Feasibility of total intravesical endoscopic surgery using mini-instruments in a porcine model

Background and Objectives: The aim of minimally invasive approaches to vesi coureteral reflux, such as endoscopic trigonoplasty, is to lower the morbid ity of open procedures without compromising the results, Initial successes have not been sustained, mainly because of trigonal splitting, which result s in the ureteral orifices returning to their preoperative positions. This study was designed to address trigonal splitting by mobilizing the ureters before repositioning them and to evaluate the feasibility of accomplishing this intravesically with 2- to 3-mm endoscopic mini-instruments. Methods: B ilateral vesicoureteral reflux was surgically created in 10 minipigs, After radiologic confirmation of success 4 weeks later, modified trigonoplasty w as performed by endoscopic intravesical mobilization of bath ureters and in cision of the trigonal mucosa using 2-mm instruments. The ureteral orifices were then advanced toward the midline and sutured in place, The initial su rgical techniques were modified to permit the entire procedure to be perfor med endoscopically in the last four minipigs, Cystograms and intravenous ur ograms were obtained 4 weeks later. Results: Two minipigs died postoperativ ely, Six of the remaining eight had persistent reflux, including three of t he four in the group treated completely by endoscopic means. None of the di ssected ureters showed evidence of stricture or necrosis, Conclusions: Alth ough the procedure was not successful in correcting reflux in this model, t his study demonstrates the feasibility of endoscopic ureteral mobilization, With current instrumentation, there is no significant technical obstacle t o complete intravesical endoscopic surgery, including ureteral reimplantati on.