Vesicoureteral reflux: surgical approaches

Asymmetrical primary vesicoureteral reflux: Which is the best surgical strategy?

INTRODUCTION

No report has been published regarding the recommended surgical treatment in patients presenting with symptomatic primary asymmetrical vesicoureteral reflux (VUR): high grade on one side and low grade on the contralateral side. The aim of this study was to evaluate the effectiveness and outcome of combined Lich-Gregoir extravesical reimplantation and subureteric Deflux® injection, of high grade and low grade VUR respectively. Non-inferiority to bilateral cross-trigonal reimplantation was investigated in terms of surgical complications, number of post-operative fUTIs and need for re-intervention.

PATIENTS AND METHODS

A monocentric retrospective study was undertaken of all consecutive children with primary asymmetrical VUR on MCUG treated over an 18-year period (2004-2022). Surgery was indicated following an episode of febrile urinary tract infection despite appropriate non-operative management. Demographic and clinical such as length of hospital stay for pain management, use of urinary Foley catheter and complications were analyzed.

RESULTS

A total of 80 children met the study criteria: 40 patients underwent bilateral cross-trigonal re-implantation (Group 1) and 40 patients the combined Lich-Gregoir extra vesical reimplantation and Deflux® sub ureteric injection (Group 2). Complication and success rates were comparable in the two groups. The median hospital stay was significantly shorter for Group 2, with 50 % of patients who were discharged on day 1. Moreover, the data showed a significant lesser need in number and length of bladder catheter and ureteral stents in Group 2.

DISCUSSION

The technique proposed overcome the inconveniences of the other procedures that are commonly used in bilateral RVU: difficulty in retrograde catheterization or ureteroscopy after bilateral cross-trigonal reimplantation, the risk of transient bladder dysfunction after bilateral extravesical reimplantation and the low rate of success for high grade reflux of the sub ureteric Deflux® injection. The main limitation of the study lies in its retrospective nature and in the relatively short median follow-up.

CONCLUSION

The combined Lich-Gregoir extra-vesical ureteral reimplantation and sub-ureteric Deflux® injection for the treatment of primary asymmetrical VUR is an effective alternative to the gold standard cross-trigonal ureteral reimplantation. Moreover, the position of the ureteric orifice is not modified in the eventuality of endourological procedures into adulthood.

Therapeutic Management of Children with Vesicoureteral Reflux

Contrasting data refer to therapies for vesicoureteral reflux (VUR), such as surgical treatments and continuous antibiotic prophylaxis (CAP). This study evaluated the effectiveness of these approaches in children with VUR, analyzing the recurrence of febrile urinary tract infections (UTIs) and the resolution of VUR after the treatment. A total of 350 pediatric patients underwent contrast-enhanced voiding urosonography (ceVUS) to diagnose a VUR, whereas renal scintigraphy evaluated potential scars. After 12 months from the treatment, the VUR, the relapse of febrile UTIs, and reflux-related nephropathy were analyzed. Twenty-seven children had recurrent febrile UTIs after surgical therapy, with a greater rate of relapses observed in III and V VUR grades. Thirteen patients who underwent surgery had scars, independently of VUR grades and gender, with evidence of chronic renal failure at the end of the follow-up period. A total of 140 subjects were treated with CAP, and 30% of them continued to suffer from febrile UTIs. Ninety-five patients with VUR underwent ceVUS after 12 months, with persistent reflux in fifty-two patients. All of them had severe VUR, correlating with the age at diagnosis and gender. CAP therapy prevented scarring better than surgery, especially in children with III and V grades of VUR. A late onset of VUR or VUR involving neonatal patients is rarely a reversible process. This study identified predictors of success or failure of surgical or CAP therapies, evaluating the relapse of UTIs or persistent reflux after the treatment and giving prognostic information in children with VUR.

Effectiveness of various treatment modalities in children with vesicoureteral reflux grades II-IV: a systematic review and network meta-analysis

BACKGROUND

Vesicoureteral reflux (VUR) is one of the most common risk factors of urinary tract infection (UTI) among children. Various treatment modalities including antibiotic prophylaxis, surgical or endoscopic corrections and conservative treatment were used depending on the severity of VUR. The aim of this study is to compare the effectiveness of these treatment modalities in children with VUR grades II-IV by conducting a systematic review and network meta-analysis.

METHODS

A systematic search from different databases was performed from their earliest records to December 2022 without any language restriction. Only randomised controlled trials were included in this study. Effectiveness of treatment modalities was mainly compared by UTI. Other outcomes for renal scarring and resolution by renal units were also measured between treatments.

RESULTS

A total of 11 studies with 1447 children were included in this study. While comparing with antibiotic prophylaxis in network meta-analysis for UTI recurrence, surgical treatment probably lowers the rate of UTI recurrence (Log OR -0.26, 95% CI -0.54 to 0.02, high quality). However, endoscopic treatment (Log OR 0.2, 95% CI -1.41 to 1.81, high quality) and conservative treatment (Log OR 0.15, 95% CI -0.45 to 0.75, high quality) revealed probably inferior to antibiotic treatment.

CONCLUSION

Both pairwise and network meta-analytic results probably showed no difference between the treatments in terms of their impact on UTI recurrence, progression of previous renal scars, or formation of new renal scars in children with VUR grades II-IV. These findings may offer a better understanding of each treatment and evidence-based suggestions for the choice of treatment, which should be individualised and based on the patient's risk factors.

Vesicoscopic vs. Open Ureteral Reimplantation According to Cohen and Leadbetter-Politano for Vesicoureteral Reflux

BACKGROUND

The minimally invasive implementations of the established open methods for the correction of primary vesicoureteral reflux have proven to be successful in terms of feasibility and safety. The aim of this study was to investigate to what extent pediatric patients benefit from vesicoscopic operations.

METHODS

Between 2010 and 2022, 224 children (359 ureters) underwent ureteral reimplantation for vesicoureteral reflux in our clinic. Children, operated on according to the COHEN technique, underwent an open approach in 39 cases, whereas 151 patients were operated on vesicoscopically. A total of thirty-four children have received a ureteral reimplantation according to the LEADBETTER-POLITANO technique: twenty-nine openly and five vesicoscopically. The open and vesicoscopic groups were compared with regards to perioperative data and postoperative course.

RESULTS

The mean operating time was significantly shorter for open than for the vesicoscopic procedures in the COHEN group (99 vs. 149 min, p < 0.001). Similarly, a comparison of ureteral reimplantations, according to LEADBETTER-POLITANO, favored the open procedure, although this was not significant (161 vs. 196 min, p = 0.135). There was no significant difference in the recurrence rate of all the groups. All procedures remained within the accepted range with a success rate of at least 96%. In the postoperative course, a significantly shorter hospital stay (4.1 vs. 7.9 days, p < 0.001 for COHEN-patients; 5.6 vs. 9.2 days for LEADBETTER-POLITANO-patients), as well as a significantly lower need for continuous analgesic administration, was observed for the vesicoscopic approaches of both methods (0.8 days in both vesicoscopic groups vs. 3.7 resp. 3.8 days in open groups, p < 0.001). In addition, the time of bladder drainage was significantly shorter in open techniques (7.2 vs. 1.9 days, p < 0.001 for COHEN-patients; 3 vs. 8.7 days for LEADBETTER-POLITANO-patients).

CONCLUSIONS

For almost all underlying causes, the surgical treatment of vesicoureteral reflux can be performed vesicoscopically, even if bilateral, in one session. Patients benefit significantly from the use of minimally invasive surgery in the postoperative course with faster mobilization, less need for analgesics, a shorter bladder drainage and a reduced hospital stay, compared with its open counterparts.

Does STING failure affect short-term graft functions in renal transplant patients: a single-center study

PURPOSE

The aim of the present study was to evaluate outcomes of symptomatic VUR treatment in transplant patients, compare open and endoscopic approaches in terms of graft functions, success rates, complications and recurrent UTIs.

METHODS

67 patients who undergone only STING and STING followed redo UNC due to symptomatic VUR after kidney transplantation were included into the investigation. Patients who had lower urinary tract dysfunctions were excluded from the trial. For 67 patients, baseline and before final surgery and 3rd month creatinine and GFR levels were recorded. Twenty-six of those 67 patients had redo UNC due to failed STING. The data of those patients were compared with the remaining 41 patients who had only STING.

RESULTS

In both groups no statistically significant variations in serum creatinine and GFR levels were detected during follow-up (p > 0.05). Serum levels after STING and in the 3rd month of redo UNC were compared. Although variation was observed in serum creatinine levels and in GFR levels, was not statistically significant (p: 0.59 and p: 0.23). The success rate of STING was %61.1 in 67 patients, and was not significantly different when three VUR grade groups (Grade 3 n:17, Grade 4 n:24, Grade 5 n:36) were compared (p > 0.05).

CONCLUSION

The present study revealed that subureteral endoscopic injection is cost effective and safe for the first-line treatment due to its minimally invasive nature, does not cause delay which leads to deterioration of graft functions. Redo-UNC has acceptable morbidity and complication rates, should be considered when STING is failed.

Robotic ureteral reimplantation and uretero-ureterostomy treating the ureterovesical junction pathologies in children: technical considerations and preliminary results

Robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR) and robotic ureteroureterostomy (RUU) are two mini-invasive surgical techniques that have begun to be performed in pediatric urology in recent years. RALUR has been employed especially for VUR treatment, while RUU is considered principally in case of complex doubled ureteral systems. Our aim is to discuss the safety and feasibility of these approaches in children, focusing on technical considerations and supporting their use in different anomalies and pathologies of the ureterovesical junction. We retrospectively collected data about 58 patients who underwent 44 dismembered RALUR (D-RALUR), 28 non-dismembered RALUR (ND-RALUR) and 5 RUU between May 2020 and December 2021. Indications for surgery were primary or secondary vesicoureteral reflux, megaureter, secondary UVJ obstructions, complicated doubled ureteral systems. Mean age was 3.5 years (range 0.6-12.9) and mean weight 17.1 (range 7.2-80). No intraoperative complications occurred nor conversion to open approach were reported. Major postoperative complications were reported in 11.7% of cases with a higher incidence for ND-RALUR. Mean hospital stay was 2.14 days (range 1-8). Success rate at the short-term follow-up was 91.9% for D-RALUR, 96.3% for ND-RALUR and 100% for RUU. RALUR and RUU are two feasible and safe procedures to perform in children. RALUR represents the most required and adequate technique in the treatment of UVJ pathologies, however, in selected cases RUU could represent an effective alternative that has to be considered.

Vesicoscopic Cross-Trigonal Ureteral Reimplantation for Vesicoureteral Reflux: Intermediate Results

For the treatment of vesicoureteral reflux, the introduction of vesicoscopic procedures offers new perspectives for improving patient comfort and quality. Our aim was to examine whether minimally invasive vesicoscopic cross-trigonal ureteral reimplantation (VCUR) would meet expectations. Between 2012 and 2021, 99 girls and 35 boys with high-grade vesicoureteral reflux (VUR) underwent VCUR. For two boys, we failed to establish the pneumovesicum, leading to conversion to open surgery. The mean age was 4.5 years, ranging from 10 months to 18 years. VCUR was successfully performed in 132 patients, including 75 patients with bilateral VUR and 12 children with double ureters with unilateral or bilateral VUR, corresponding to a total of 229 operated ureters. The mean time of operation was 151 min for all patients. There were no perioperative complications, with the exception of three cases of pneumoperitoneum without consequences. Postoperatively, we recognized three cases of acute hydronephrosis, two of them required transient drainage. Three patients developed extravasation of urine after the postoperative removal of the transurethral catheter, rapidly resolved by new drainage. In two patients, we combined VCUR with laparoscopic heminephrectomy and opposite laparoscopic nephrectomy, respectively. Overall, mean postoperative hospital stay was 4.2 days. We observed recurrent VUR in seven ureters, resulting in a success rate for VCUR of 96.9%. These results demonstrate the feasibility of VCUR and its potential to displace open surgery with high safety and wide applicability.

Trends in the surgical management of vesicoureteral reflux in Finland in 2004-2014

OBJECTIVES

Previous data on the trends of surgical treatment of vesicoureteral reflux outside USA are scarce. The aim of this study was to clarify the national trends of operative treatment of vesicoureteral reflux (VUR) in Finland.

METHODS

We analyzed national data from Finnish Care Register for Health Care on children (<16 years of age) surgically treated for VUR in 2004-2014.

RESULTS

Endoscopic injections of the ureteral orifices were primarily performed for 1212 and open ureteral reimplantation for 272 children. The use of both types of surgery decreased during the study period (p = 0.0043 and p < 0.001, respectively). The median age at surgery for VUR was lower in those treated with open ureteral reimplantation than those with endoscopic injections of the ureteral orifices [3 and 4 years, respectively] (p = 0.0001). The length of hospital stay was significantly longer (median 9.9 days) with open ureteral reimplantation compared to that (median 1.3 days) with endoscopic injections (p < 0.0001) and did not change during the study period. Reoperations were significantly more common in patients who were primarily treated with endoscopic injections (n = 146/1072, 14%) than with ureteral reimplantation (n = 7/230, 3%) (p < 0.0001).

CONCLUSIONS

While the best treatment options for VUR remain debatable, operative treatment of VUR has become less common in Finland. HIGHLIGHTS Recent data on the trends of treatment of vesicoureteral reflux outside USA are scarce. Surgical treatment for vesicoureteral reflux decreased in Finland during the study period. The length of stay was longer but reoperations were needed less often with ureteral reimplantation compared to endoscopic injections.

Comparison of Cohen and Lich-Gregoir ureteral reimplantation in the surgical management of primary unilateral vesicoureteral reflux in children

OBJECTIVE

Vesicoureteral reflux (VUR) represents one of the most significant risk factors for acute pyelonephritis in children. Various intravesical and extravesical techniques have been described for the surgical correction of VUR. The aim of our study was to compare the results of open intravesical and extravesical procedures for unilateral primary VUR in children.

METHODS

Between January 2012 and August 2018, 38 children with primary VUR who underwent open ureteral reimplantation surgery were retrospectively reviewed. The Cohen (intravesical) and the Lich-Gregoir (extravesical) approach were grouped as groups A and B, respectively. The groups were compared for age, gender, preoperative reflux grade, presence of lower urinary tract symptoms, operation time, discomfort and pain, analgesic requirements, duration of hematuria, postoperative complications, and hospital stay. All the parameters were statistically compared.

RESULTS

There were 38 patients in this study. Group A had 18 patients, and group B had 20 patients. The mean operative time was significantly shorter in group B than in group A. The mean hospital stay was also shorter in group B. The urethral foley stay period was 4.7±0.9 days 2±0 days (p = 0.000*), respectively, for group A and B. Macroscopic hematuria was seen in group A. The objective pain scale was worse after intravesical surgery. Analgesic requirements were higher in group A (p =0.131).

CONCLUSION

Intravesical and extravesical ureteroneocystostomy methods are equally successful and feasible in the treatment of primary unilateral VUR. The Cohen technique is associated with a longer and more painful hospital stay, gross hematuria, and longer operative time, compared to the Lich-Gregoir technique.

Endoscopic Treatment for Post-Transplant Vesicoureteral Reflux

INTRODUCTION

Vesicoureteral reflux (VUR) is one of the most common ureteric complications after kidney transplantation that might cause symptomatic infections which deteriorate graft function. Surgical reimplantation has been the standard treatment; recently, endoscopic injection has been an alternative approach. We report our endoscopic treatment results and analyze the long-term outcome, even in patients with less optimal graft function.

MATERIALS AND METHODS

A total of 16 patients and 19 symptomatic VUR were diagnosed at mean time of 88.3 months after their transplantation. The distribution of VUR grade was 1, 2, 8, 6, and 2 for grade I to V, respectively, with a mean VUR grade of 3.26 according to their voiding cystourethrogram images. Endoscopic Deflux injections were performed by a single urologist via rigid cystoscope with a beveled needle system. They were followed monthly thereafter.

RESULT

The average number of admissions due to symptomatic urinary tract infection was 2.68/person, and the mean creatinine level before endoscopic treatment was 1.63 mg/dL. The amount of Deflux injection was 0.7 to 1.2 mL per affected ureter; the mean creatinine level after endoscopic treatment was 1.41 mg/dL. The eGFR remained stationary in both eGFR > 60 and eGFR < 60 mL/min groups with a clinical success rate of 75% in both groups.

CONCLUSION

Endoscopic dextranomer-hyaluronic acid injection is a safe and feasible treatment option for VUR after kidney transplantation. Our data showed its efficacy in recipients whose eGFR is less than 60 mL/min.

Urologic complications in renal transplants

Urologic complications of renal transplant occur commonly and can have significant impact on graft function, survival, and patient morbidity. This review examines the prevalence of urologic complications, risk factors, diagnosis and options for management of the most common urologic complications.

Current status of robotic-assisted surgery for the treatment of vesicoureteral reflux in children

PURPOSE OF REVIEW

Although open ureteral reimplantation remains the gold standard for surgical correction of vesicoureteral reflux (VUR), robotic-assisted laparoscopic ureteral reimplantation (RALUR) holds promise and is becoming more widely utilized. The present article outlines primary operative techniques for RALUR, summarizes the current literature with respect to surgical outcomes and costs, and discusses early applications of RALUR to complex and reoperative cases.

RECENT FINDINGS

Intravesical and extravesical techniques for RALUR have been described. Published outcomes vary with respect to operational definitions of surgical success and reporting of complications. Several studies have directly compared RALUR and open reimplant, suggesting equivalent efficacy and safety. Recent noncomparative studies have reported lower VUR resolution rates and higher complication rates for RALUR, particularly in bilateral cases. The application of RALUR to reoperative surgery and cases requiring tapering and dismemberment is under very early investigation. RALUR is consistently associated with lower postoperative analgesic requirements and decreased hospital stay, but longer operative times and higher costs compared to open reimplant.

SUMMARY

Published outcomes after RALUR show mixed results that, on average, may be inferior to open reimplant. Future investigations should seek to identify patient-related and intraoperative factors associated with successful and unsuccessful outcomes.

Extravesical Ureteral Reimplantation Following Lich-Gregoir Technique for the Correction of Vesico-Ureteral Reflux Retrospective Comparative Study Open vs. Laparoscopy

Introduction: The aim is to compare the outcome of open versus laparoscopic Lich-Gregoir technique in patients with vesicoureteral reflux. We report a retrospective multicenter comparative study between open and laparoscopic extra-vesical ureteral reimplantation (EVUR) following Lich-Gregoir (LG) technique for the correction of Vesico-Ureteral Reflux (VUR). Materials and Methods: Between January 2007 and December 2015, 96 patients with VUR (69 females and 27 males) and deterioration of the renal function, underwent EVUR following LG technique. Fifty patients (16 males and 34 females) were operated by open surgery (group A). The mean age was 4.22 years-old, (14-147 months). Laparoscopic approach (group B) was performed in 46 patients (11 males and 35 females). The mean age was 4.19 years-old (15-110 months). We compared the results in relation to degree of VUR, operative time, hospital stay, post-operative pain medications, recovery time, complications, successful rate, recurrence, and follow-up. Statistical analysis was done used Chi square test for categorical variables and the Student t-test for continuous variables. P < 0.05 was considered significant. Results: In both groups no correlation was identified between age or weight and operative time, length of stay or total analgesia used. The mean operative time for group A was 63.2 and 125.4 min for unilateral and bilateral VUR, respectively, and for the group B was 127.90 and 184.5 min, respectively. There was no conversion in the laparoscopic group. Perioperative mucosal perforation of the bladder occurred in 6 patients of group A and 4 patients of group B and was immediately repaired. One patient had to be reoperated for leakage in group B. The mean duration of Morphine, IV and PO analgesia was shorter in group B. The mean hospital stay was 5.46 days for group A and 1.54 days for Group B. The success rate was 98% in group A and 97, 8% in group B. The mean follow-up was 3.67 years for the open and 1.54 years for the laparoscopic group. Transitory voiding dysfunction occurred in bilateral EVUR in one case in each group. Conclusion: Laparoscopic or Open approach for the correction of VUR following Lich-Gregoir technique is effective in unilateral and bilateral VUR with similar results. Laparoscopic approach reduces significantly (p < 0.05 in each item) post-operative pain medication, hospital stay, and allows for a faster return to normal activity.

Contemporary Management of Vesicoureteral Reflux

CONTEXT

Vesicoureteral reflux (VUR) remains the most interesting topic of pediatric urology due to the dynamic nature of recent controversial publications. Starting from the need for a diagnosis to the necessity and effectiveness of treatment in preventing scars, VUR remains in the mist. Although recent strong evidence helped as fog lights in this blurriness, more data are required for achieving crystal clearance. This article aims to summarize and discuss the current state of the evidence regarding VUR management.

OBJECTIVE

To provide a comprehensive synthesis of the main evidence in the literature on the current and contemporary management of VUR in children; to discuss conservative management with continuous antibiotic prophylaxis (CAP), especially its effectiveness and safety; and to review the current evidence regarding contemporary surgical techniques.

EVIDENCE ACQUISITION

We conducted a nonsystematic review of the literature using the recent guidelines and PubMed database regarding surveillance, CAP, endoscopic, open, laparoscopic, and robot-assisted ureteral surgical treatment.

EVIDENCE SYNTHESIS

Despite the striking results of previous studies revealing the ineffectiveness of CAP, more recent studies and their two fresh meta-analyses revealed a positive role for CAP in the contemporary management of VUR. One of the most interesting findings is the redundant rising of endoscopic correction and its final settlement to real indicated cases. Patient individualization in the contemporary management of VUR seems to be the keyword. The evidence in the literature showed a safe and effective use of laparoscopic and robot-assisted laparoscopic reimplantations.

CONCLUSIONS

The goal of VUR treatment is to prevent the occurrence of febrile urinary tract infections and formation of scars in the renal parenchyma. The approach should be risk adapted and individualized according to current knowledge. Individual risk is influenced by the presentation age, sex, history of pyelonephritis and renal damage, grade of reflux, bladder bowel dysfunction, and circumcision status.

PATIENT SUMMARY

Vesicoureteral reflux is a nonphysiological reflux of urine from the bladder through the ureters to the kidney. Treatment depends on the presentation of the vesicoureteral reflux (VUR). Therapeutic options range from watchful waiting to open surgery. This article aims to summarize and discuss the current state of the evidence regarding VUR management.

Treatment of vesico-ureteral reflux in infants and children using endoscopic approaches

Vesicoureteral reflux (VUR) represents one of the most significant risk factors for acute pyelonephritis in children. Endoscopic treatment of VUR dates back to 1981 when Matouschek first described injection of the ureteral orifice in an attempt to correct VUR. In addition, also Politano and colleagues and McDonald described successful correction of reflux using endoscopic techniques. After these reports subureteral Teflon injection (STING) came to be appreciated as a viable new way to less invasively correct one of the most common pediatric urologic problems. The technique is technically easy to perform and is usually performed as an outpatient procedure. It is performed in general anesthesia in children and may require repeat injections, particularly in patients with high-grade reflux. As for endoscopic technique, a main problem existed. The success in children with high grade reflux was less than reported for open or laparoscopic reimplant techniques. However, in the past 10 years, newer products have become available that are changing the indications for endoscopic correction. In these review, we analyzed the papers published in the literature on this topic to give to the readers an updated overview about the results of endoscopic treatment of VUR after 30-years of his first description.

Surgical Management of Pediatric Vesicoureteral Reflux: A Comparative Study Between Endoscopic, Laparoscopic, and Open Surgery

AIM

Our retrospective study compared the results of three surgical procedures for correction of pediatric vesicoureteral reflux (VUR): open Cohen, laparoscopic Lich-Gregoir reimplantation (LEVUR), and endoscopic subureteric injection (STING) procedure.

METHODS

We analyzed 90 patients (50 girls, 40 boys, average age 4.86 years) operated in two centers of pediatric surgery for VUR. Exclusion criteria were Grade 1 VUR, Grade 5 VUR with megaureters requiring ureteral tapering, secondary VUR, and patients already operated for VUR. Thirty patients underwent Cohen, 30 LEVUR, and 30 STING procedure. Follow-up included renal ultrasonography and voiding cystourethrography 6 months postoperatively. The statistical analysis was performed using χ(2) Pearson and Fisher tests.

RESULTS

Operative time was shorter using STING either for unilateral or bilateral correction (P = .001). Hospitalization was statistically shorter using STING and LEVUR compared to Cohen (P = .001). The pain scores were worse after Cohen (P = .001). Analgesic requirements were higher after Cohen (P = .001). Reflux persistence was higher after STING (10 cases versus 5 Cohen and 4 LEVUR). Cohen presented more complications compared to LEVUR and STING (P = .001). Intraoperative costs were higher for STING procedure (P = .001), while hospitalization costs were significantly higher for Cohen procedure (P = .001).

CONCLUSIONS

In children affected by VUR, open Cohen and LEVUR reported a higher success rate than STING procedure. However, Cohen procedure had a very long and painful hospital stay, more complications, more analgesic requirements compared to STING and LEVUR. Comparing the three techniques, it seems that LEVUR presents a high success rate similar to the Cohen procedure, but in addition, it presents the same advantages of STING procedure with no postoperative pain and a lower postoperative morbidity.

Outcomes of complex robot-assisted extravesical ureteral reimplantation in the pediatric population

INTRODUCTION AND OBJECTIVE

While open ureteral reimplantation remains the gold standard for surgical treatment of vesicoureteral reflux (VUR), minimally invasive approaches offer potential benefits. This study evaluated the outcomes of children undergoing complex robot-assisted laparoscopic ureteral reimplantation (RALUR) for failed previous anti-reflux surgery, complex anatomy, or ureterovesical junction obstruction (UVJO), and compared them with patients undergoing open extravesical repair.

STUDY DESIGN

Children undergoing complex RALUR or open extravesical ureteral reimplantation (OUR) were identified. Reimplantation was classified as complex if ureters: 1) had previous anti-reflux surgery, 2) required tapering and/or dismembering, or 3) had associated duplication or diverticulum.

RESULTS

Seventeen children underwent complex RALUR during a 24-month period, compared with 41 OUR. The mean follow-up was 16.6 ± 6.5 months. The RALUR children were significantly older (9.3 ± 3.7 years) than the OUR patients (3.1 ± 2.7 years; P < 0.001). All RALUR patients were discharged on postoperative day one, while 24.4% of children in the open group required longer hospitalization (mean 1.3 ± 0.7 days; P = 0.03). Adjusting for age, there was no significant difference in inpatient analgesic usage between the two cohorts. Three OUR patients (7.3%) developed postoperative febrile urinary tract infection compared with a single child (5.9%) undergoing RALUR (P = 1.00). There was no significant difference in complication rate between the two groups (12.2% OUR versus 11.8% RALUR; P = 1.00). A postoperative cystogram was performed in the majority of RALUR patients, with no persistent VUR detected, and one child (6.7%) was diagnosed with contralateral reflux.

DISCUSSION

Reported VUR resolution rates following robot-assisted ureteral reimplantation are varied. In the present series, children undergoing RALUR following failed previous anti-reflux surgery, with complex anatomy, or UVJO experienced a shorter length of stay but had similar analgesic requirements to those undergoing open repair. Radiographic, clinical success rates and complication risk were comparable. This study had several limitations, aside from lack of randomization. Analgesic use was limited to an inpatient setting, and pain scores were not assessed. Not all children underwent a postoperative VCUG, so the true radiographic success rate is unknown. A larger patient cohort with longer follow-up is necessary to determine predictors of radiographic and clinical failure.

CONCLUSION

Older children with a previous history of anti-reflux surgery were more likely to undergo RALUR. These children had success and complication rates comparable to younger patients following complex open extravesical reimplantation, which underscores the expanding role of robot-assisted lower urinary tract reconstructive surgery in the pediatric population.

Insertion of a single double-J stent for bilateral open ureteral reimplantation: introducing a novel technique and assessment of feasibility

PURPOSE

To propose a novel technique for bilateral placement of a single double-J stent during bilateral open ureteral reimplantation in order to reduce the intravesical length of stent and potentially minimize the irritative symptoms.

METHODS

A retrospective chart review was performed to find patients who underwent bilateral open ureteral reimplantation. According to the patient's age, an appropriate single double-J stent is used for stenting both ureters after open reimplantation using the Politano-Leadbetter technique. The stent is fixed to the bladder wall with a 4-0 chromic absorbable suture in the midline, superior to the intertrigonal ridge. A non-absorbable suture is also fixed to the stent in the midline as an extraction string.

RESULTS

From June 2009 to July 2013, 20 patients underwent bilateral ureteric surgery. Twelve (60 %) were female. Patients' age ranged from 3 months to 2 years. Double-J stents were successfully removed within 2 weeks postoperatively in all patients.

CONCLUSIONS

This technique might reduce the stent-related symptoms after open bladder surgery for bilateral ureteral surgery. Using this technique will reduce the redundant mass of ureteral stents in bladder and potentially minimize the trigonal irritation and subsequent pain and discomfort.

Vesicoureteral Reflux in Pediatric Age: Where are we Today?

Although the diagnosis of vesicoureteral reflux and of reflux nephropathy is a well-established and shared procedure, its treatment nowadays is still very controversial. New developments on the knowledge of pathophysiology of renal damage associated to reflux opened the way towards a different diagnostic work-up and different therapeutic approaches.

Recently, the “top-down” diagnostic approach has gained wider interest, versus the “down-top” protocol. The attention has recently focused on the renal parenchyma damage and less interest has been given to the presence and the radiological degree of vesicoureteral reflux.

The review criteria were based on an in-depth search of references conducted on PubMed, using the terms “vesicoureteral reflux”, “children”, “incidence”, “etiology”, “diagnosis”, “treatment” and “outcomes”. The selection of the papers cited in this review was influenced by the content and the relevance to the points focused in the article.

Conservative approaches include no treatment option with watchful waiting, long-term antibiotic prophylaxis and bladder rehabilitation. The operative treatment consists of endoscopic, open, laparoscopic and robotic procedures to stop the refluxing ureter.

No final consensus has been achieved in literature yet, and further studies are necessary in order to better define the subset of children at risk of developing progression of renal damage.

This review aims to clarify the diagnostic management and the urological-nephrological treatment of reflux in pediatric age, on the basis of a review of the best-published evidence.

The long-term incidence of urinary tract infection after endoscopic management of vesicoureteral reflux

OBJECTIVE

To evaluate the long-term urinary tract infection (UTI) rates after endoscopic correction of vesicoureteral reflux and the possible risk factors for urinary infection.

MATERIALS AND METHODS

A retrospective study of patients who underwent endoscopic management of vesicoureteral reflux at a single institution from 2001 to 2011 was performed. Patients were followed up for a minimum of 1 year. Voiding cystourethrograms were completed 3 months postoperatively. UTI questionnaire pertaining to the patient's UTI history before and after the surgery was mailed to each patient. Data were first evaluated looking only at culture-confirmed UTIs, and a second analysis included all patient-reported and culture-confirmed urinary infections. Factors considered in the analysis included sex, age, preoperative dimercaptosuccinic acid (DMSA) scan, reflux on postoperative voiding cystourethrogram, voiding dysfunction, and preoperative reflux grade.

RESULTS

Data on 175 patients for a minimum of 1 year were collected. There were 34 of 175 confirmed UTIs after endoscopic management, and 11 confirmed febrile UTIs. There were no significant predictors of febrile or afebrile UTIs in this group. Fifty-three of 175 patients (30%) experienced any UTI, 19 of which were febrile (10%). In this group, recurrent reflux was the only significant predictor of UTI (P=.03) and febrile UTIs (P=.04). Patients with more UTIs preoperatively were more likely to have a postoperative febrile UTI.

CONCLUSION

Rates of UTI and febrile UTI in endoscopic management are similar and no better than those for open ureteral reimplantation. Longer follow-up suggests an association of recurrent reflux and preoperative UTI rates as predictors of postoperative febrile UTIs. These patients benefit from closer postoperative observation.

Laparoscopic surgery of vesicoureteral reflux: an experience in 42 patients with the Lich-Gregoir extravesical technique

INTRODUCTION

Vesico-ureteral reflux (VUR) is a common congenital anomaly of the urinary tract in the pediatric population, existing controversy regarding its management. Patients selected for treatment options are offered, from endoscopic injection of substances sub-ureteral to ureteral reimplantation surgery.

OBJECTIVE

To evaluate the use of the laparoscopic surgical technique for the treatment of vesico-ureteral reflux, with an analysis of the procedure, results and complications.

MATERIAL AND METHODS

We evaluated a series of 50 ureteral units in 42 patients, who undergoing laparoscopic transperitoneal ureteral reimplant, using the classic technique of Lich-Gregoir detrusorrafia.

RESULTS

The mean operative time was 74 min. There were no intraoperative nor immediate postoperative. At longer follow-up VUR was cured in all cases.

CONCLUSIONS

Laparoscopic surgery is an effective alternative in the surgical treatment of vesico-ureteral reflux, with results comparable to open surgery techniques and over sub-ureteral injection techniques.

Patients with a history of infection and voiding dysfunction are at risk for recurrence after successful endoscopic treatment of vesico ureteral reflux and deserve long-term follow up

Aim of the Study:

Subureteral endoscopic injection of a bulking agent is an attractive alternative to open surgery or antibiotic prophylaxis for vesico ureteral reflux (VUR). Little information is available about long-term risk of recurrence after an initially successful treatment. Aim of this paper was to review short- and long-term success rate of endoscopic treatment in a single Center series after risk stratification of individual patients.

Materials and Methods:

The records of 126 patients who underwent Deflux injection for primary VUR were examined. Indications to treatment were an unvaried high grade VUR (IV-V) at 1 year from diagnosis and/or and recurrent urinary tract infection (UTI) on antibiotic prophylaxis even in the presence of mild grade VUR (III grade). Gender, age and mode of diagnosis, infections (UTI), voiding dysfunctions, VUR grade and side, renal function, number of treatments were correlated to outcome. Long-term evaluation was planned at a minimum of 1 year from the last negative post-injection cystogram (MCUG). A new MCUG and DMSA scan were also offered to those complaining new UTI episodes. Late recurrences were correlated to history and grade of reflux. Data were analyzed with Graph Pad Instat software; the Chi-square test was used for univariate comparisons, the Fisher's exact test for categorical variables.and multiple regression tests for factors influencing outcome.

Results:

M/F ratio was 62 to 64; median age at diagnosis was 28 months. VUR affected 198 renal units. Preinjection VUR grade was I in 1, II in 27, III in 107, IV in 59, and V in 4 units. Reduced DMSA uptake was evidenced in 51 units and scarring in 24. Median age at treatment was 34.5 months, for persistent high grade VUR (IV–V) in 55 patients and recurrent IVU in 92. Two hundred sixty seven injections were performed on 198 ureters. Complete resolution was documented by MCUG at 3-5 months in 68%, low grading < II in 20%, persistence or unsignificant reduction in 11%. Preoperative recurrent UTI, higher grade VUR, and bilaterality were correlated to a poorer surgical outcome. Among 80 successfully treated cases, 12 complained of persistent UTI. Recurrence of VUR was demonstrated in 31% of them. Deteriorated uptake or additional scarring in 25% was independent from VUR recurrence. Preoperative recurrent UTI and voiding dysfunction correlated significantly to late outcome.

Conclusions:

Preoperative recurrent IVU, together with high-grade reflux, seem to correlate to lower success rate of Deflux injection for primary VUR. Even after successful endoscopic treatment, long-term surveillance may be needed among these cases, mainly if voiding dysfunction is also recorded. Late recurring VUR must be actively excluded in case of new IVU episodes.

Hydronephrosis following ureteral reimplantation: when is it concerning?

OBJECTIVES

Hydronephrosis without obstruction is common prior to ureteral reimplant, especially in patients with high-grade VUR. Consequently, when hydronephrosis is present post-operatively, it is unclear when it should be concerning. We evaluated the finding of hydronephrosis in children undergoing reimplantation and its evolution following surgery.

METHODS

After obtaining IRB approval, we identified 938 children who underwent reimplantation at our institution from 1998 to 2006. Their pre- and post-operative US and clinical course were analyzed.

RESULTS

Hydronephrosis was observed in 24% pre-operatively and 21% post-operatively. 52% with pre-operative hydronephrosis had it post-operatively, while 12% without pre-operative hydronephrosis had it post-operatively. 71% of post-operative hydronephrosis resolved on average in 1.36 years. 19% didn't resolve and 0.1% had ureteral obstruction. Risk factors for post-operative hydronephrosis included increasing severity of VUR, and high degree of pre-operative hydronephrosis.

CONCLUSION

Hydronephrosis following ureteral reimplantation is not rare, and correlated to pre-operative evaluations. Post-operative hydronephrosis is frequently transient and benign, and usually resolves within the first 2 years. These patients do not require follow-up ultrasounds or further imaging, and can be followed clinically. Patients with high-grade VUR and hydronephrosis pre-operatively, however, are at risk for developing worsened hydronephrosis and should be followed with a 3-month post-operative ultrasound.

Endoscopic treatment of vesicoureteral reflux in children with posterior urethral valves

PURPOSE

We reviewed the clinical outcome of endoscopic injection therapy in children with vesicoureteral reflux persisting after posterior urethral valve ablation.

METHODS

We retrospectively reviewed the charts of 16 patients with posterior urethral valves who have undergone endoscopic injection to correct persistent reflux after successful relief of urethral obstruction. Breakthrough urinary tract infections, persistent high-grade reflux and failed ureteroneocystostomy were the indications of endoscopic antireflux surgery.

RESULTS

Reflux was grade I in 1, grade II in 3, grade III in 11 and grade IV in 4 ureters. Mean age at injection was 6.9 ± 3.8 years and the mean interval from initial intervention to injection was 4.3 ± 2.4 years. Injected material was dextranomer/hyaluronic acid in the majority (87.5 %) of cases. Reflux was resolved or downgraded in 12 ureters (63.1 %) after a single injection. All failed cases had urodynamically documented bladder dysfunction.

CONCLUSION

More than half of the patients with vesicoureteral reflux, persisting after initial valve ablation, showed complete resolution or significant downgrading in their reflux grade after endoscopic injection. Given the technical difficulties and potential complications of open surgical reimplantation in valve patients, endoscopic subureteral injection can be considered as an effective alternative to cure persistent vesicoureteral reflux.

Diagnosis and management of vesicoureteral reflux in children

Critical evaluation of previously accepted dogma regarding the evaluation and treatment of vesicoureteral reflux (VUR) has raised significant questions regarding all aspects of VUR management. Whereas the standard of care previously consisted of antibiotic prophylaxis for any child with VUR, it is now unclear which children, if any, truly benefit from antibiotic prophylaxis. Operative intervention for VUR constitutes overtreatment in many children, yet there are limited data available to indicate which children benefit from VUR correction through decreased rates of adverse long-term clinical sequelae. Studies with longer follow-up demonstrate decreased efficacy of endoscopic therapy that was previously hoped to approach the success of ureteroneocystostomy. Prospective studies might identify risk factors for pyelonephritis and renal scarring without antibiotic prophylaxis. Careful retrospective reviews of adults with a history of reflux might allow childhood risk factors for adverse sequelae to be characterized. Through analysis of multiple characteristics, better clinical management of VUR on an individualized basis will become the new standard of care.

Voiding cystography practices and preferences of North American pediatric urologists

PURPOSE

Little consensus exists regarding the choice of a specific modality of voiding cystography in the evaluation and management of vesicoureteral reflux. We hypothesized that choices of pediatric urologists are based on technical factors of the studies themselves, as well as institutional factors unique to their hospital(s). Therefore, we surveyed pediatric urologists to determine their current practices and preferences of modalities of voiding cystography.

MATERIALS AND METHODS

We mailed an anonymous survey of 40 questions to all fellows of the American Academy of Pediatrics Section on Urology.

RESULTS

Surveys were returned from 186 of 301 fellows (62%). Of the respondents 57% were in academic, 30% in private and 13% in mixed practices. Given a choice of fluoroscopic voiding cystourethrography, radionuclide cystography and voiding ultrasonography, fluoroscopic voiding cystourethrography was preferred by 98% and 96% of respondents for initial evaluation of urinary tract infection in males and females, respectively, 96% for assessment of prenatal hydronephrosis, 54% for followup of vesicoureteral reflux, 59% for screening siblings, and 63% and 66%, respectively, after open and endoscopic correction of vesicoureteral reflux. Voiding ultrasonography was preferred by less than 10% of respondents in all groups, and radionuclide cystography was preferred by the remainder. Voiding images of the urethra, child-friendliness of staff, sensitivity and accuracy were factors most important in choosing a test. Of the respondents 83% reported full-time access to pediatric radiologists at their primary hospital, although a minority had full-time access to pediatric radiologists at additional institutions. Sedation was used in some or most cases by 29%, rarely by 56% and never by 15% of respondents.

CONCLUSIONS

Pediatric urologists prefer fluoroscopic voiding cystography in all situations to evaluate vesicoureteral reflux but the proportion varies by indication. Diagnostic and patient issues are of greater concern than radiation dose. Variability in access to pediatric radiologists and ability to obtain the desired study may also alter ordering practices.

Endoscopic treatment of vesicoureteral reflux with polydimethylsiloxane in adults: do location and appearance of the ureteric orifice have a role in the success rates?

INTRODUCTION

Low success rate for high grade reflux and anatomical abnormality of ureteric orifices continues to be the most important dilemma of the endoscopic treatment of vesicoureteral reflux (VUR). The aim of this study was to evaluate the efficacy of endoscopic polydimethylsiloxane injection in adults with VUR concerning reflux severity and the status of the ureteric orifice.

MATERIALS AND METHODS

Fifty-three ureters (34 patients) were treated with endoscopic polydimethylsiloxane injection. The grade of VUR was I, II, III, IV and V in 2, 13, 25, 10 and 3 ureters, respectively. Any endoscopic characteristics of 'golf hole', broad appearance or lateral placement of ureteric orifices were classified as complex appearance ureters (CAU). Patients with persistent reflux were considered for second and third injections with the same material. Success was determined as no reflux.

RESULTS

The total success rate was 100, 92.30, 92, 80 and 66.66% for grade I, II, III, IV and V reflux after the third injection, respectively. The cure rates of ureters with normal appearance were 100, 88.88, 90, 100 and 100% for grade I, II, III, IV and V reflux. The cure rates of CAU were 100% for both grade II and III, 60% for grade IV and 50% for grade V reflux. The injected volumes per renal unit ranged between 0.2 and 3.2 ml (mean 1.05 ml).

CONCLUSIONS

Although there are disadvantages in the usage of higher volumes of injectable material for successful results and difficulty in subureteral injection both in high grade reflux and complex anatomical situations in adults when compared to children, our results indicate that endoscopic treatment of VUR is an effective therapy for adults.

Extravesical seromuscular ureteroneocystostomy: an effective and simple operation for treatment of vesicoureteral reflux

PURPOSE

To evaluate the success rate of extravesical seromuscular ureteroneocystostomy in the treatment of children with vesicoureteral reflux (VUR).

PATIENTS AND METHODS

In a prospective study from August 2005 to January of 2006, 15 patients (11 girls, 4 boys), median age of 9.5 years (range: 1-24 years), with high-grade VUR underwent operation. Urinary tract ultrasonography and voiding cystoureterography (VCUG) were the main diagnostic tools to detect VUR before the operation and at 3 months after the operation.

RESULTS

No VUR was detected at evaluation of 3-month postoperative VCUGs (14 cases, 93%). However, one child (7%) still had persistent VUR. This patient underwent reoperation and the length of the seromuscular tunnel was increased more with a favorable result. The overall success rate of this technique was about 93%.

CONCLUSION

Extravesical seromuscular ureteroneocystostomy is simple and effective method for the treatment of VUR in children.

Health-related quality of life in children with vesicoureteral reflux - impact of successful endoscopic therapy

OBJECTIVES

Endoscopic therapy for vesicoureteral reflux (VUR) using dextranomer/hyaluronic acid (Dx/HA) has become increasingly popular, but the subjective impact of this therapy and subsequent reflux resolution on health-related quality of life (HRQoL) remains unclear. The aim of this study was to address this issue.

MATERIALS AND METHODS

One hundred children (65 girls, 35 boys; mean age 4.46 years) cured of primary VUR by endoscopic treatment were retrospectively reviewed. The Glasgow children's benefit inventory (GCBI) - a validated, reproducible, post-interventional questionnaire consisting of four subscales - supplemented by sociodemographic and disease-specific questions was employed. The HRQoL benefit was calculated on a scale ranging from -100 (complete failure) to +100 (complete success) and correlated with supplementary data.

RESULTS

Total response rate was 88%. Mean total GCBI score was 28.4+/-20.3 representing a significant HRQoL amelioration. All GCBI subscores improved with the physical health subscale being most relevant. A gender-specific, significant difference in relative GCBI scores was discovered. Correlation with critical life events and time since operation proved the positive effect on HRQoL to be durable.

CONCLUSIONS

Resolution of primary VUR secondary to Dx/HA treatment significantly improves HRQoL. HRQoL is positively affected in many areas and not only in those directly associated with VUR. These improvements are not temporary, suggesting that successful Dx/HA therapy may be superior to medical management in terms of children's quality of life.

Treatment of vesicoureteral reflux after puberty

Vesicoureteral reflux is uncommonly diagnosed and treated after puberty. The natural history of uncorrected VUR after puberty is not documented. Postpubertal patients with recurrent pyelonephritis and VUR should be considered for treatment. Ureteral reimplantation, endoscopic injections, and laparoscopic or robotic ureteral reimplantation may be utilized. Endoscopic injection is an appealing option for these patients. The role of laparoscopic or robotic ureteral reimplantation in these patients is evolving.

Modified extravesical ureteral reimplantation technique for kidney transplants

PURPOSE

We describe a modification and evaluate a technique of extravesical ureteral reimplantation for kidney transplant.

MATERIALS AND METHODS

We reviewed the records of 120 kidney transplant recipients who underwent ureteral reimplantation via a modified extravesical technique. Follow-up evaluation included renal ultrasonography. Because reflux is not routinely assessed in transplant cases, only symptomatic reflux was considered a complication and accessed with voiding cystourethrography (VCUG). The urological complications evaluated included urinary fistula, ureteral stenosis and symptomatic vesicoureteral reflux.

RESULTS

The modified extravesical technique produced a successful result in 93.4% of patients with no symptomatic reflux or anastomotic obstruction. Anastomotic complications included stenosis in four patients, prolonged leakage and fistula in three patients, and symptomatic vesicoureteral reflux in one patient. Other urologic complications included complicated hematuria in three patients, postoperative urosepsis in one patient, and ureteral stenosis caused by extrinsic compression in three patients due to lymphocele (two patients) and by adhesions (one patient).

CONCLUSIONS

The modified extravesical ureteral reimplantation is a reliable procedure with predictable results comparable to those of more-traditional techniques and proved to be efficient without increasing the incidence of urological or anastomotic complications. This modified technique offers two advantages; removal of the ureteral stent with the urethral catheter without the need for a postoperative cystoscopy and facilitation of postoperative endoscopic maneuvers if needed.

Management of Nephrolithiasis After Cohen Cross-Trigonal and Glenn-Anderson Advancement Ureteroneocystostomy

PURPOSE

Ureteroneocystotomy is frequently performed for ureteral injury or vesicoureteral reflux. The Glenn-Anderson technique advances the ureteral orifice distal to its native position, while the Cohen technique crosses the orifice to the opposite trigone. Each treatment can alter access to the upper genitourinary tracts. We report our experience with subsequent nephrolithiasis in these patients.

MATERIALS AND METHODS

We performed a retrospective chart review of all patients treated with ureteroneocystotomy since 1980 who had nephrolithiasis.

RESULTS

Nephrolithiasis developed in 9 patients with prior Cohen ureteroneocystotomy and in 15 with prior Glenn-Anderson ureteroneocystotomy. Stones size was 2 to 20 mm (mean 6.4). In the Cohen group ureteroscopy was attempted and failed in 2 patients, requiring percutaneous nephrolithotomy. Attempted shock wave lithotripsy failed in 2 patients, of whom 1 required percutaneous nephrolithotomy and 1 required observation. Primary percutaneous nephrolithotomy was performed in 1 patient. One patient required nephrectomy for chronic pyelonephritis related to nephrolithiasis. Two patients had active stone disease and were awaiting further treatment, while 1 passed the stone. In the Glenn-Anderson group ureteroscopy was successful in all 4 attempts. Attempted shock wave lithotripsy in 2 patients was successful in 1. The other patient required subsequent percutaneous nephrolithotomy. Primary percutaneous nephrolithotomy was required in 2 patients. All other patients were asymptomatic and under observation.

CONCLUSIONS

Treatment for upper tract nephrolithiasis is effected by prior ureteroneocystotomy. Minimally invasive treatments were less successful after Cohen ureteroneocystotomy than after Glenn-Anderson ureteroneocystotomy. In this study patients with prior cross-trigonal ureteroneocystotomy required more invasive therapies for symptomatic nephrolithiasis.

Laparoscopic Extravesical Transperitoneal Approach for Vesicoureteral Reflux

INTRODUCTION

Laparoscopy may have a place in the treatment of vesicoureteral reflux. In this study, we present the results of laparoscopic extravesical transperitoneal treatment in 15 children (19 ureters) of vesicoureteral reflux.

MATERIALS AND METHODS

Between January 2001 and February 2004, 15 children (11 with unilateral and 4 with bilateral vesicoureteral reflux) were treated with extravesical reimplantation (Lich- Gregoir technique) via a transperitoneal laparoscopic approach. The mean age was 48.2 months (range 12-62), and there were 14 females and 1 male. Two patients had a double total collector system associated with reflux without ureterocele.

RESULTS

The mean surgical time was 110 minutes in unilateral and 180 in bilateral vesicoureteral reflux. All procedures were successfully completed laparoscopically and the reflux was corrected in all but one patient, whose grade III vesicoureteral reflux changed to grade I. We had 3 mucosal perforations without leakage. The longest hospital stay was 72 hours. After follow-up ranging 15-49 months, only one patient had urinary tract infection.

CONCLUSION

Laparoscopic extravesical transperitoneal reimplantation for vesicoureteral reflux is a safe and effective approach even in bilateral simultaneous and duplex ureters, with success rates similar to the open technique, and a dramatic reduction in postoperative stay. Mucosal perforation was treated by maintaining a Foley catheter for 3-4 days postoperatively.

Lich-Gregoir Reimplantation Causes Less Discomfort than Politano-Leadbetter Technique: Results of a Prospective, Randomized, Pain Scale-Oriented Study in a Pediatric Population

OBJECTIVE

There is a consensus that transvesical reimplantation is more appropriate in cases of bilateral vesicoureteral reflex (VUR). In contrast to that it is not yet clear which approach should be used in unilateral VUR. This prospective, randomized trial compared the benefits and drawbacks of the intravesical and extravesical techniques in terms of operative comorbidity.

METHODS

Forty-four children (29 girls, 15 boys, mean age, 67.23 mo) with unilateral VUR were assigned to two groups: 22 patients underwent Lich-Gregoir reimplantation and 22 underwent the intravesical Politano-Leadbetter technique. Follow-up evaluation included renal ultrasonography and voiding cystourethrography (VCUG) 6 mo postoperatively. The groups were compared for operative time, duration of hematuria, upper tract dilation, discomfort and pain, analgesic requirements, voiding dysfunction, and reflux persistency.

RESULTS

No child had persistent VUR. Contralateral degrees II VUR was noted in five patients without significant difference regarding the treatment (p = 0.345). It was transient in all cases. Operative time was shorter using the extravesical technique (66.73 min versus 79.28 min; p < 0.0001). Gross hematuria occurred only after intravesical reimplantation lasting 4.19 d (p < 0.00001). The objective pain score was worse after intravesical surgery (p = 0.002). Analgesic requirements were higher after the Politano reimplantation (p = 0.039).

CONCLUSIONS

Both unilateral extravesical and intravesical reimplantation definitively correct VUR. The mean operative time was significantly shorter using the Lich-Gregoir technique, which underlines its simplicity; additionally, gross hematuria can be avoided. Postoperative pain and bladder spasms were reduced using the extravesical approach. Consequently, it represents an effective surgical technique to correct reflux while operative morbidity is low. Therefore it is the method of choice in cases of unilateral VUR requiring correction.

Endoscopic treatment of vesicoureteral reflux

PURPOSE OF REVIEW

The treatment of vesicoureteral reflux in children has seen a shift from invasive surgery to endoscopic management in recent years. Early studies demonstrate favorable outcomes but do not reach the success of surgery. Subspecialization also may play a role in the successful outcomes of all reflux management. This review focuses on the recent literature regarding endoscopic treatment of reflux and the role of subspecialization in treatment of children.

RECENT FINDINGS

Dextranomer/hyaluronic acid copolymer has emerged as the favored bulking agent since its Food and Drug Administration approval in the United States. Although success is defined somewhat differently than surgery, overall success rates range from 82-89% with initial injection of dextranomer/hyaluronic acid. The outpatient nature of the procedure and its high success rate have led to a shift in treatment strategies especially in Europe, where endoscopic management is often considered first-line therapy. Extravesical reimplants can be performed on an outpatient basis safely. Subspecialization leads to improved outcomes with no difference in cost.

SUMMARY

Endoscopic treatment of reflux is promising, but long-term results are not available to ascertain the efficacy of treatment into adulthood. Open surgery remains the gold standard.