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Cohen Cross-Trigonal Technique
Cohens technique (1975) overcomes the limitation of the tunnel
length in the Glenn-Anderson technique by directing the tunnel
across the trigone toward the contralateral bladder wall (Figs. 137-190)
Paquin described this combined extravesical/intravesical technique
in 1959 (Paquin, 1959). The new ureteral hiatus is created from
outside the bladder, thus avoiding the difficulties associated with
this maneuver in the Politano-Leadbetter technique. As with most
of the other open techniques, a success rate greater than 95% for
primary VUR is achieved with this method (Woodard and Keats,
The ureter in the Paquin technique can be approached extravesically
(see Extravesical Procedures) before opening the bladder. A
right-angle clamp is applied at the UVJ, the ureter is divided, and a
3-0 polyglactin suture is used to suture ligate the original hiatus.
The bladder is then opened in the midline, and a new hiatus is
created, located cephalad to the prior position. The peritoneum is
carefully cleared off the back wall of the bladder at the site of the
new hiatus. A right-angle clamp is passed from inside the bladder
under direct vision, and one end of a 5-mm Penrose drain is pulled
into the bladder. A mosquito snap is applied to the Penrose drain,
which acts as a holder and facilitates the creation of the submucosal
tunnel. The mucosa is dissected off the detrusor circumferentially
at the new hiatus. The length of the submucosal tunnel is governed
by the diameter of the ureter, and a 5 : 1 ratio is usually achievable.
In more complex cases a psoas hitch may be required to achieve a
longer tunnel length. The tunnel is developed by carefully lifting
the mucosa off the detrusor using tenotomy scissors. Countertraction
on the mucosa is helpful, especially in cases that must be
redone and when the bladder wall is trabeculated. Once the tunnel
is developed the remainder of the reimplants is similar to the
Politano-Leadbetter procedure.
The modified Paquin technique is particularly suited for dilated
ureters and complex (El-Sherbiny et al, 2002) and failed reimplants
(Mesrobian et al, 1985) because of the versatility offered by the
combined extravesical/intravesical approach to the ureter and the
ability to achieve longer submucosal tunnel lengths.


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