+ MODEL
Journal of Pediatric Urology (xxxx) xxx xxx
a
Department of Pediatric
Surgery, Pediatric Urology and
Renal Transplant Unit,
University Hospital Vall
dHebron Barcelona, Hospital
Vall dHebron, Passeig de la Vall
dHebrón 119-129, 08035
Barcelona, Spain
b
Department of Pediatric
Surgery, University Hospital Vall
dHebron, Barcelona, Spain
c
Hospital Vall dHebron, Passeig
de la Vall dHebrón 119-129,
08035 Barcelona, Spain
d
Universidad autónoma de
Barcelona, Hospital Vall
dHebron, Passeig de la Vall
dHebrón 119-129, 08035
Barcelona, Spain
* Correspondence to: Romy
Gander, Passeig de la Vall
dHebron 119-139, 08032
Barcelona, Spain, Tel.: þ34
934893142
rgander@vhebron.net (R.
Gander)
Keywords
Pediatrics; Laparoscopy;
Obstructed megaureter; Lapa-
roscopic ureteral reimplanta-
tion; Minimally invasive surgery
Received 23 February 2021
Revised 7 June 2021
Accepted 28 June 2021
Available online xxx
https://doi.org/10.1016/j.jpurol.2021.06.030
1477-5131/ª 2021 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Please cite this article as: Gander R et al., Laparoscopic extravesical ureteral reimplantation (LEUR) of obstructed megaureters: STEP-BY-
STEP video of a simplified approach, Journal of Pediatric Urology, https://doi.org/10.1016/j.jpurol.2021.06.030
Video Bank
Laparoscopic extravesical ureteral
reimplantation (LEUR) of obstructed
megaureters: STEP-BY-STEP video of a
simplified approach
Romy Gander a,*, Marino Asensio a, Gloria Fatou Royo a,
Manuel López b,c,d
Summary
Introduction
In this video we aim to describe step-by-step a
simplified surgical technique for the treatment of
primary and secondary obstructed megaureters in
children by laparoscopic extravesical ureteral reim-
plantation (LEUR).
Material and methods
A transperitoneal approach is used in all cases. The
distal ureter is dissected and transected at the level
of the stenosis. Detrusor fibers are divided to expose
bladder mucosa and the distal ureter is introduced
into the bladder to create a valve-like mechanism
(modified-Shanfield technique).
Introduction
Laparoscopic extravesical ureteral reimplanta-
tion (LEUR) is technically demanding and there-
fore currently only performed in a few centers
[1e3]. Continuous vesicoureteral anastomosis
performed deep in the pelvis requires advanced
laparoscopic skills and experience in minimally
invasive surgery in children [1,4]. We aim to
describe a novel simplified and reproducible
surgical technique for laparoscopic treatment of
megaureters in children.
Material and methods[3]
The patient is placed in a supine position with
slightly open legs. The operating table is placed in
Trendelenburg position and the surgeon and as-
sistant are standing at the head of the patient. A
urinary catheter is inserted in the sterile field at
the beginning of the procedure. Transperitoneal
approach with three ports is used in all cases: one
5 mm- 30 for the telescope at the level of the
umbilicus and two 3 mm ports at the left and
right lower abdomen. The ureter is identified at
Results
Between 2016 and 2020, 9 patients underwent LEUR
(5 female, 4 male). Mean age at surgery was 31.6
months (SD:22.74) and indications were infection (2),
obstruction (3), increase hydronephrosis (2) and
decrease in renal differential function (2). The pro-
cedure was completed laparoscopically in all cases
with a median operative time of 144 min (r: 120e160).
The postoperative MAG-3 renogram revealed a non-
obstructive pattern in 8/9 patients and MCUG
demonstrated absence of VUR in all 8/9. With a mean
follow-up of 2.4 years (SD:1.4) all are asymptomatic.
Conclusions
LEUR by this new simplified technique is a feasible
treatment of megaureters associated with good
short and long-term results.
the level where it crosses the iliac vessels and
mobilized to achieve a tension-free anasto-
mosis. An umbilical tape is passed around the
ureter for traction. Once dissected, the distal
ureter is transected at the level of the stenosis.
The ureteral stump is closed with an endoloop or
a simple ligation only in case of pre-existing VUR,
otherwise we left it open. The bladder is filled
with air to keep it distended and facilitate
identification of the mucosa. Using monopolar
scissors the peritoneum is incised to expose the
detrusor. Two trans-abdominal traction sutures
are placed on both sides of the top of the bladder
to allow exposure of the ureterovesical junction
and stabilize the anastomosis. The superficial
detrusor is cauterized and the remaining muscle
fibers are divided sharply with scissors until the
mucosa is exposed. An incision length of 2e3 cm
is sufficient since the antireflux mechanism in
this technique depends mainly on the valvular
mechanism of the ureteral segment introduced
into the bladder and does not rely entirely on the
length of the tunnel. The bladder mucosa is then
opened at the top of the detrusoromyotomy and
1e1.5 cm of the distal ureter are introduced into
the bladder to create a valve-like mechanism
 + MODEL
2 R. Gander et al.
similar to the Shanfield technique. The ureter is fixed to the
bladder mucosa with 4 stitches of absorbable sutures at
60 ,120 ,30 and 9’o clock. The detrusor is then closed over the
reimplanted ureter. No ureteral stent is left in place.
Results
9 patients underwent LEUR at our center (5 female, 4 male).
Mean age at surgery was 31.6 months (SD: 22.74). Indications
were: infection (2), obstruction (3), increase hydronephrosis
(2) and decrease in renal differential function (2). The pro-
cedure was completed laparoscopically in all cases without
intraoperative complications. Postoperative MAG-3 reno-
gram revealed a non-obstructive pattern in 8/9 patients. In
one patient the MAG-3 shows a flattened washout curve
(delay in drainage) but with no criteria of obstruction and
has been asymptomatic with a stable renal differential
function and is under follow-up. MCUG demonstrated
absence of VUR in 8/9 patients. Only one patient has a low-
grade residual VUR and remains asymptomatic. With a mean
follow-up of 2.4 years (SD:1.4) all are asymptomatic.
Discussion
The key point of this technique is not only to avoid a complex
vesicoureteral anastomosis, but also the need of ureteral
tailoring.
Conclusions
LEUR by this new simplified technique is a feasible treat-
ment of megaureters associated with good short and long-
term results.
Please cite this article as: Gander R et al., Laparoscopic extravesical ureteral reimplantation (LEUR) of obstructed megaureters: STEP-BY-
STEP video of a simplified approach, Journal of Pediatric Urology, https://doi.org/10.1016/j.jpurol.2021.06.030
Ethical approval
Ethical approval was not required.
Conflict of interest statement
All authors have seen and agreed to the submitted
version and we have no conflicts of interest.
Acknowledgement
We have no funding source to declare.
References
[1] Lopez M, Gander R, Royo G, Varlet F, Asensio M. Laparoscopic-
assisted extravesical ureteral reimplantation and extracorporeal
ureteral tapering repair for primary obstructive megaureter in
children. J Laparoendosc Adv Surg Tech 2017;27(8):851e7.
[2] Bondarenko S. Laparoscopic extravesical transverse ureteral
reimplantation in children with obstructive megaureter. J
Pediatr Urol 2013;9(4):437e41.
[3] Gander R, Asensio M, Royo GF, López M. Laparoscopic extra-
vesical ureteral reimplantation for correction of primary and
secondary megaureters: preliminary report of a new simplified
technique. J Pediatr Surg 2020;55(3):558e63.
[4] Laparoscopic extravesical reimplantation in children with primary
obstructive magaureter. J Laparoendosc Adv Surg Tech A 2020;26.
Appendix A. Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.jpurol.2021.06.030.