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Incidence and resolution of de novo hydronephrosis after pediatric robot-assisted laparoscopic extravesical ureteral reimplantation for primary vesicoureteral reflux

  • Author Footnotes
    1 Co-first author.
    Sameer Mittal
    Footnotes
    1 Co-first author.
    Affiliations
    Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA

    Division of Urology, Hospital of the University of Pennsylvania, Perelman Center for Advanced Care, 3400 Civic Center Blvd, 3rd Floor West Pavilion, Philadelphia, PA 19104, USA
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  • Author Footnotes
    1 Co-first author.
    Sahar Eftekharzadeh
    Footnotes
    1 Co-first author.
    Affiliations
    Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA
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  • Aznive Aghababian
    Affiliations
    Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA
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  • John Weaver
    Affiliations
    Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA
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  • Katherine Fischer
    Affiliations
    Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA
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  • Christopher J. Long
    Affiliations
    Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA

    Division of Urology, Hospital of the University of Pennsylvania, Perelman Center for Advanced Care, 3400 Civic Center Blvd, 3rd Floor West Pavilion, Philadelphia, PA 19104, USA
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  • Dana A. Weiss
    Affiliations
    Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA

    Division of Urology, Hospital of the University of Pennsylvania, Perelman Center for Advanced Care, 3400 Civic Center Blvd, 3rd Floor West Pavilion, Philadelphia, PA 19104, USA
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  • Jason Van Batavia
    Affiliations
    Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA

    Division of Urology, Hospital of the University of Pennsylvania, Perelman Center for Advanced Care, 3400 Civic Center Blvd, 3rd Floor West Pavilion, Philadelphia, PA 19104, USA
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  • Arun K. Srinivasan
    Affiliations
    Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA

    Division of Urology, Hospital of the University of Pennsylvania, Perelman Center for Advanced Care, 3400 Civic Center Blvd, 3rd Floor West Pavilion, Philadelphia, PA 19104, USA
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  • Aseem R. Shukla
    Correspondence
    Correspondence to: Aseem R. Shukla, Children's Hospital of Philadelphia, Department of Surgery, Division of Urology, Wood 3rd Floor, Philadelphia, PA 19104, USA, Tel.: +(215) 590 7889; fax: +(215) 590 3985
    Affiliations
    Division of Urology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA

    Division of Urology, Hospital of the University of Pennsylvania, Perelman Center for Advanced Care, 3400 Civic Center Blvd, 3rd Floor West Pavilion, Philadelphia, PA 19104, USA
    Search for articles by this author
  • Author Footnotes
    1 Co-first author.

      Summary

      Introduction

      With the advent of robot-assisted laparoscopic ureteral reimplantation (RALUR) for primary vesicoureteral reflux (VUR), understanding and minimizing its complications continues to be critical. Incidence of de novo hydronephrosis after RALUR could be indicative of an outcome that needs further study or could be a benign transient finding.

      Objective

      In the present study, we hypothesized that the incidence of de novo hydronephrosis after RALUR is low and resolves spontaneously.

      Methods

      An IRB-approved prospective single-institutional registry was utilized to identify all patients undergoing RALUR via an extravesical approach from 2012 to 2020. Patients with primary VUR and minimal (Grade I SFU) or no hydronephrosis prior to surgery were included. Patients who had other associated pathology or underwent concomitant procedures were excluded. Preoperative characteristics including VUR and hydronephrosis grades as well as post-operative clinical details and hydronephrosis grades were aggregated and analyzed.

      Results

      86/172 (50%) patients (133 ureters), with median reflux grade of 3 (IQR: G2, G3) met the inclusion criteria. Patients underwent RALUR at a median age of 5.7 years (IQR: 3.4, 8.7) with median 36.2 months (IQR: 19.6, 63.6) follow-up. Renal ultrasound at 4–6 weeks post-op showed de novo hydronephrosis in 18 (13.5%) ureters; the complete resolution was seen in 13 ureters (72%) at a median of 4.5 months from surgery. Among the 5 with non-resolved hydronephrosis (SFU G2:4, G3:1), 2 patients (3 ureters) underwent subsequent interventions.

      Discussion

      The present study evaluating the natural history of de novo hydronephrosis after RALUR-EV performed for primary VUR, is to our knowledge the largest cohort of patients undergoing RALUR that this has been studied in. In our cohort, the incidence of de novo hydronephrosis after RALUR was 13.5%, similar to rates reported in two OUR cohorts, and significantly lower than reported incidence rates of 22–26% in several OUR cohorts, and 30% in a RALUR cohort. In the present cohort, hydronephrosis resolved spontaneously in more than 72% of cases. The median time from surgery until resolution of hydronephrosis was 4.5 (1.6, 10.5) months, which is shorter in comparison to the average time to resolution of 7.6 months, reported by Kim et al. in an earlier study.

      Conclusions

      Summary Table
      Number of Patients 86
      Number of ureters 133
      Age at surgery (years), median (IQR) 5.7 (3.4, 8.7)
      Follow-up duration (months), median (IQR) 36.2 (19.6, 63.6)
      Worsened/de novo hydronephrosis after RALUR 18 (13.5%)
       Grade 2 14 (10.5%)
       Grade 3 2 (1.5%)
       Grade 4 2 (1.5%)
      Resolution of de novo hydronephrosis 13 (72.2%)
      Time to hydronephrosis resolution (months), median (IQR) 4.5 (1.6, 10.5)
      Procedures performed after RALUR 3 (16.7%)

      Keywords

      Abbreviations:

      OUR (Open ureteral reimplant), RALUR (Robotic-assisted laparoscopic ureteral reimplant), RALUR-EV (RALUR via an extravesical approach), VUR (Vesicoureteral reflux), UTI (Urinary tract infection), UVJ (Ureterovesical junction)
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      References

        • Peters C.A.
        • Skoog S.J.
        • Arant B.S.
        • Copp H.L.
        • Elder J.S.
        • Hudson R.G.
        • et al.
        Summary of the AUA guideline on management of primary vesicoureteral reflux in Children.
        J Urol. 2010; 184: 1134-1144
        • Bowen D.K.
        • Faasse M.A.
        • Liu D.B.
        • Gong E.M.
        • Lindgren B.W.
        • Johnson E.K.
        Use of pediatric open, laparoscopic and robot-assisted laparoscopic ureteral reimplantation in the United States: 2000 to 2012.
        J Urol. 2016; 196: 207-212
        • Schomburg J.L.
        • Haberman K.
        • Willihnganz-Lawson K.H.
        • Shukla A.R.
        Robot-assisted laparoscopic ureteral reimplantation: a single surgeon comparison to open surgery.
        J Pediatr Urol. 2014; 10: 875-879
        • Marchini G.S.
        • Hong Y.K.
        • Minnillo B.J.
        • Diamond D.A.
        • Houck C.S.
        • Meier P.M.
        • et al.
        Robotic assisted laparoscopic ureteral reimplantation in children: case matched comparative study with open surgical approach.
        J Urol. 2011; 185: 1870-1875
        • Smith R.P.
        • Oliver J.L.
        • Peters C.A.
        Pediatric robotic extravesical ureteral reimplantation: comparison with open surgery.
        J Urol. 2011; 185: 1876-1881
        • Arlen A.M.
        • Broderick K.M.
        • Travers C.
        • Smith E.A.
        • Elmore J.M.
        • Kirsch A.J.
        Outcomes of complex robot-assisted extravesical ureteral reimplantation in the pediatric population.
        J Pediatr Urol. 2016; 12 (e1-. e6): 169
        • Sung J.
        • Skoog S.
        Surgical management of vesicoureteral reflux in children.
        Pediatr Nephrol. 2012; 27: 551-561
        • Boysen W.R.
        • Akhavan A.
        • Ko J.
        • Ellison J.S.
        • Lendvay T.S.
        • Huang J.
        • et al.
        Prospective multicenter study on robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR-EV): outcomes and complications.
        J Pediatr Urol. 2018; 14 (e1-.e6): 262
        • Esposito C.
        • Masieri L.
        • Steyaert H.
        • Escolino M.
        • Cerchione R.
        • La Manna A.
        • et al.
        Robot-assisted extravesical ureteral reimplantation (revur) for unilateral vesico-ureteral reflux in children: results of a multicentric international survey.
        World J Urol. 2018; 36: 481-488
        • Deng T.
        • Liu B.
        • Luo L.
        • Duan X.
        • Cai C.
        • Zhao Z.
        • et al.
        Robot-assisted laparoscopic versus open ureteral reimplantation for pediatric vesicoureteral reflux: a systematic review and meta-analysis.
        World J Urol. 2018; 36: 819-828
        • Lee Y.S.
        • Im Y.J.
        • Jung H.J.
        • Hah Y.S.
        • Hong C.H.
        • Han S.W.
        Does hydronephrosis after extravesical ureteral reimplantation deteriorate renal function?.
        J Urol. 2012; 187: 670-675
        • Rosman B.M.
        • Passerotti C.C.
        • Kohn D.
        • Recabal P.
        • Retik A.B.
        • Nguyen H.T.
        Hydronephrosis following ureteral reimplantation: when is it concerning?.
        J Pediatr Urol. 2012; 8: 481-487
        • Kim E.J.
        • Song S.H.
        • Sheth K.
        • Baccam T.
        • Elizondo R.
        • Baek M.
        • et al.
        Does de novo hydronephrosis after pediatric robot-assisted laparoscopic ureteral re-implantation behave similarly to open re-implantation?.
        J Pediatr Urol. 2019; 15 (e1-.e6): 604
        • Sahadev R.
        • Spencer K.
        • Srinivasan A.K.
        • Long C.J.
        • Shukla A.R.
        The robot-assisted extravesical anti-reflux surgery: how we overcame the learning curve.
        Front Pediatr. 2019; 7: 93
        • Aboutaleb H.
        • Bolduc S.
        • Bägli D.J.
        • Khoury A.E.
        Correlation of vesicoureteral reflux with degree of hydronephrosis and the impact of antireflux surgery.
        J Urol. 2003; 170 (discussion 2): 1560-1562
        • Barrieras D.
        • Lapointe S.
        • Reddy P.P.
        • Williot P.
        • McLorie G.A.
        • fGli D.
        • et al.
        Are postoperative studies justified after extravesical ureteral reimplantation?.
        J Urol. 2000; 164: 1064-1066