From laparoscopic to robot-assisted extravesical ureteral reimplantation: evolution of a new standard treatment for pediatric vesicoureteral reflux

BACKGROUND: This paper aimed to compare laparoscopic (LEVUR) vs. robot-assisted (REVUR) Lich Gregoir extravesical ureteral reimplantation (UR) in children with vesicoureteral reflux (VUR). METHODS: The charts of all patients with moderate to high-grade VUR (3 to 5), who received LEVUR or REVUR over a 10-year period (2014-2024), were retrospectively reviewed. RESULTS: Seventy-six patients (40 girls and 36 boys), with median age of 5.7 years (range 2-11) and moderate to highgrade VUR, were enrolled. VUR was unilateral in 55/76 (72.3%) and bilateral in 21/76 (27.7%). Patients were grouped according to the MIS approach and pathology side. The median operative time (OT) of unilateral non-dismembered UR was similar in LEVUR (65 min) and REVUR (50 min) (P=0.56). REVUR was faster than LEVUR in unilateral dismembered (90 vs. 120 min) (P=0.001) and bilateral UR (105 vs. 160 min) (P=0.001). The radiographic VUR resolution rate was similar between REVUR and LEVUR (97.8% vs. 96.7%) (P=0.89). Two patients (2.6%) reported low-grade persistent reflux without need for additional treatments. Mild bladder dysfunction developed in 2/21 (9.5%) undergoing bilateral UR (Clavien-Dindo 2). CONCLUSIONS: REVUR is technically easier, faster and provides better ergonomics compared to LEVUR. The postoperative outcomes are excellent in both techniques, with success rates higher than 95%. Complications developed after bilateral reimplantation in patients who had previous history of bladder dysfunction. Given the robot availability, we believe that the best indication for LEVUR remains unilateral reflux without need for ureteral tapering. In unilateral refluxing megaureter, para-ureteral diverticulum or bilateral cases, REVUR represents the best choice.