title: Endoscopic cross-trigonal ureteral reimplantation under carbon dioxide bladder insufflation: a novel technique.
abstract: OBJECTIVE
  To report on a novel technique of endoscopic intravesical ureteral mobilization and cross-trigonal ureteral reimplantation under carbon dioxide insufflation of the bladder (pneumovesicum) for correcting primary vesicoureteral reflux (VUR) in infants and children.
  
  
  METHODS
  Ten boys and six girls with dilating primary VUR (7 bilateral; 23 refluxing ureters) associated with recurrent urinary-tract infections and multiple pyelonephritic renal scars underwent endoscopic Cohen's cross-trigonal ureteral reimplantation with CO(2) pneumovesicum. Their ages ranged from 10 months to 13 years (mean 4.1 years). The endoscopic procedure was preceded by distention of the bladder with saline and insertion of a 5-mm Step port over the bladder dome under cystoscopic guidance. The bladder was then drained and insufflated with CO(2) to 10 to 12 mm Hg pressure with a suction catheter inserted per urethra to occlude the internal urethral meatus. A 5-mm 30 degrees endoscope was used to provide intravesical vision. Two more 3- to 5-mm working ports were inserted on the lateral bladder wall on either side. Endoscopic intravesical mobilization of the ureter, dissection of a submucosal tunnel, and a Cohen's type of crosstrigonal ureteral reimplantation using interrupted 5-0 monofilament sutures was then performed under videoscopic guidance. Bladder drainage by a urethral catheter was maintained for 24 hours postoperatively.
  
  
  RESULTS
  Endoscopic cross-trigonal ureteral reimplantation under CO(2) pneumovesicum was successfully performed in all except one patient, who had displacement of a port into the extravesical space after completion of the ureteral reimplantation necessitating a small vesicotomy for closure of the mucosal defect. The mean operating time was 136 minutes (range 80-230 minutes), being 112 minutes for unilateral cases and 178 minutes for bilateral cases. Two boys developed mild suprapubic and scrotal emphysema postoperatively that subsided spontaneously. All other patients recovered uneventfully and remained well. Follow-up cystograms showed complete resolution of VUR in all except one unit that had persistent grade I reflux, thus giving a success rate of 96%.
  
  
  CONCLUSIONS
  This early experience illustrates that endoscopic intravesical ureteral mobilization and crosstrigonal ureteral reimplantation can be performed safely and effectively with routine laparoscopic surgical techniques and instruments under CO(2) insufflation of the bladder, achieving a high success rate in reflux resolution that is equivalent to that obtained with the open technique but with minimal invasiveness and much faster recovery. The longer-term outcome and potential physiological effects of CO(2) pneumovesicum on the bladder and upper-tract function will need to be evaluated further.
authors.affiliation: Division of Paediatric Surgery, Department of Surgery, Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China. ckyeung@cuhk.edu.hk
authors.forename: C K
authors.initials: CK
authors.lastname: Yeung
authors.forename: J D Y
authors.initials: JD
authors.lastname: Sihoe
authors.forename: P A
authors.initials: PA
authors.lastname: Borzi
mesh_terms: D000293:Adolescent; D000714:Anastomosis, Surgical; D002245:Carbon Dioxide / Q000494:pharmacology; D002648:Child; D002675:Child, Preschool; D003558:Cystoscopy / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007223:Infant; D007327:Insufflation / Q000379:methods*; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D019060:Minimally Invasive Surgical Procedures / Q000379:methods; D011446:Prospective Studies; D012092:Replantation / Q000379:methods*; D018570:Risk Assessment; D012494:Sampling Studies; D012720:Severity of Illness Index; D016896:Treatment Outcome; D014513:Ureter / Q000601:surgery; D001743:Urinary Bladder / Q000601:surgery*; D014718:Vesico-Ureteral Reflux / Q000175:diagnosis* / Q000601:surgery*
chemical_list: D002245:Carbon Dioxide