Laparoscopic cross-trigonal Cohen ureteroneocystostomy: Novel technique

Purpose: We describe a novel technique of laparoscopic transvesical cross-t rigonal Cohen anti-reflux ureteroneocystostomy. Materials and Methods: A 10, an 11 and a 32-year-old patient with symptomat ic unilateral vesicoureteral reflux underwent laparoscopic cross-trigonal u reteral reimplantation. Two 5 mm. balloon tip ports were suprapubically ins erted into the bladder. Using a transurethral resectoscope with a Collins k nife a 4 to 5 cm. cross-trigonal submucosal trough was created from the ref luxing ureteral orifice to the contralateral side of the bladder. The reflu xing ureteral orifice and intramural ureter were completely mobilized intra vesically, advanced transtrigonally and secured to the detrusor muscle at t he apex of the trough with 3 deep interrupted sutures. The elevated mucosal flaps of the trough were suture approximated over the ureter to create a s ubmucosal tunnel. All suturing was performed by freehand laparoscopic techn ique. Results: Operative time was between 2.5 and 4.5 hours and blood loss was 10 to 50 cc. Adequate submucosal trough creation, ureteral extravesical mobil ization and intravesical advancement, and bladder mucosal flap reapproximat ion were done to create a submucosal tunnel in all cases. Satisfactory tran strigonal anchoring of the neoureteral orifice to the detrusor muscle and m ucosa was achieved with 3 stitches. Hospital stay was 2, 2 and I days in th e 3 cases, and the Foley catheter remained in place for 3, 1 and 1 week, re spectively. At 6 months reflux had resolved in 2 patients, while in 1 grade II reflux persisted, which was improved from grade IV preoperatively. All patients have remained infection-free without antibiotics. Conclusions: Laparoscopic transvesical cross-trigonal antireflux ureteral r eimplantation is technically feasible. Intravesical laparoscopic suturing i s possible. Potential advantages include a decreased hospital stay, decreas ed narcotic requirement and better cosmesis. Further experience is necessar y to refine the technical nuances and evaluate outcomes compared to the ope n technique.