Intraoperative Problems and Solutions in Pneumovesicum Laparoscopic Cross-trigonal Ureteral Reimplantation in Children by a Beginner Surgeon

Abstract

Objective: Many beginner surgeons feel anxious when first doing the procedure. Some may encounter many intraoperative difficulties or problems, resulting in abandoning the technique. We will demonstrate our methods and the solutions to major intraoperative problems. Materials and Methods: A beginner surgeon performed the operation on 13 children with VUR (20 ureters) who met the indications for surgery between October 2016 and August 2017. Age ranged from 2 to 7 years. Each operation comprised 2 main steps: anchoring the urinary bladder wall to the anterior abdominal wall under cystoscopic vision, followed by a cross-trigonal ureteral reimplantation under pneumovesicum laparoscopy. The intraoperative problems, postoperative care, and follow-up periods were recorded to identify surgical outcomes. Results: Most significant, intraoperative problems were air leakage, bleeding, tear of the bladder mucosa above the tunnel, and inability to insert a tube into the ureter pre- and post-reimplantation. Most problems could be managed. Only one case had to be converted to open reimplantation due to uncontrolled air leakage. Postoperatively, 2 patients had hydroureteronephrosis at 4 weeks, but it eventually spontaneously regressed. One patient had cystitis, treated with oral antibiotics. Between the 1-year and 4-year follow-up, no patients had hydroureteronephrosis or urinary tract infections (UTI). Conclusion: Pneumovesicum laparoscopic ureteral reimplantation is a feasible technique for beginner surgeons. Although many intraoperative problems may be encountered, most can be managed, resulting in the completion of the laparoscopic procedure.