Introduction: Recurrence of vesicoureteral reflux (VUR) after reimplantation is a therapeutic challenge. Options include conservative management with surveillance, endoscopic treatment with injection of a Dextranomer-hyaluronic acid bulking agent, and re-operation, either by open or minimally invasive approach. High grade reflux (grade 3-5) recurrence is unlikely to resolve with surveillance or endoscopic treatment. We demonstrate the steps to a redo extravesical robotic-assisted laparoscopic left ureteral reimplant using the LUAA technique (Length of detrusor tunnel (L), use of a U stitch (U) in the proximal detrusorraphy, placement of permanent ureteral alignment suture (A) at the apex of the closure, and inclusion of ureteral adventitia (A) in the detrusorraphy).
Methods: A 12-year-old male presents after a urinary tract infection and a recurrence of grade 3 VUR on the left secondary to volitional urinary holding. He had previously had an extravesical robotic-assisted laparoscopic bilateral ureteral reimplant for bilateral grade 4 VUR seven years prior with resolution of the reflux and urinary tract infections. Pre-operative video urodynamics revealed a smooth, large capacity bladder (740cc) with normal sensation and without detrusor overactivity. After consideration of the options, the patient and his parents elected to undergo a redo extravesical robotic-assisted laparoscopic left ureteral reimplant.
Results: Successful completion of the redo extravesical robotic-assisted laparoscopic left ureteral reimplant. There was significant adhesion of the vas deferens to the distal left ureter requiring extensive dissection.
Conclusions: This video demonstrates that an extravesical robotic-assisted laparoscopic left ureteral reimplant is feasible and safe to perform as a re-operation after previous robotic ureteral reimplant. The most significant adhesion encountered was at the distal ureter, with the vas deferens densely adhered. We demonstrate the steps to this advanced procedure.