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Editorial Comment to Transvesical laparoscopic surgery for double renal pelvis and ureter with or without ureterocele

In this issue of the journal, Naitoh et al. retrospectively reported their experience with transvesical laparoscopic crosstrigonal ureteral reimplantation (TLCUR) in 10 pediatric and adult patients with double pelvis and ureter. The authors have compared their results between the patients with ureterocele and without ureterocele. Using the vesicoscopic approach, they carried out reimplantation of double barrel ureters with and without bladder reconstruction, respectively. TLCUR for treatment of vesicoureteral reflux has been reported from various institutions since 2001; however, still very few centers have attempted to utilize this technique. This is the first report of the use of TLCUR in the treatment of duplex kidney and ureters with and without ureterocele. The investigators did study a new technique in two groups of patients with reflux into duplex kidneys and recurrent febrile urinary tract infections: five patients with ureterocele who underwent prior endoscopic incision, and five with two intravesical ureteric orifices and no ureterocele. The surgical technique was described in detail. The report includes operative times, hospital stay, postoperative complications and urinary tract infection rate. The described procedure was technically very challenging, with a very long operating time. The theoretical advantages of laparoscopic surgery include the following: better cosmesis, shorter hospitalization, decreased pain, faster recovery and comparable success rates nearly identical to standard open repair. In the presented study, the mean operation time in patients with ureterocele was 304.6 min (range 242–346 min). In the group without ureterocele, the mean operation time was 207.8 min (range 150–249 min). The longer operating times compared with TLCUR of single refluxing ureters shows the procedure’s higher level of technical complexity, especially in patients with ureterocele. The success rate in reflux resolution was 70%, and an additional 30% downgraded their reflux to grade 1 or grade 2, without febrile UTI. This outcome might justify the longer operating time. These preliminary results show that endoscopic intravesical ureteral mobilization and cross-trigonal ureteral reimplantation can be carried out safely and effectively even in duplex ureters with ureterocele. This report is an excellent example for laparoscopic urologists of what is possible, safe and feasible. However, the surgical technique is very demanding and time-consuming, therefore it will be hard to apply into clinical practice. Thus, TLCUR appears to be a useful laparoscopic method, but only in institutions with a high level of competence in laparoscopic urology. Further refinement of the technique and critical analysis of the long-term outcomes are required to understand fully its place in the treatment of double ureters and ureterocele.