Ureteric Reimplantation (Laparoscopic)

Laparoscopic ureteric reimplantation

It is a surgery for ureteral diseases. The surgeon excises the ureter and the abnormal (diseased/traumatized) implantation and re-implants it in a position on the bladder that enables it to drain well and minimize urinary stasis. 

Usually it is done through 3 -4 small incisions the size of keyholes instead of one big open cut. 

Advantages of Laparoscopic method

• Smaller incisions
• Less postoperative pain
• Faster recovery
• Lower infection risk
• Shorter hospital stay
• Better cosmetic outcome

Laparoscopic ureteral reimplantation surgery

Indications

Ureteral Stricture

Narrowing or blockage due to:

• Scar tissue
• Previous surgery
• Stones
• Inflammation or infections in the body

Vesicoureteral Reflux (VUR)

• Urine flow from bladder to kidney in Retrograde.

Ureteral Injury

Often occurs during:

• Gynecologic surgery
• Surgery of the colon
• Pelvic procedures

Ectopic Ureter

• Ureter empties in a wrong position like urethra or vagina.

Duplex System Anomalies or Ureterocele

Ureteric reimplantation laparoscopic procedure

Laparoscopic ureteric reimplantation is one of minimal invasive reconstructive surgery that is performed for the correction of obstruction/strictures/vesicoureteral reflux (VUR) in the ureters. The technique consists in excising the ureter from its abnormal implantation and reimplanting it in a different anatomical site in such a way that the ureter drains the urine properly and does not reflux. 

The extravesical Lich-Gregoir technique is the most commonly used laparoscopic technique.

Laparoscopic Surgery- Step by Step:

Anaesthesia and Positioning

• General anaesthesia is administered on the patient.

• Lying down with table in Trendelenburg to push bowel loops out of the way.

Port Placement

They are normally 3-4 laparoscopic ports:

• A single 10 mm umbilical port camera.
• The lower abdomen has two or three 5 mm working ports.
• Carbon dioxide pneumoperitoneum is constructed and gives a chance to visualize the surgery.

Exposure and Bladder Mobilization

• The peritoneum of the bladder is cut.
• The bladder is moved downwards to reveal distal ureter and wall of the bladder.
• The development of the perivesical space is done in the careful way avoiding the harm of adjacent structures.

The Ureter is located by palpating the abdomen

• The blocked or infected ureter is detected.
• The ureter is then dissected carefully without affecting the blood supply of the peri ureter.
• Any strictured part is removed when necessary.

Mobilization of Ureter

• An adequate ureteral length is brought in place to secure tension free reimplantation.
• Scarred or redundant tissue can be excised.

Bladder tunnel (Extraviscial Technique) Preparation

There is the formation of a submucosal tunnel on the bladder wall:

• The longitudinal division of the detrusor muscle takes place.
• There is no entry into the bladder lumen but exposes the mucosa to the bladder.
• This is done by creating a tunnel of the right length (typically 45 times ureteral diameter), which allows an antireflux become possible.

Ureteric Reimplantation

• The ureter is inserted in the bladder tunnel created.
• Fine absorbable sutures are used to fasten the ureter to the mucosa.
• This is achieved by the detrusor muscle being closed around the ureter making a detrusor tunnel.
• This forms an anti-reflux, oblique urine flow.

DJ Stent Placement

• A DJ stent is inserted to keep the ureter and bladder patent. 
• Stent supports uninterrupted urine flow and prevents early occlusion.

Bladder Closure (Intravesical Technique)- (Intravesical Technique Used) 

In intravesical (Cohen technique):

• Bladder is opened
• Ureter reimplanted with transvesical tunnel.
• Bladder closed afterward

Hemostasis and Port Closure

• Inspection of the surgical field detected to be bleeding or leaking.
• Instruments removed.
• Absorbable sutures put on ports.

Procedure Duration

• Mean time spent on operation: 2-3 hrs.
• Bases on the indication (stricture, reflux, injury, ectopic ureter)

Postoperative Care

• Foley catheter: 5–7 days
• Hospital stay: 2–4 days
• DJ stents removal: 4-6 weeks post-surgery.
• An ultrasound/CT was done to confirm complete drainage.

Ureteric reimplantation in vesicoureteral reflux

What is Vesicoureteral Reflux?

VUR is a condition where urine flows in the wrong direction – back up the ureters toward the kidneys from the bladder. This back flow predisposes the risk of:

• Recurrent UTIs.
• Kidney scarring
• Hydronephrosis
• Long-term renal damage

Surgery is advised in case of severe, persistent and symptomatic infections of reflux despite the medical treatment.

Surgical Suggestions of VUR

VUR is suggested to be repaired through ureteric reimplantation in case:

High-Grade Reflux

• Grade III-V VUR, particularly among children.

Recurrent Febrile UTIs

• Although there is a long-term treatment with antibiotics prophylaxis.

Renal Cortical Scarring or Damage

• Scans identified renal disease.

Unsuccessful Endoscopic Therapy

• (e.g., failed Deflux injection)

Symptomatic or Bilateral VUR

• Suspending hydronephrosis or recurring infections.

Parental sensitivity towards conclusive cure

• In order to prevent long-term antibiotics.

Form of Reimplantation surgery on VUR

Extravesical Lich Gregoir Technique (Most Common)

• No need to open the bladder.
• Gives great anti-reflux mechanism.
• Less postoperative pain.

Intravesical Cohen Cross-Trigonal Technique.

• Bladder perineal; ureter tunnelled through trigone of bladder.
• Applicable in complicated anomalies, scarring or bilateral cases.

Politano–Leadbetter Technique

• Conventional intravesical method.
• Enables the design of a longer submucosal tunnel.

Best hospital for laparoscopic ureteric reimplantation India

• Artemis Hospital, Gurgaon
• Medanta-The Medicity, Gurgaon
• Fortis Memorial Research Institute, Gurgaon
• Max Hospital, Saket

Laparoscopic ureteral reimplantation success rate

The outcome of laparoscopic ureteral reimplantation is excellent and equivalent to that of open surgery and is, by far better than that of endoscopic (Deflux) treatment in most of the cases. 

Overall Success Rate

• Success rates of 90 percent--98 percent in the treatment of obstruction, strictures, or vesicoureteral reflux (VUR).

Conclusion

Ureteral reimplantation is an excellent and minimally invasive surgery in the correction of vesicoureteral reflux, strictures, and obstruction of the ureters. It has small incisions, less pain, quicker recovery and superior cosmetic results, and the success rates 90-98 are similar to those of open surgery. The process of intervention is normalizing urine flow, avoiding the destruction of kidneys, and long-term relief with minimal risk of complications. In general, it is a safe, reliable as well as durable method to be used by children as well as adults in need of ureteric reconstruction.

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FAQ

1. Is Laparoscopic reimplantation has a better outcome than open surgery?

• Yes. The same success can be achieved through smaller cuts, less pain, shorter hospital stay, and earlier recovery.

2. Does stent required for the surgery?

• Yes. A Double-J (DJ) stent is typically placed for 4–6 weeks to facilitate healing and maintain good urine flow.

3. Is Laparoscopic Reimplantation Safe for Children?

• Yes. It is widely used for paediatric VUR with good results and low recurrence.

4. Can VUR or obstruction come back after surgery?

• Not often. With proper technique, recurrence is <5%.

5. Can both sides be repaired in one surgery?

• Yes. Bilateral laparoscopic reimplantation is feasible and performed routinely in high volume centers.

6. Is robotic reimplantation available?

• Sure. The enhanced precision can be utilized gold in many cases, especially complex or reoperative ones, and is often preferred.