Does previous endoscopic subureteric injection (STING) effect the outcomes of robot-assisted laparoscopic ureteral reimplantation surgery (RALUR) in children?

Abstract

Background: There is lack of evidence on the success of robot-assisted laparoscopic ureteral reimplantation (RALUR) for the treatment of vesicoureteral reflux (VUR) who had prior intervention.

Objective: This study aimed to evaluate the effect of previous unsuccessful STING on the outcomes of RALUR in children.

Study design: A total of 67 children treated with RALUR by a single surgeon for the treatment of VUR were scanned between February 2018 and April 2022. Two patients were excluded from the final data analysis due to the presence of a megaureter. Patients were divided into two groups: those with a history of STING (Group A - n:14) and those without STING (Group B - n:51). Patient characteristics, previous numbers of injections, console time, total operative time, perioperative and postoperative complications and clinical success data were collected. Clavien Dindo and Satava complication scales were used as the standard record of peri and postoperative complications. Radiographic success was defined as absence of reflux detected on postoperative voiding cystourethrography, whereas clinical success was defined as the absence of a febrile urinary tract infection during the follow-up. Mann-Whitney U and Chi-square tests and Fisher exact test were used where appropriate.

Results: A total of 36 (55.3%) female versus 29 (44.6%) male patients were operated for 96 refluxive ureters. Nearly half of the patients were with bilateral VUR (n = 31). The mean follow-up was 20.2 ± 15.4 months. The median age of patients was 59 ± 31 (range: 28-132 months) versus 46 ± 33.1 (range: 7-206 months) for groups A and B respectively (p = 0.22). Gender, age, peri- and postoperative complication rates, and clinical success were comparable between the two groups. The median operative time and the console time was significantly higher in children with history of STING (op time: 142.5 ± 27.4 versus 120 ± 24.9 min (p = 0.008), console time: 117.5 ± 28.2 versus 100 ± 24.5 min (p = 0.011) for groups A and B, respectively. A total of six complications (9.2%) occurred with none of them were greater than Clavien grade 3b. The overall clinical success rate was 97%, with 2 cases of clinical failure. In both cases, VCUG demonstrated absence of VUR.

Discussion: The outcomes of our study provided that RALUR is effective with more than 95% success rates despite failed endoscopic injection procedures.

Conclusion: The previous history of STING neither changes the success nor the complication rates of RALUR. However, this can lead to more challenging surgery by increasing the total operative times.

Keywords: Children; Robotic; STING; Ureteral reimplantation; Vesicoureteral reflux.