Laparoscopic Augmentation Ureterocystoplasty

Laparoscopic ureterocystoplasty was performed in all five animals after 3 to 4 weeks of ureteral expansion. All procedures were performed using a four-port transperitoneal approach with the pig under general anesthesia. Initially, the ureteral balloon was completely deflated, and the amount of fluid aspirated was measured. The balloon was subsequently refilled with the same amount of dilute antibiotic solution to facilitate intraoperative identification and to prevent intraoperative spillage of potentially infected fluid should inadvertent puncture of the balloon occur intraoperatively. After port placement, the pelvic organs were examined laparoscopically. The expanded ureter was identified as a readily visible bulge adjacent to the urinary bladder. The medial peritoneum overlying the expanded ureter was incised to expose the ureteral wall. The fallopian tube and ovary on the ipsilateral side were mobilized away from the ureter. The bladder was mobilized by dividing the medial umbilical ligament and the superior vesical pedicle and incised laterally in a longitudinal fashion from just above the ureteral orifice up to the dome. The ureteral orifice and intramural ureter were preserved. While in the initial two animals the bladder dome was not excised, in the latter three approximately 80% of the bladder was removed. The medial wall of the expanded ureteral segment was then incised using a J-hook monopolar cautery electrode, thus opening the expanded ureteral segment medially. Care was taken to minimize any mobilization of the ureter, thus maintaining intact the laterally based vascularity of the expanded ureter (Fig. 4). The length, site, and orientation of the ureteral incision were tailored to correspond to the bladder defect (Fig. 5). After the ureteral incision was completed, the balloon was deflated and the catheter removed. The in-line tissue-expanded ureteral patch was then anastomosed to the bladder in a running fashion using 2-0 Vicryl sutures on a computed tomography-1 needle with freehand intracorporeal laparoscopic suturing and knot-tying techniques (Fig. 6). After the posterior wall was sutured, an 18F red rubber urethral catheter was inserted antegrade into the urethra through the bladder neck. The anterior wall was then sutured to complete the augmentation ureterocystoplasty. A 22F Malecot suprapubic catheter was left indwelling and brought out through the suture line in the initial two animals only. A 22F

The inflation could be carried out without anesthesia or analgesia while the overnight fasting animal was busily eating.

Malecot Drain Abdomen

FIGURE4 ■ Plain radiographs of abdomen document progressive ureteral expansion (A) at one week with 12 mL volume. (B) At two weeks, volume in balloon has increased to 46 mL. (C) At 25 days just prior to augmentation ureterocystoplasty with 140 mL in the balloon.

FIGURE3 ■ Light microscopic examination of: (A) normal ureter, (B) tissue-expanded ureter that reveals muscle hypertrophy and hyperplasia, and variable inflammatory infiltrate, and (C) native bladder. Note: The expanded ureter (B) more closely resembles the thickness of the bladder wall (C) than the normal ureter (A).

FIGURE4 ■ Plain radiographs of abdomen document progressive ureteral expansion (A) at one week with 12 mL volume. (B) At two weeks, volume in balloon has increased to 46 mL. (C) At 25 days just prior to augmentation ureterocystoplasty with 140 mL in the balloon.

FIGURE5 ■ Steps during the laparoscopic ureterocystoplasty.

FIGURE 6 ■ Cystogram performed immediately prior to autopsy at three months. Augmented bladder reveals capacity of 600 mL. There is grade II reflux in the right ureter.

FIGURE 6 ■ Cystogram performed immediately prior to autopsy at three months. Augmented bladder reveals capacity of 600 mL. There is grade II reflux in the right ureter.

tube drain was positioned in the prevesical space in all five animals and brought out through a port site. The animals were returned to the chronic animal care facility.

Oral antibiotics were administered until urethral catheter was removed. The suprapubic catheter was removed after seven days, and the urethral catheter was removed after 14 days if not spontaneously expelled earlier. The drain, if not spontaneously expelled, was removed a day after the urethral catheter was removed. All animals underwent laboratory, radiologic, urodynamic, and histologic investigations (Table 1). Additionally, transmission electron microscopy of the expanded ureter and measurement of vascular endothelial growth factor and transforming growth factor-P2 in expanded ureteral tissue were performed in selected animals. Animals were euthanized at 15 days (N = 1), one month (N = 1), two months (N = 1), and three months (N = 2).

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