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Ureteral reimplantation under pneumovesicoscopy according to Cohen technique in children

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Abstract

This didactic video describes in detail the technique of ureteral reimplantation in the bladder using a pneumovesicoscopic approach. Dr. Valla, MD shares some of the finer points to be observed during this procedure.

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Duration

09'30''

Publication

2007-01

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E-publication

WeBSurg.com, Jan 2007;7(01).
URL: http://www.websurg.com/doi-vd01en2053.htm

Ureteral reimplantation under pneumovesicoscopy according to Cohen technique in children

1. Principles and patient preparation 00'11''

The principles of ureteral reimplantation under pneumovesicoscopy consist of introducing into the bladder 3 suprapubic trocars, one medial for the camera and 2 laterally for the instruments. The patient is placed in the lithotomy position for access to the perineum because the procedure starts with the usual transurethral cystoscopy under normal saline fluid distension.

2. Cystoscopy 00'38''

During the 1st step, the 3 trocars are reintroduced, and also if possible ureteral catheters. The position of the trocars can vary according to the size of the patient. Locking trocars are very useful to prevent any slippage out of the bladder wall.

3. Port placement 00'59''

The 1st 5mm locking trocar is pushed through the abdominal wall, then the bladder wall under visual control by the cystoscope, taking care not to injure the bladder floor. Once inserted, the umbrella is opened. The 2 lateral trocars are also introduced under cystoscopic control, not too close to the ureteric orifices in order to get enough room for ureteric dissection. If normal trocars are used, the bladder wall must first be suspended to the abdominal wall by transcutaneous transfixion sutures. Again, the needle is controlled by the cystoscope. This suture is tied. It keeps the bladder wall attached to the abdominal wall preventing inadvertent dislodgement of trocars out of the bladder during the procedure. In this case, 3mm reusable trocars are used and also fixed to the skin.

4. Pneumovesicoscopy 02'53''

Once the 3 trocars are introduced, the bladder is emptied and the cystoscope removed. The team and the video column are moved for the 2nd pneumovesicoscopic step. The bladder is insufflated with CO2. During the 2nd step, the most ergonomic position for the surgeon is to stand at the head of the child, but that is possible only in small children. To hold the camera is tiring for the assistant so the camera holder is very helpful for stability of the vision, especially when suturing during dissection. As for all reconstructive surgery in a small space this is an essential point. In this case, we use an automatic camera holder. All the steps of classical ureteroneocystostomy are reproduced using minimally invasive surgery.

5. Ureter mobilization 03'50''

The ureteral catheter is secured around the refluxing orifice by sutures. This serves as a stent to facilitate ureteric mobilization. The ureter is mobilized by first dissecting circumferentially around the orifice using a 3mm hook. With traction on the ureter, the tissues surrounding the distal ureter are divided. Due to the magnification, hemostasis is very precise, so usually no bleeding occurs. But during the dissection, the vision could be obscured by smoke. A bladder catheter is introduced per-urethra in order to evacuate the smoke and also to aspirate the urine. Mobilization of the ureter is continued for 3 to 5 centimeters to the extravesical space using endo-peanuts until adequate length of ureter is obtained.

6. Closure of extravesical space 05'09''

The muscular defect in the bladder floor is repaired as quickly as possible using 5/0 absorbable sutures and extraperitoneal slipping knots. This avoids excessive carbon dioxide leakage into the perivesical space. At that time, the ureter could be attached to the detrusor with one superficial stitch to prevent its retraction into the perivesical space.

7. Creation of tunnel 05'49''

A transvesical submucosal tunnel is created with 3mm scissors and in this first example the tunnel goes from the right to the left in order to reimplant the right duplex system. This second example will show a left ureteral reimplantation. The position of the new ureteral orifice is chosen to be lateral and superior to the contralateral orifice. This last example shows a tunnel for bilateral reimplantation.

8. Passing the ureter through tunnel 06'35''

The ureter is gently passed through its new tunnel by grasping the catheter and taking care not to twist the ureter. The ureter is fastened to the detrusor muscle by 1 or 2 full-thickness 5/0 sutures using extracorporeal slipping knots. We favour the resection of the terminal part of the ureter. If the ureteric calibre is too small, the ureter could be spatulated with scissors.

9. Ureterovesical anastomosis 07'35''

Ureteroneocystostomy is performed using 5 to 6/0 absorbable sutures and intracorporeal knots. This anastomosis is quite simple in the case of single ureter as shown in this case. But this anastomosis could be more complex in the cases of duplex ureter. However, the use of ureteric catheterization avoids any obstructive sutures. The mucosal incision at the original orifice is closed by a running suture. After a final check, the ureteric catheter is removed.

10. Closure of ports 08'32''

The lateral trocar wounds are then closed under visual control by using a suture passer or by using the technique described by CKeio and demonstrated here. An opsite is put on the skin to avoid any air leak. Two 16 gauge angiocatheters are inserted on each side of the bladder hole. A suture loop is introduced in one angiocatheter and a 3/0 absorbable suture in the other angiocatheter. This last one is manipulated to pass through the suture loop. The thread is then caught by the loop and extracted. This maneuver could be facilitated by a transurethral grasper and is also repeated on the other side. The 3rd 5mm medial hole is closed directly under visual control and the bladder catheter is left for 2 to 3 days. During a 3-year period, 40 patients underwent this endoscopic Cohen procedure. A total of 78 ureters were re-implanted. No case was converted. A follow-up voiding cystography was performed in 28 patients. The success rate is 96%. Because of the quality of preliminary results, the advantages related to the reduction of abdominal wall trauma and reduction of bladder wall trauma. This new technique represents an important alternative to other anti-reflux techniques and should be considered in a referral centre before open surgical ureteral re-implantation.

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