a redo laparo-
scopic extravesical ureteral reimplantation by following
Lich Gregoir technique was done with an uneventful course
in a long-term follow-up. For this patient, the parents were
informed about endoscopic and laparoscopic options, and
the decision was taken in conjunction with the surgical
team. In postoperative MAG3 renograms, the results
showed statistical differences before and after surgery (T½
59.10 minutes versus 13.57 minutes, P < .0001) and no ob-
structive pattern occurred.
In a comparison with historical series in open surgery by
the extravesical approach for megaureters, in 1994, McLorie
et al. reported that 23 children underwent extravesical
megaureter repair. Three of them had bilateral megaureters.
There were 14 obstructing and 12 refluxing ureters. Only 8 of
the 26 ureters were tapering.
For obstructive megaureters, a stent was placed, and drains
were placed whenever the ureter was dismembered or tapered
but not otherwise. A urethral catheter was left indwelling for
4 or 5 days. Regarding complications in this series, 4 children
had postoperative UTIs, 2 had stent-related complications,
including a dislodged stent and an encrusted stent. Transient
6 LOPEZ ET AL.
voiding difficulty was observed in 3 children and was man-
aged by clean intermittent catheterization (CIC). One of them
had a unilateral reimplant for high-grade reflux, and CIC was
employed for 1 week after catheter removal. The other 2
underwent bilateral reimplantations for reflux and continued
CIC for 1 and 4 months, respectively. Spontaneous voiding
was achieved in all 3 children.40
In our series, there were no major intraoperative compli-
cations. The mean hospital stay was 2.8 days. No urinary
leakage occurred in the early postoperative period. None of
the patients experienced postoperative voiding dysfunction.
Only 1 patient presented a VUR, and a redo laparoscopic
surgery was done with an uneventful course in a long-term
follow-up. The overall POM resolution of obstruction was
100%. After medium-term follow-up, all patients were asymp-
tomatic without recurrence of POM or VUR.
In conclusion, this study represents our initial experi-
ence of laparoscopic approach in POM, which shows that
laparoscopic-assisted extracorporeal ureteral tapering repair
and ureteral extravesical reimplantation by following Lich
Gregoir technique is a feasible and effective procedure, with
a success rate comparable to open surgery. We consider it a
safe and good option when the first line of treatment fails;
nevertheless, larger randomized prospective trials and long-
term follow-up are required to validate this technique.
Disclosure Statement
No conflict of interest or financial disclosure has been
declared by M.L., R.G., G.R., F.V., and M.A. Ethical stan-
dard: This study was done with anonymized patient data, and
therefore, ethics committee approval was not necessary.
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Address correspondence to:
Manuel Lopez, MD, PhD, HDR
Department of Paediatric Surgery and Urology
University Hospital of Vall d’Hebron
Barcelona 08035
Spain
E-mail: mlopez-paredes@hotmail.fr