Single-port plus one in pediatric robotic-assisted Lich-Gregoir ureteral reimplantation for vesicoureteral reflux, a comparative analysis with short-term outcomes.

OBJECTIVE: To observe the safety and short-term outcomes of a new way of laparoscopic trocar placement in pediatric robotic-assisted Lich-Gregoir ureteral reimplantation for vesicoureteral reflux. METHODS: The retrospective study included 32 patients under 14 years diagnosed with primary vesicoureteral reflux (VUR). All these patients underwent robotic-assisted Lich-Gregoir ureteral reimplantation in our department from December 2020 to August 2022. These patients were divided into the following groups according to the different ways of trocar placement: 13 patients in group single-port plus one (SR) and 19 patients in group multiple-port (MR). Patients' characteristics as well as their perioperative and follow-up data were collected and evaluated. RESULTS: There was no significant difference in the data regarding patients' characteristics and preoperative data. These data included the grade of vesicoureteral reflux according to the voiding cystourethrogram (VCUG), and the differential degree of renal function (DRF) at the following time points: preoperative, postoperative, and comparison of preoperative and postoperative. There was no difference between the two groups. During surgery, the time of artificial pneumoperitoneum establishment, ureteral reimplantation time, and total operative time in the SR group were longer than those in the MR group. Yet only the time of artificial pneumoperitoneum establishment shows a statistical difference (P < 0.0001). Also, the peri-operative data, including the volume of blood loss, fasting time, hospitalization, and length of time that a ureteral catheter remained in place, and the number of postoperative complications demonstrate no difference. In addition, the SFU grade and VCUG grade at the following time point also show no difference between the two groups. CONCLUSION: The study demonstrates that SR in robotic-assisted Lich-Gregoir ureteral reimplantation has reached the same surgical effects as MR. In addition, the single-port plus one trocar placement receives a higher cosmetic satisfaction score from parents and did not increase the surgical time and complexity.

Clinical efficacy of laparoscopic Lich-Gregoir versus transvesicoscopic Cohen reimplantation for ureterobladder junction malformations in children.

OBJECTIVE: To assess the clinical efficacy of laparoscopic Lich-Gregoir (LLG) and transvesicoscopic Cohen reimplantation (TCR) in the treatment of vesicoureteral junction obstruction (VUJO) and vesicoureteral reflux (VUR). METHODS: This study retrospectively analyzed the clinical data of 66 pediatric patients with VUJO and VUR. They were classified into two groups, undergoing either the laparoscopic Lich-Gregoir operation (LLGO) (n = 35) or transvesicoscopic Cohen reimplantation operation (TCRO) (n = 31). The surgeries were performed between April 2018 and September 2022 at the First Affiliated Hospital of Guangxi Medical University, China. General characteristics, preoperative attributes, postoperative complications, renal function recovery, and improvement of hydronephrosis were compared between the two groups. RESULTS: All surgical procedures were successful with no requirement for reoperation. Both groups were comparable with respect to gender, affected side, weight, and postoperative complications. Nonetheless, the LLGO group contained a greater number of children younger than 12 months. The LLGO group demonstrated superiority over the TCRO group regarding the duration of the operation, intraoperative blood loss, and length of postoperative hospital stay. In contrast, postoperative complications, recovery of renal function, and hydronephrosis improvement did not exhibit statistically significant differences between the two groups. CONCLUSION: Both LLGO and TCRO were demonstrated to be precise, safe, and reliable surgical methods for treating pediatric VUJO and VUR. LLGO ureteral reimplantation offers particular advantages in selecting cases and appears more suitable for children younger than 12 months who have a small bladder capacity.

Robotic-assisted vs. open ureteral reimplantation: a multicentre comparison.

PURPOSE: Open ureteral reimplantation is considered the standard surgical approach to treat distal ureteral strictures or injuries. These procedures are increasingly performed in a minimally invasive and robotic-assisted manner. Notably, no series comparing perioperative outcomes and safety of the open vs. robotic approach are available so far. METHODS: In this retrospective multi-center study, we compared data from 51 robotic ureteral reimplantations (RUR) with 79 open ureteral reimplantations (OUR). Both cohorts were comparatively assessed using different baseline characteristics and perioperative outcomes. Moreover, a multivariate logistic regression for independent predictors was performed. RESULTS: Surgery time, length of hospital stay and dwell time of bladder catheter were shorter in the robotic cohort, whereas estimated blood loss, postoperative blood transfusion rate and postoperative complications were lower than in the open cohort. In the multivariate linear regression analysis, robotic approach was an independent predictor for a shorter operation time (coefficient - 0.254, 95% confidence interval [CI] - 0.342 to - 0.166; p < 0.001), a lower estimated blood loss (coefficient - 0.390, 95% CI - 0.549 to - 0.231, p < 0.001) and a shorter length of hospital stay (coefficient - 0.455, 95% CI - 0.552 to - 0.358, p < 0.001). Moreover, robotic surgery was an independent predictor for a shorter dwell time of bladder catheter (coefficient - 0.210, 95% CI - 0.278 to - 0.142, p < 0.001). CONCLUSION: RUR represents a safe alternative to OUR, with a shorter operative time, decreased blood loss and length of hospital stay. Prospective research are needed to further define the extent of the advantages of the robotic approach over open surgery.

Ureteral reimplantation for the management of pelvic lipomatosis.

Introduction: Pelvic lipomatosis is a rare benign disease characterized by urethral elongation, bladder deformity, and/or hydronephrosis. Conservative management is not effective, and urinary diversion is the most effective treatment option but is usually unacceptable for relatively young patients. Ureteral reimplantation seemed to be an appropriate modality under these conditions. We present one case in which pelvic lipomatosis was managed with ureteral reimplantation. Patient presentation: A 45-year-old, previously healthy man presented with right flank pain. Pelvic CT and CT urography showed excessive pelvic fat, bilateral hydronephrosis, tortuous ureters, and a pear-shaped bladder, all of which indicated a diagnosis of pelvic lipomatosis. We performed laparoscopic bilateral urinary tract infection on this patient. At follow-up, bilateral hydronephrosis and flank pain were greatly relieved. Conclusion: Pelvic lipomatosis can be managed safely and effectively by urinary tract infection, but longer follow-up periods are needed to evaluate the long-term efficacy of this approach.

[Palliative surgery for metastatic prostate cancer]. / Palliative Chirurgie des metastasierten Prostatakarzinoms.

Androgen deprivation in combination with novel hormonal agents, docetaxel, or in combination with abiraterone/prednisone plus docetaxel or darolutamid plus docetaxel represent the standard therapeutic approach in metastatic hormone-sensitive prostate cancer (mHSPC). Patients with low-risk prostate cancer also benefit from additional radiation therapy or radical prostatectomy in terms of progression-free and overall survival. Despite favorable response rates, basically all patients will develop castration resistant prostate cancer (CRPC) within 2.5 to 4 years. In addition to systemic chemotherapy, second-line hormonal treatment of systemic application of radionuclides such as radium223 or 177Lu-PSMA represent salvage management options. However, nowadays about 50-65% of patients will develop symptoms due to local progression of prostate cancer which is the result of improved oncological outcomes with significantly prolonged survival times due to the new medical treatment options. Management of such symptomatic local progression will become more important in upcoming years so that all uro-oncologists need to be aware of the various surgical management options. Complications of the lower urogenital tract such as recurrent gross hematuria ± bladder clotting and with the necessity for red blood cell transfusions, subvesical obstruction and acute urinary retention, rectourethral or rectovesical fistulas might be managed by palliative surgery such as palliative transurethral resection of the prostate (TURP), radical cystectomy, radical cystoprostatectomy with urinary diversion, and pelvic exenteration. Symptomatic or asymptomatic obstruction of the upper urinary tract might be managed by endoluminal or percutaneous urinary diversion, ureteral reimplantation, ileal ureter replacement, or implantation of the Detour® system (Coloplast GmbH, Hamburg, Germany).

Update and Summary of the European Association of Urology/European Society of Paediatric Urology Paediatric Guidelines on Vesicoureteral Reflux in Children.

BACKGROUND AND OBJECTIVE: The prescriptive literature on vesicoureteral reflux (VUR) is still limited and thus the level of evidence is generally low. The aim of these guidelines is to provide a practical approach to the treatment of VUR that is based on risk analysis and selective indications for both diagnostic tests and interventions. We provide a 2023 update on the chapter on VUR in children from the European Association of Urology (EAU) and European Society for Paediatric Urology (ESPU) guidelines. METHODS: A structured literature review was performed for all relevant publications published from the last update up to March 2022. KEY FINDINGS AND LIMITATIONS: The most important updates are as follows. Bladder and bowel dysfunction (BBD) is common in toilet-trained children presenting with urinary tract infection (UTI) with or without primary VUR and increases the risk of febrile UTI and focal uptake defects on a radionuclide scan. Continuous antibiotic prophylaxis (CAP) may not be required in every VUR patient. Although the literature does not provide any reliable information on CAP duration in VUR patients, a practical approach would be to consider CAP until there is no further BBD. Recommendations for children with febrile UTI and high-grade VUR include initial medical treatment, with surgical care reserved for CAP noncompliance, breakthrough febrile UTIs despite CAP, and symptomatic VUR that persists during long-term follow-up. Comparison of laparoscopic extravesical versus transvesicoscopic ureteral reimplantation demonstrated that both are good option in terms of resolution and complication rates. Extravesical surgery is the most common approach used for robotic reimplantation, with a wide range of variations and success rates. CONCLUSIONS AND CLINICAL IMPLICATIONS: This summary of the updated 2023 EAU/ESPU guidelines provides practical considerations for the management and diagnostic evaluation of VUR in children. ADVANCING PRACTICE: For children with VUR, it is important to treat BBD if present. A practical approach regarding the duration of CAP is to consider administration until BBD resolution. PATIENT SUMMARY: We provide a summary and update of guidelines on the diagnosis and management of urinary reflux (where urine flows back up through the urinary tract) in children. Treatment of bladder and bowel dysfunction is critical, as this is common in toilet-trained children presenting with urinary tract infection.

Ureteral obstruction following transurethral resection of bladder cancer within the Hutch's diverticulum.

Here, we report a rare case of bladder cancer within the left congenital periureteral diverticulum, termed the Hutch's diverticulum. Following transurethral resection of the bladder tumor, repeated pyelonephritis was caused by stricture of the diverticulum orifice and ureter. We attempted transurethral dilation and ureteral stenting, but the obstruction did not improve. The patient's renal dysfunction showed gradual progression due to recurrent left pyelonephritis as well as the ureteral obstruction. Therefore, we finally performed a partial cystectomy, involving stricture and ureteral reimplantation. No tumor recurrence was observed over 39 months, and renal dysfunction did not progress following partial cystectomy.

Treating Multifocal Ureteral Strictures with Combined Techniques: 14 Cases of Initial Experience.

Purpose: To evaluate the safety and feasibility of lingual mucosal graft ureteroplasty (LMGU) combined with ureteral reimplantation (UR) for repairing managing multifocal ureteral strictures (MUS). Methods: Between December 2020 and December 2022, 14 patients underwent LMGU combined with UR. Their perioperative data were collected retrospectively and analyzed. For the proximal diseased ureter, the narrow segment was incised longitudinally to open the ventral wall of ureter, and a lingual mucosal graft was placed as an onlay graft. Meanwhile, UR was applied to treat distal ureteral strictures. Results: Of 14 patients, three (21.4%) had previously undergone a failed ureteral reconstruction. The mean (standard deviation [SD]) proximal stricture length was 4.0 cm (1.56), and distal ureteral stricture length was 4.3 cm (0.94). The mean (SD) operative time was 236 minutes (57), the estimated blood loss was 78 mL (41.5), and the length of postoperative stay was 6 days. One (7%) patient underwent double LMGU to treat proximal 2 segments of ureteral stricture. No open conversions and intraoperative complications occurred. With a mean follow-up of 15 months (range 6-29), the recurrence-free rate was 14/14 (100%). Conclusions: LMGU combined with UR is a feasible and effective technique for managing MUS and can be an alternative to ileal ureteral replacement or renal autotransplantation in some selected patients with MUS.

A multi-institutional European comparative study of open versus robotic-assisted laparoscopic ureteral reimplantation in children with high grade (IV-V) vesicoureteral reflux.

INTRODUCTION: Traditionally, open ureteral reimplantation (OUR) has been the standard treatment for primary vesicoureteral reflux (VUR) requiring reimplantation. Robotic-assisted laparoscopic ureteral reimplantation (RALUR) is gaining popularity and high success rates have been reported. OBJECTIVE: In this multi-institutional study, we aimed to compare the perioperative and postoperative outcomes of OUR and RALUR for high-grade (IV + V) VUR in children. STUDY DESIGN: A retrospective evaluation was performed collecting data from 135 children (0-18 years) who underwent high grade VUR surgical correction at nine European institutions between 01/01/2009 and 01/12/2020, involving either open or robotic approaches. Institutional review board approval was obtained. Patients with lower grades of VUR (≤III), previous history of open or endoscopic ureteral surgery, neurogenic bladder, or refluxing megaureter in need of ureteral tapering were excluded. Pre-, peri- and post-operative data were statistically compared. RESULTS: Overall, 135 children who underwent either OUR (n = 68), or RALUR (n = 67) were included, and their clinic and demographic features were collected. The mean age of the open group was 11 months (interquartile range [IQR] 9.9-16.6 months), in the RALUR group it was 59 months (IQR 29-78mo) (p < 0.01); the open cohort had a weight of 11 kg (IQR 9.9-16.6 kg) while the RALUR group had 19 kg (IQR 13-25 kg) (p < 0.01). No significant differences were found for intraoperative (1.5 % vs 7.5 %, p = 0.09) or for postoperative complication rates (7.4 % vs 9 %, p = 0.15). Favorable outcomes were reported in the RALUR group: shorter time to stooling (1 vs 2 days), fewer indwelling urethral catheter days (1 vs 5 days), perioperative drain insertion time (1 vs 5 days) and a shorter length of hospital stay (2 vs 5 days) (p < 0.01). The success rate was 94.0 % and 98.5 % in the open and RALUR groups, respectively. The long-term clinical success rates from both groups was comparable:42 vs 23 months for open and RALUR, respectively. DISCUSSION: This study reported a large multicentric experience focusing on high grade VUR. Furthermore, this study compares favorably to OUR in a safety analysis. There was also a trend towards higher success rates with RALUR utilizing an extravesical approach which has not been previously reported. CONCLUSION: RALUR is an efficacious and safe platform to use during ureteral reimplantation for high grade VUR. The overall peri-operative and post-operative complication rates are at least equivalent to OUR, but it is associated with a faster functional recovery and time to discharge. Medium to long term success rates are also equivalent to OUR.

Robotic-assisted appendiceal onlay flap ureteroplasty combined with ureteral reimplantation for multifocal ureteral strictures: Case report and technical description.

BACKGROUND: To describe the surgical technique of robotic-assisted appendiceal onlay flap ureteroplasty combined with ureteral reimplantation to repair unilateral multifocal ureteral strictures in one stage and report 9-month follow-up outcomes. METHOD: A longitudinal ventral incision of proximal ureter strictures No. 1 and 2 was performed, and the appendix was detubularised along its antimesenteric border. Then, the appendiceal onlay flap was anastomosed with the spatulated ureter in an onlay fashion. To manage the distal ureteral stricture No. 3, ureteral reimplantation was performed in a tension-free manner. RESULTS: Voiding cystourethrography and antegrade urography showed urine regurgitation into the ureter without dilation and no obstruction of the reconstructed ureteral segment 7 weeks after surgery. No postoperative complications occurred during the 9-month follow-up. CONCLUSIONS: Robotic-assisted appendiceal onlay flap ureteroplasty combined with ureteral reimplantation appears to be a safe and effective surgical method for repairing the unilateral multifocal ureteral strictures.

The LUAA Gundeti Technique for Bilateral Robotic Ureteral Reimplantation: Lessons Learned over a Decade for Optimal (Resolution, Urinary Retention, and Perioperative Complications) Trifecta Outcomes.

Background: Ureteral reimplantation is the gold standard treatment for high-grade vesicoureteral reflux (VUR) in pediatric patients. Robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR-EV) using the LUAA technique has emerged as a viable alternative to traditional open and laparoscopic surgical correction. Objective: To evaluate the outcomes, reflux resolution, urinary retention, and complications associated with bilateral RALUR-EV for primary VUR using the LUAA Gundeti technique in pediatric patients. Design setting and participants: A retrospective study was conducted at a single academic center, involving 34 consecutive pediatric patients who underwent RALUR-EV for bilateral VUR management between December 2008 and December 2022. The study included only patients who were evaluated with postoperative voiding cystourethrogram (VCUG). Surgical procedure: The LUAA extravesical ureteral reimplantation technique was performed, involving the identification and mobilization of the ureter, creation of a peritoneal window, dissection close to the neurovascular bundle, Y dissection at the ureterovesical junction, detrusorotomy, detrusorrhaphy with advential inclusion, and apical alignment suture. Measurements: The primary outcome was radiographic resolution of VUR on VCUG. The secondary outcomes included urinary retention and Clavien-Dindo grade III complications. Results and limitations: The overall radiographic resolution rate was 85.2%, with success rates of 76.7%, 75%, and 96.7% across the three distinct patient cohorts. The overall Clavien-Dindo grade III complication rate was 5.8%, and transient urinary retention was 8.8%. Resolution of urinary retention occurred within 7-28 d. The study's limitations include the small sample size, single-center design, and retrospective nature. Conclusions: The LUAA technique demonstrates sustainable outcomes for VUR resolution with a low incidence of transient urinary retention and complications. A thorough understanding of pelvic anatomy is essential for successful dissection and minimization of the risk of complications. Further studies are needed to evaluate the effectiveness of different approaches in reducing the incidence of transient urinary retention following bilateral extravesical reimplantation. Patient summary: In this study, we examined the results of the Gundeti LUAA surgical technique for treating primary vesicoureteral reflux in children. We identified various essential modifications that increase the likelihood of achieving favorable outcomes.

Vesicoscopic vs. Open Ureteral Reimplantation According to Cohen and Leadbetter-Politano for Vesicoureteral Reflux.

BACKGROUND: The minimally invasive implementations of the established open methods for the correction of primary vesicoureteral reflux have proven to be successful in terms of feasibility and safety. The aim of this study was to investigate to what extent pediatric patients benefit from vesicoscopic operations. METHODS: Between 2010 and 2022, 224 children (359 ureters) underwent ureteral reimplantation for vesicoureteral reflux in our clinic. Children, operated on according to the COHEN technique, underwent an open approach in 39 cases, whereas 151 patients were operated on vesicoscopically. A total of thirty-four children have received a ureteral reimplantation according to the LEADBETTER-POLITANO technique: twenty-nine openly and five vesicoscopically. The open and vesicoscopic groups were compared with regards to perioperative data and postoperative course. RESULTS: The mean operating time was significantly shorter for open than for the vesicoscopic procedures in the COHEN group (99 vs. 149 min, p < 0.001). Similarly, a comparison of ureteral reimplantations, according to LEADBETTER-POLITANO, favored the open procedure, although this was not significant (161 vs. 196 min, p = 0.135). There was no significant difference in the recurrence rate of all the groups. All procedures remained within the accepted range with a success rate of at least 96%. In the postoperative course, a significantly shorter hospital stay (4.1 vs. 7.9 days, p < 0.001 for COHEN-patients; 5.6 vs. 9.2 days for LEADBETTER-POLITANO-patients), as well as a significantly lower need for continuous analgesic administration, was observed for the vesicoscopic approaches of both methods (0.8 days in both vesicoscopic groups vs. 3.7 resp. 3.8 days in open groups, p < 0.001). In addition, the time of bladder drainage was significantly shorter in open techniques (7.2 vs. 1.9 days, p < 0.001 for COHEN-patients; 3 vs. 8.7 days for LEADBETTER-POLITANO-patients). CONCLUSIONS: For almost all underlying causes, the surgical treatment of vesicoureteral reflux can be performed vesicoscopically, even if bilateral, in one session. Patients benefit significantly from the use of minimally invasive surgery in the postoperative course with faster mobilization, less need for analgesics, a shorter bladder drainage and a reduced hospital stay, compared with its open counterparts.

Vesicoureteral reflux severity is not associated with unplanned urinary catheterization or length of hospital stay after ureteroneocystostomy.

INTRODUCTION: Vesicoureteral reflux (VUR) is a common urologic condition affecting approximately 1% of all children. Surgical success often depends on the grade of VUR, as patients with grades 4 or 5 have been have a greater risk for postoperative complications. Unplanned urinary catheter placement (UCP) postoperatively and prolonged length of hospital stay (LOS) are indicative of unexpected complications. The association between VUR severity and such metrics remain unclear. OBJECTIVE: The study's objective is to determine if the severity of VUR is associated with higher rates of UCP or prolonged LOS after ureteroneocystostomy (UNC). STUDY DESIGN: The 2020 National Surgical Quality Improvement Program Pediatric database was analyzed for patients with VUR. A total of 1742 patients were initially evaluated with 1373 meeting exclusion criteria. The patients were divided into 3 groups of varying voiding cystourethrogram (VCUG) or radionuclide cystogram (RNC) severity: VCUG Grade 1 or RNC Grade 1 (Group A), VCUG Grade 2 or 3 or RNC Grade 2 (Group B), and VCUG Grade 4 or 5 or RNC Grade 3 (Group C). Basic statistical analysis was performed, and logistic regression was performed with both UCP and LOS as dependent variables. RESULTS: Among the 1373 patients, 2.9% were included in Group A, 32.5% were in Group B, and 64.6% were in Group C. Significant differences were found among the groups for mean age, gender, inpatient status, rate of congenital malformation, ureteral stents, and ASA classification. Regarding surgical treatment, differences were also found comparing mean operative time, LOS, laterality and type of procedure, urine culture results, rates of UTI, surgical site infections, postoperative returns to the emergency department, and unplanned procedures and catheterization. Multivariate analysis demonstrated no significant association between the rate of UCP and VUR severity, while postoperative UTI and unplanned procedure were both independent factors associated with UCP postoperatively. Additionally, postoperative UTI, ASA classification, mean operation time, ureteral stent placement, unplanned procedure, and UCP were independent factors found to contribute to LOS. CONCLUSION: Greater VUR severity does not appear to increase the need for catheterization or prolong hospital stay, while the development of a UTI postoperatively or having an additional unplanned procedure are associated with an increased likelihood of both. The postoperative course after UNC also appears to be influenced more so by other factors such as the operative approach and whether complications arise.

Bladder Sparing Extirpation of Pelvic Mass With Ureteral Reimplantation: A Case Report on Pelvic Lipomatosis Treatment.

Pelvic lipomatosis is a proliferative disease characterised by excessive fat growth in retroperitoneal space leading to inadequate bladder drainage and ureteral compression. Cystitis glandularis, cystitis cystica, or cystitis follicularis can be found in the majority of patients with the disease. We report a case of a 63-year-old man diagnosed outside our hospital with pelvic lipomatosis after finding a pelvic mass behind the bladder causing severe bilateral hydronephrosis. A bladder-sparing excision of the pelvic lipomatosis mass with bilateral ureteric reimplantation was performed, thereby avoiding the need for urinary diversion. Our case supports the hypothesis that pelvic fat mass extirpation and ureteral reimplantation is an effective surgical treatment strategy for pelvic lipomatosis.

Successful rescue pneumovesicoscopic surgery for post-Deflux® vesicoureteral junction obstruction.

BACKGROUND: Vesicoureteral junction (VUJ) obstruction after Deflux® subureteral injection for vesicoureteral reflux (VUR) is rare and minimally invasive management has not been reported. This work investigated the patients who underwent Deflux® injection for VUR and identified those with subsequent VUJ obstruction. METHODS: Medical records of matched patients from October 2003 to March 2022 were reviewed, and parameters were retrospectively studied. All patients underwent Deflux® injection. The injection was performed under general anesthesia using the same manner. For patients complicated with VUJ obstruction, the symptoms, signs, management, images, renal ultrasounds, Tc-99m dimercaptosuccinic acid renal scintigraphy, histology of VUJ region, and outcomes were documented and reported. VUJ stenosis was diagnosed by performing renal ultrasound and magnetic resonance imaging. RESULTS: Totally 407 patients (554 ureterorenal units) received Dx/HA injections for VUR. VUJ obstruction was found in three patients (four ureterorenal units). Originally, three were grade V VUR, and one was grade IV. The repeated injection was not a risk factor for VUJ obstruction. The overall incidence of VUJ obstruction post-Dx/HA injection was 0.7% by ureter. The incidences were 0%, 0.75%, and 2.25% for grade I-III, IV, and V VUR, respectively. After the initial conversion case of pneumovesicoscopic ureteral reimplantation, the procedure was performed smoothly and successfully in the two following cases. CONCLUSIONS: Pneumovesicoscopic ureteral reimplantation offers an alternative for VUJ obstruction following Dx/HA injection for VUR. Fibrosis and foreign-body reaction may influence the feasibility. High-grade VUR and young age of injection were related to VUJ obstruction.

Does the distal ureteral diameter ratio (UDR) matter in the surgical management of vesicoureteral reflux in children?

PURPOSE: To evaluate UDR reliability, sensitivity, specificity and to identify the best treatment basing on UDR among single or double endoscopic injections and ureteral reimplantation. METHODS: Data of patients affected by primary VUR and treated by endoscopic injection over a 10 years period were retrospectively analyzed. Two radiologist attributed reflux grade and UDR on voiding cystourethrogram twice and blinded. Follow-up focused on resolution after 1 or 2 endoscopic injections. Relation between UDR, reflux grade and outcomes were analyzed. RESULTS: Patient enrolled were 198. Low grade VUR was present in 24.8%, grade 3 in 41.6%, grade 4-5 in 33.6%. Resolution after one injection was obtained in 88 patients; among 110 not resolved 104 cases had a second injection. Success after 2 injections was reported in 138 cases. UDR showed a higher reliability compared with reflux grade both in intra than inter-reader measurement (ICC > 90%). Success after 1 or 2 injections was reported for UDR < 0.33 and UDR < 0.47 respectively. CONCLUSION: UDR shows to be a more reliable measurement that allows for an objective estimation of VUR severity and prognosis. It represents a quantitative parameter that might be useful to identify patients who may benefit endoscopic or surgical treatment, avoiding unnecessary under or over-treatment.

Does previous endoscopic subureteric injection (STING) effect the outcomes of robot-assisted laparoscopic ureteral reimplantation surgery (RALUR) in children?

BACKGROUND: There is lack of evidence on the success of robot-assisted laparoscopic ureteral reimplantation (RALUR) for the treatment of vesicoureteral reflux (VUR) who had prior intervention. OBJECTIVE: This study aimed to evaluate the effect of previous unsuccessful STING on the outcomes of RALUR in children. STUDY DESIGN: A total of 67 children treated with RALUR by a single surgeon for the treatment of VUR were scanned between February 2018 and April 2022. Two patients were excluded from the final data analysis due to the presence of a megaureter. Patients were divided into two groups: those with a history of STING (Group A - n:14) and those without STING (Group B - n:51). Patient characteristics, previous numbers of injections, console time, total operative time, perioperative and postoperative complications and clinical success data were collected. Clavien Dindo and Satava complication scales were used as the standard record of peri and postoperative complications. Radiographic success was defined as absence of reflux detected on postoperative voiding cystourethrography, whereas clinical success was defined as the absence of a febrile urinary tract infection during the follow-up. Mann-Whitney U and Chi-square tests and Fisher exact test were used where appropriate. RESULTS: A total of 36 (55.3%) female versus 29 (44.6%) male patients were operated for 96 refluxive ureters. Nearly half of the patients were with bilateral VUR (n = 31). The mean follow-up was 20.2 ± 15.4 months. The median age of patients was 59 ± 31 (range: 28-132 months) versus 46 ± 33.1 (range: 7-206 months) for groups A and B respectively (p = 0.22). Gender, age, peri- and postoperative complication rates, and clinical success were comparable between the two groups. The median operative time and the console time was significantly higher in children with history of STING (op time: 142.5 ± 27.4 versus 120 ± 24.9 min (p = 0.008), console time: 117.5 ± 28.2 versus 100 ± 24.5 min (p = 0.011) for groups A and B, respectively. A total of six complications (9.2%) occurred with none of them were greater than Clavien grade 3b. The overall clinical success rate was 97%, with 2 cases of clinical failure. In both cases, VCUG demonstrated absence of VUR. DISCUSSION: The outcomes of our study provided that RALUR is effective with more than 95% success rates despite failed endoscopic injection procedures. CONCLUSION: The previous history of STING neither changes the success nor the complication rates of RALUR. However, this can lead to more challenging surgery by increasing the total operative times.

Bilateral proximal ureteral and ureterovesical junction obstruction in a child.

The most common sites of ureteral obstruction in children are at the level of the ureteropelvic junction (UPJ) and ureterovesical junction (UVJ). Bilateral hydronephrosis or hydroureteronephrosis due to varying degrees of obstruction at the UPJ or UVJ is common in children and typically improves with time. Clinically significant obstruction at both locations in an ipsilateral ureter occurs less commonly and rarely requires both dismembered pyeloplasty and ureteral reimplantation. We believe this case report is the first description of bilateral proximal and distal ureteral obstruction requiring both dismembered pyeloplasty and ureteral reimplantation.

Vesicoureteral Reflux: Current Care Trends and Future Possibilities.

Although investigations over the past 2 decades have improved our understanding of the natural history of vesicoureteral reflux (VUR) and helped identify those at higher risk of both VUR itself as well as its potential severe sequelae, debate exists regarding key aspects of care, including when to perform diagnostic imaging and which patients benefit from continuous antibiotic prophylaxis. Artificial intelligence and machine learning have the potential to distill large volumes of granular data into practical tools that clinicians can use to guide diagnosis and management decisions. Surgical treatment, when indicated, remains highly effective and is associated with low morbidity.