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of Pages 6

EUROPEAN UROLOGY XXX (2016) XXX–XXX

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Surgery in Motion

Robot-assisted Laparoscopic Extravesical Ureteral

Reimplantation: Technique Modifications Contribute to
Optimized Outcomes

Mohan S. Gundeti *, William R. Boysen, Anup Shah

Section of Urology, University of Chicago Medicine Comer Children’s Hospital, Chicago, IL, USA

Article info Abstract

Article history: Background: Robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR-

Accepted February 26, 2016 EV) is being adopted at large pediatric urology centers in the United States, but currently
there is not consensus on surgical technique to facilitate the best possible outcomes.
Associate Editor: Objective: To describe technique modifications that may lead to improved radiographic
Alexandre Mottrie vesicoureteral reflux (VUR) resolution.
Design, setting, and participants: Between December 2008 and February 2015, a single
surgeon performed RALUR-EV at an academic medical center. Only children with
Keywords: persistent grade 3–5 VUR at age 5 yr on voiding cystourethrogram (VCUG), those
Vesicoureteral reflux who had breakthrough urinary tract infections, or those with renal scarring were
selected to undergo surgical correction of VUR with RALUR-EV. Children undergoing
Robotic surgery
RALUR-EV for obstructive megaureter or ureterovesical junction obstruction were
Reimplantation excluded. Fifty-eight patients (83 ureters) fit the inclusion criteria.
Extravesical Surgical procedure: We highlighted adjustments to our technique, called LUAA to
represent length of detrusor tunnel (L), use of a U stitch (U), placement of permanent
ureteral alignment suture (A), and inclusion of ureteral adventitia (A) in detrusorraphy.
Please visit Outcome measurements and statistical analysis: The primary end point was resolution
www.europeanurology.com and of VUR on postoperative VCUG.
www.urosource.com to view the Results and limitations: Because technique modifications were made at two distinct
time points, we generated three patient groups for comparison. We observed complete
accompanying video.
resolution of VUR in 82% of ureters, including 8 of 12 ureters (67%), 8 of 11 ureters (73%),
and 52 of 60 ureters (87%) for technique modification cohorts 1, 2, and 3, respectively.
There were no ureteral complications at median follow-up of 30 mo. Retrospective
design and possible confounding from the learning curve limit this study.
Conclusions: Using the standardized LUAA technique, we demonstrated an improve-
ment in outcomes. Given the wide range of published resolution rates following RALUR-
EV, there is a need for standardization of technique to facilitate best possible outcomes.
We propose the LUAA technique as a new standard for RALUR-EV to achieve this goal.
Patient summary: We examined the safety and efficacy of a minimally invasive surgery
in children. We identified several critical adjustments to surgical technique that improve
rates of successful outcome.
# 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.

* Corresponding author. Comer Children’s Hospital, University of Chicago Medicine, 5821 S. Mary-
land Avenue, P-217, MC 7122, Chicago, IL 60637, USA. Tel. +1 773 702 6150; Fax: +1 773 834 2666.
E-mail address: mgundeti@surgery.bsd.uchicago.edu (M.S. Gundeti).

http://dx.doi.org/10.1016/j.eururo.2016.02.065
0302-2838/# 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Please cite this article in press as: Gundeti MS, et al. Robot-assisted Laparoscopic Extravesical Ureteral Reimplantation: Technique
Modifications Contribute to Optimized Outcomes. Eur Urol (2016), http://dx.doi.org/10.1016/j.eururo.2016.02.065
EURURO-6708; No. of Pages 6

2 EUROPEAN UROLOGY XXX (2016) XXX–XXX

1. Introduction
The gold standard surgical intervention for vesicoureteral
reflux (VUR) is ureteral reimplantation, a procedure that
traditionally has been performed using an open approach.
In recent years, there has been rapid adoption of minimally
invasive techniques for the treatment of various congenital
urologic anomalies, especially with the use of robotic
assistance. With the transition to minimally invasive
approaches, urologists have adopted techniques that mimic
the standard open approach. Open extravesical reimplan-
tation has been well described in the literature since 1971
[1], further characterized by Lich and Gregoir in 1977 [2],
and popularized by Zaontz et al in 1987 with a reported
success rate of 93% [1,3]. The trend toward a minimally
invasive approach began in 2000, when Lakshmanan and
Fung first demonstrated the viability of the Lich-Gregoir
extravesical ureteral reimplantation technique with lapa-
roscopy [4]. In 2004, Peters [5] reported a series of robot-
assisted laparoscopic extravesical ureteral reimplantation
(RALUR-EV) with a success rate of 88%, and subsequent
published series of RALUR-EV have reported success rates
varying widely from 72% to 98% [6–13].
Clearly there has been a wide range of success rates since
the adoption of RALUR-EV in the past decade, and details of
the surgical technique have not been well described. We
believe that this variation in success rates may be related to
the technical learning curve as well as variation in
technique; therefore, there is a discipline wide need to
standardize the current RALUR-EV technique to maximize
surgical success. In this paper, we have reported modifica-
tions to our technique based on periodic review and critical
analysis of video recordings of the procedure and reported
an increased success rate in resolution of high-grade VUR
following technique modification.
2. Material and methods
Following institutional review board approval, we analyzed all RALUR-
EV procedures performed by a single surgeon (M.S.G.) at the University
of Chicago Medical Center between December 2008 and February
2015. We collected pertinent information on all cases including
indication for surgery, preoperative imaging, operative course, compli-
cations, and outcome. Videos were recorded for all surgeries prospec-
tively as quality control. Only children with high-grade VUR (grade 3–5)
on voiding cystourethrogram (VCUG) that failed to have spontaneous
resolution by age 5 yr, those who had breakthrough urinary tract
infections, or those with renal scarring on radionucleotide imaging were
selected to undergo surgical correction of VUR with RALUR-EV. Children
with dysfunctional elimination syndrome underwent elimination
training and counseling with a dedicated urology nurse practitioner
before undergoing surgery.
Our protocol for evaluation of VUR consists of preoperative VCUG,
ultrasound scan (USS), and DMSA (dimercaptosuccinic acid) scan as
required to determine the presence of renal scarring. A postoperative
VCUG is performed 4 mo following surgery, and USS is performed at
1 and 12 mo postoperatively. Only patients who underwent RALUR-EV
for VUR and had completion of preoperative and postoperative VCUG
were included in the analysis. A successful surgery was defined as no
reflux on postoperative VCUG. Patients undergoing surgery for
ureterovesical junction (UVJ) obstruction (n = 1), obstructed megaureter
(n = 4), and open conversions (n = 1) were excluded from this study. All
duplex ureters (n = 8) were counted as a single system. Patients with
complex anatomy including bladder diverticula (n = 1) and prior deflux
(n = 2) were included in the study.
Video recordings of individual surgical procedures were reviewed at
regular intervals during the study period to identify possible reasons for
success or failure of a particular procedure. After thorough video
analysis, we made interval modifications to our technique, as described
below.
In all study groups, we began the procedure by placing a urethral
catheter in the sterile field. An open Hassan technique is used for
transperitoneal placement of a 12-mm umbilical camera trocar, followed
by two 8-mm robotic trocars and a 5-mm assistant port placed under
direct vision (Fig. 1). The robot is docked between the legs. If cystoscopy
is clinically indicated, it is performed prior to docking of the robot,
although this is not our routine. We prefer to use 8-mm instruments:
precise bipolar in the left hand and monopolar scissor in the right hand
for the dissection and two needle drivers for the suturing. We find that
the 5-mm pediatric instruments are not well suited for use in a narrow
space like the pelvis, as these instruments have a longer distance from
the pulley mechanism to the organ being operated on, which decreases
the precision of movements. We prefer to use the 08 lens throughout the
procedure but will sometimes switch to the 308 up lens for
detrusorraphy if needed.
The ureter is identified at the pelvic brim, and the peritoneum
covering the ureter is incised. The ureter is then mobilized to the level of
the vas deferens or uterine artery, and umbilical tape is used for
atraumatic handling of the ureter (Fig. 2a and 2b). A peritoneal window
is created distal to the vas deferens or uterine artery, and the ureter is
then freed underneath, preserving these structures. The dissection is
kept close to the ureter to avoid injury to the presumed neurovascular
bundle located dorsomedially [14]. A Y dissection is performed at the
UVJ, taking care to ensure that the UVJ and detrusorotomy are in a
straight line. Next, 60 ml of sterile saline are instilled into the bladder,
and a transabdominal stay stitch is used to elevate the bladder and
improve visualization. Utmost precautions are taken to perform a
detrusorotomy that aligns with the UVJ to prevent angulation. The
detrusorotomy length is measured with premarked umbilical tape.
Several modifications to our detrusorotomy and detrusorraphy were
implemented throughout the time period of our study [15].
On review of intraoperative video recordings, technique modifica-
tions were made at two points during the study period in an effort to
improve success rates. Because modifications were made at two distinct
time points, we classified the patients into three groups accordingly. A
comparison of our operative and postoperative outcomes for the cohort
and the three groups was then performed.
Patients in group 1 underwent RALUR-EV with a detrusor tunnel
length of 3 cm and detrusorraphy performed with simple interrupted
Vicryl suture. The first modification to our technique consisted of
increasing the detrusor tunnel length to 4 cm and using a temporary
alignment suture at the apex to align the ureter within the tunnel
(group 2).
Fig. 1 – Patient positioning and port placement.

Please cite this article in press as: Gundeti MS, et al. Robot-assisted Laparoscopic Extravesical Ureteral Reimplantation: Technique
Modifications Contribute to Optimized Outcomes. Eur Urol (2016), http://dx.doi.org/10.1016/j.eururo.2016.02.065
EURURO-6708; No. of Pages 6
EUROPEAN UROLOGY XXX (2016) XXX–XXX
Fig. 2 – Ureteral dissection (a) in a female patient and (b) in a male patient.
Our current standardized technique for all patients undergoing
RALUR-EV (group 3) is to create a detrusorotomy of 4–5 cm, regardless of
preoperative VUR grade or patient age. Although there is no advance-
ment suture, the U stitch at the distal end of the detrusorotomy is placed
in such a manner to advance the ureter by taking the detrusor at
5 o’clock, followed by ureteral adventitia, and then detrusor at 7 o’clock
(Fig. 3). A permanent stay stitch (5-0 PDS) is placed at the apex of the
detrusorotomy through the ureteral adventitia to align the ureter within
the tunnel and to prevent slippage after the surgery is completed. The
detrusorraphy is performed using a running stitch that starts at the distal
aspect of the detrusorotomy and incorporates the ureteral adventitia in
every other throw (Fig. 4). Care is taken that the tunnel is not too tight.
This is confirmed by placing one prong of the needle holder in the tunnel
at the apex after completion of detrusorraphy. We named this technique
LUAA, stressing the length of the submucosal detrusor tunnel (L), use of a
U stitch (U), a permanent apical stay stitch (A), and incorporation of the
ureteral adventitia (A) during detrusorraphy. The completed detrusor-
raphy is demonstrated in Supplementary Figure 1.
At the end of the procedure, the fascia is closed at each port site,
including the 5-mm assistant port. We adopted this practice after
encountering omental hernias that occurred in our pediatric population
following traditional laparoscopic procedures.
Following surgery, we observe most patients in the hospital for one
night (unilateral reimplantation) or two nights (bilateral reimplanta-
tion). Prior to discharge, the catheter is removed and a bladder scan is
performed to ensure adequate bladder emptying.
3. Results
Between December 2008 and February 2015, a single
surgeon (M.S.G.) performed RALUR-EV on a total of
71 patients. One patient was excluded because of conver-
sion to open reimplantation following a vascular injury.
Four were excluded because the indication for surgery was
Please cite this article in press as: Gundeti MS, et al. Robot-assisted Laparoscopic Extravesical Ureteral Reimplantation: Technique
Modifications Contribute to Optimized Outcomes. Eur Urol (2016), http://dx.doi.org/10.1016/j.eururo.2016.02.065
3
obstructing megaureter, and one was excluded because the
indication was UVJ obstruction. Seven did not have follow
up VUCG and were excluded. Fifty-eight patients
(83 ureters) with VUR met the inclusion criteria. An
associated duplex kidney was found with eight ureters.
All duplicated systems were treated with common sheath
reimplantation and thus were considered to be a single
reimplanted ureter in our analysis. Two patients had
previously failed bulking agent injection prior to RALUR-
EV. Mean age at the time of surgery was 5.3 yr (standard
deviation 2.2 yr). Table 1 presents patient demographics.
There was no statistical difference between the three
groups with respect to age and preoperative VUR grade
(one-way analysis of variance, p > 0.05), but there was a
trend toward higher mean grade VUR in group 3.
Preoperatively, 33 ureters had grade 3 reflux, 31 had
grade 4 reflux, and 7 ureters had grade 5 reflux. Ureters with
grade 1–2 VUR were reimplanted only in patients with
contralateral high-grade reflux. Two ureters had grade
1 reflux, and 10 had grade 2 reflux. Ureters without reflux
were not reimplanted, even if high-grade VUR was present
in the contralateral ureter. The mean length of stay was
2.0 d (range: 1–6 d). Median follow-up time was 30 mo
(range: 4–69 mo).
There were no ureteral complications defined as urine
leak, ureteral stenosis, or need for immediate redo
operation. A small number of patients had hospitalization
stays longer than typically anticipated due to hematuria
(n = 3), poor oral intake (n = 2), or decreased urine output
(n = 1). We routinely performed bladder scans following
removal of the urethral catheter to ensure adequate bladder
emptying. We had a single episode of transient urinary
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4 EUROPEAN UROLOGY XXX (2016) XXX–XXX

Fig. 3 – Highlighting the Length of detrusor tunnel, placement of U Fig. 4 – Placement of running detrusorraphy suture, with inclusion of
stitch, and use of Apical alignment suture. the ureteral Adventitia.

Table 1 – Patient demographics by group 4. Discussion

Group 1 Group 2 Group 3 Overall
cohort In the majority of published series on RALUR-EV (summa-
rized in Table 2), reflux resolution rates have been
No. of patients 8 6 44 58
Age, yr, mean (SD) 5.8 (1.2) 5.4 (1.5) 5.3 (2.5) 5.3 (2.2)
increasing over time [9,12]. Improved success rates are
Sex, n often credited to increased surgeon experience without
Male 1 1 11 13 (22.4%) documentation of specific improvement in technique. To
Female 7 5 33 45 (77.6%)
optimize success of RALUR-EV, it is necessary to carefully
VUR laterality, n
Right 0 1 10 11
detail the modifications that result in improved surgical
Left 4 0 18 22 outcomes. Our current technique demonstrates a RALUR-
Bilateral 4 5 16 25 EV success rate of 87% for a population of children with
Total ureters 12 11 60 83
predominantly high-grade VUR. This value is within a wide
Preoperative VUR grade, n
1 0 0 2 2 range of reported outcomes, from 72% to 97%.
2 4 1 5 10 Case selection may account for the variation in success
3 3 7 23 33 rates across all reported series, as one would expect better
4 5 3 23 31
rates of resolution among patients with lower grade
5 0 0 7 7
Mean (SD) 3.1 (0.9) 3.2 (0.6) 3.5 (0.9) 3.4 (0.9) preoperative VUR. Our study is specifically focused on
Prior bulking agent, n 0 0 2 2 ureters with high-grade reflux, with 84% of the ureters in
Duplex system, n 0 1 7 8 our study having reflux grade 3. We also limit our practice
Radiographic resolution 67 73 87 82
of bilateral reimplantation to patients with demonstrated
rate (%)
bilateral reflux on VCUG, whereas some surgeons will
VUR = vesicoureteral reflux.
perform bilateral reimplantation for all children, even if the
contralateral ureter does not reflux [7]. One would expect
higher rates of postoperative VCUG showing no VUR among
retention in our 58 patients, or a 1.7% retention rate, which this patient population.
is comparable to other series (Table 2). This may be the Our surgical technique was developed though analysis of
result of decreased trauma to the neurovascular bundle prospectively recorded intraoperative video recordings to
[11,16]. identify areas needing technical improvement. During the
The resolution rate of VUR on postoperative VCUG was study period, we noted two early time points that had high
82% (68 of 83 ureters) for the entire cohort. Evaluating initial failure rates, prompting us to modify our technique.
surgical success based on technique, the resolution of VUR Because several concurrent modifications were made, it is
was 67% (8 of 12 ureters), 73% (8 of 11 ureters), and 87% difficult to determine a single maneuver that is responsible
(52 of 60 ureters) for groups 1, 2, and 3, respectively. A for increased success rates. Nevertheless, several theoretical
Fisher exact test of a 2  2 contingency table between the and intuitive modifications made in our study may have
combined outcomes of groups 1 and 2 versus group accounted for improved outcomes.
3 demonstrated a p value of 0.108. A summary of First, we increased the submucosal tunnel length to
preoperative VUR grades can be found in Table 1. Outcomes approximately 5 cm, which may account for improved
are summarized in Supplementary Figure 2. success by creating a more robust flap-valve mechanism.

Please cite this article in press as: Gundeti MS, et al. Robot-assisted Laparoscopic Extravesical Ureteral Reimplantation: Technique
Modifications Contribute to Optimized Outcomes. Eur Urol (2016), http://dx.doi.org/10.1016/j.eururo.2016.02.065
EURURO-6708; No. of Pages 6

EUROPEAN UROLOGY XXX (2016) XXX–XXX 5

Table 2 – Summary of published literature on robot-assisted laparoscopic extravesical ureteral reimplantation

Study (date) Number VUR grade, Reflux resolution Postoperative Complication, % Technique
of ureters mean rate, % VCUG, % described
Retention Other

Peters (2004) [5] 27 2.8 89 None 0.0 12.5 Partial

Casale et al (2008) [11] 41 2.1 98 All 0.0 0.0 Partial
Smith et al (2011) [9] 31 3.5 97 92 12.0 0.0 Partial
Marchini et al (2011) [19] 30 NR 100 All 10.0 10.0 None
Lendvay (2008) [7] 16 NR 81 All 0.0 12.5 None
Akhavan et al (2014) [12] 78 3 92 All 2.0 10.0 –
Chalmers et al (2012) [8] 22 2.8 91 All 0.0 0.0 None
Gargollo et al (multicenter, 2015) [13] 98 NR 77 All NR 10.0 Partial
Gundeti et al (2016) 83 3.4 82* All 1.7 0.0 Yes

NR = not reported; VCUG = voiding cystourethrogram.

*
For overall cohort; following LUAA modification, resolution rate was 87%.

The optimal length of the detrusor tunnel for successful
outcomes is unknown, although the classic goal in open
reimplantation is to achieve a 5:1 ratio of tunnel length to
ureteral diameter [17]. We feel that this measurement
cannot be estimated reliably in a patient with VUR because
the ureter is a dynamic and hollow structure that does not
have a fixed diameter. Instead, we have adopted the practice
of a standardized 5-cm detrusor tunnel length to optimize
outcomes in all patients. Measurement of tunnel length can
be challenging, but distending the bladder with a fixed
amount of saline (60 ml) and using premeasured umbilical
tape helps obtain the desired tunnel length.
The use of a U stitch at the UVJ mimics the advancement
stitch first described by Zaontz et al and serves to decrease
ureteral slippage [3]. This maneuver is important because
the advancement stitch was previously shown to increase
success rates from 80% to 100% in one series [18].
Placement of an alignment stitch at the apex of the
detrusor tunnel also decreases ureteral slippage. This is
based on the principle of the psoas hitch, although in this
procedure, the alignment suture is to the detrusor itself.
There is a theoretical increased risk of ureteral kinking that
we have not yet encountered.
Finally, incorporation of the adventitia into the align-
ment stitch may also reduce the possibility of ureteral
slippage for large dilated ureters with a tight detrusor
tunnel.
There are limitations to our study design that prevent us
from definitively concluding that our technique modifica-
tions are the sole reason for improved outcomes. Self-
evaluation and video review were performed as needed
when we thought outcomes were not optimal, and that led
to the creation of study groups of disparate sizes. Although
the groups did not differ with respect to patient age or
preoperative grade of VUR, the small sizes of groups 1 and
2 may account for the fact that we did not detect a
statistically significant difference in success rate despite the
trend from 67% to 87%. A randomized controlled trial
assessing various techniques would be the gold standard for
identifying the best possible technique, but there are
practical challenges to such a study, particularly in a
pediatric population.
There is a known learning curve to any newly adopted
procedure, and one could argue that our improved out-
comes are simply a reflection of this phenomenon.
However, the senior author (M.S.G.) had significant
pediatric robotic experience in upper urinary tract and
other lower tract procedures prior to preforming this
procedure and had already developed proficiency with
robotic surgery. Although the learning curve may factor into
the improved outcomes we observed, we think that the
technique modifications are the more likely reason for
improvement.
Similar to other RALUR-EV series, our study is limited
by a relatively small patient population [8–10,12,19]. Fur-
thermore, it represents an individual, single-surgeon
experience. Nevertheless, our study is the first to describe
specific modifications in technique that could directly
account for improved success. This technique should
serve as a guide for surgeons first attempting RALUR-EV
and also can provide parameters for future series that
look to improve on resolution rates of VUR. The reason we
wish to provide a guide is because RALUR-EV is a complex
procedure with risk of significant complications. Diligent
surgical technique and experience with other robotic
procedures (eg, pyeloplasty) are important before
embarking on this technically challenging procedure in
an area with limited working space. A great deal of work
remains to create consensus on technique to facilitate
education for a safe and effective application of this
procedure, but we propose our LUAA technique as a new
standard.
5. Conclusions
In our experience, we observed considerable improvements
in outcomes from RALUR-EV over time and with the
evolution of the LUAA technique. Although we cannot
definitively conclude that these modifications in technique
are the cause of improved success rates without a
randomized control trial, such a study is impractical. The
success rate of RALUR-EV continues to be variable in the
hands of different surgeons, and we hope to facilitate overall
improvement in success rates by proposing a new standard

Please cite this article in press as: Gundeti MS, et al. Robot-assisted Laparoscopic Extravesical Ureteral Reimplantation: Technique
Modifications Contribute to Optimized Outcomes. Eur Urol (2016), http://dx.doi.org/10.1016/j.eururo.2016.02.065
EURURO-6708; No. of Pages 6
6 EUROPEAN UROLOGY XXX (2016) XXX–XXX
technique to serve as a guide for any surgeon seeking to
improve outcomes from this procedure.
Author contributions: Mohan S. Gundeti had full access to all the data in
the study and takes responsibility for the integrity of the data and the
accuracy of the data analysis.
Study concept and design: Gundeti, Shah.
Acquisition of data: Boysen, Shah.
Analysis and interpretation of data: Boysen, Shah.
Drafting of the manuscript: Gundeti, Boysen, Shah.
Critical revision of the manuscript for important intellectual content:
Gundeti, Boysen, Shah.
Statistical analysis: Shah.
Obtaining funding: None.
Administrative, technical, or material support: Gundeti, Boysen, Shah.
Supervision: Gundeti.
Other (specify): None.
Financial disclosures: Mohan S. Gundeti certifies that all conflicts of
interest, including specific financial interests and relationships and
affiliations relevant to the subject matter or materials discussed in the
manuscript (eg, employment/affiliation, grants or funding, consultan-
cies, honoraria, stock ownership or options, expert testimony, royalties,
or patents filed, received, or pending), are the following: None.
Funding/Support and role of the sponsor: None.
Appendix A. Supplementary data
The Surgery in Motion video accompanying this article
can be found in the online version at http://dx.doi.org/10.
1016/j.eururo.2016.02.065 and via www.europeanurology.
com.
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