title: Robot-assisted Laparoscopic Extravesical Ureteral Reimplantation: Technique Modifications Contribute to Optimized Outcomes.
abstract: Robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR-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.
  
  
  
  To describe technique modifications that may lead to improved radiographic vesicoureteral reflux (VUR) resolution.
  
  
  
  Between December 2008 and February 2015, a single surgeon performed RALUR-EV at an academic medical center. Only children with persistent grade 3-5 VUR at age 5 yr on voiding cystourethrogram (VCUG), those who had breakthrough urinary tract infections, or those with renal scarring were selected to undergo surgical correction of VUR with RALUR-EV. Children undergoing RALUR-EV for obstructive megaureter or ureterovesical junction obstruction were excluded. Fifty-eight patients (83 ureters) fit the inclusion criteria.
  
  
  
  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.
  
  
  
  The primary end point was resolution of VUR on postoperative VCUG.
  
  
  
  Because technique modifications were made at two distinct time points, we generated three patient groups for comparison. We observed complete 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.
  
  
  
  Using the standardized LUAA technique, we demonstrated an improvement 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.
  
  
  
  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.
authors.affiliation: Section of Urology, University of Chicago Medicine Comer Children's Hospital, Chicago, IL, USA. Electronic address: mgundeti@surgery.bsd.uchicago.edu.
authors.forename: Mohan S
authors.initials: MS
authors.lastname: Gundeti
authors.affiliation: Section of Urology, University of Chicago Medicine Comer Children's Hospital, Chicago, IL, USA.
authors.forename: William R
authors.initials: WR
authors.lastname: Boysen
authors.affiliation: Section of Urology, University of Chicago Medicine Comer Children's Hospital, Chicago, IL, USA.
authors.forename: Anup
authors.initials: A
authors.lastname: Shah
mesh_terms: D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D008297:Male; D019060:Minimally Invasive Surgical Procedures / Q000379:methods; D010043:Outcome and Process Assessment, Health Care; D058996:Quality Improvement; D012092:Replantation / Q000379:methods*; D012189:Retrospective Studies; D065287:Robotic Surgical Procedures / Q000379:methods*; D014481:United States; D014513:Ureter / Q000000981:diagnostic imaging / Q000601:surgery; D001743:Urinary Bladder / Q000000981:diagnostic imaging / Q000601:surgery; D014552:Urinary Tract Infections / Q000209:etiology / Q000517:prevention & control; D014567:Urography / Q000379:methods / Q000706:statistics & numerical data; D014718:Vesico-Ureteral Reflux / Q000150:complications / Q000175:diagnosis / Q000601:surgery
keywords: Extravesical; Reimplantation; Robotic surgery; Vesicoureteral reflux