Infection of the urinary tract after anti-reflux surgery

The mechanism of new onset contralateral reflux following unilateral ureteroneocystostomy

PURPOSE

We studied a population of patients undergoing unilateral antireflux surgery to determine the mechanism of new onset contralateral reflux postoperatively.

MATERIALS AND METHODS

A total of 141 patients underwent unilateral antireflux surgery via the Cohen, Glenn-Anderson or extravesical technique. The 18% of patients who had new onset contralateral vesicoureteral reflux were analyzed according to grade of initial reflux, presence of a Hutch diverticulum or duplex system and surgical technique.

RESULTS

Surgical technique did not influence the development of contralateral reflux. As grade of corrected reflux increased, a significant trend toward development of contralateral reflux was noted. A Hutch diverticulum was not a risk factor for contralateral reflux but reflux into a duplicated system was a distinct risk factor (26 versus 12% in single system reflux).

CONCLUSIONS

Our study supports the concept that new onset contralateral reflux may result from elimination of a pop-off mechanism. Surgical distortion of the contralateral hemi-trigone appears not to be responsible. Correction of severe (grade V) reflux and reflux into duplex systems put patients at particular risk for development of contralateral reflux postoperatively.

Outcome analysis of bilateral Cohen cross-trigonal ureteroneocystostomy

OBJECTIVES

The perioperative and long-term outcomes of children with vesicoureteral reflux (VUR) treated by cross-trigonal ureteroneocystostomy were ascertained.

METHODS

One hundred ten consecutive children with VUR who underwent bilateral cross-trigonal ureteroneocystostomy were studied retrospectively. Nineteen children with neurovesical dysfunction or megaureters requiring tapered reimplants were excluded. Outcome parameters of the remaining 91 children consisted of operative time, length of hospitalization, days of Foley catheter drainage perioperative complications, correction of reflux, subsequent morbidity, and parental satisfaction.

RESULTS

Of 182 renal units, 11 (6%) had grade 0 VUR, 18 (10%) had grade I, 43 (24%) had grade II, 59 (32%) had grade III, 36 (20%) had grade IV, and 15 (8%) had grade V reflux. The mean operative and hospitalization times were 180 minutes and 5.6 days, respectively. No postoperative complications occurred. Three children were lost to follow-up, and the remaining 88 children had an extended mean follow-up in excess of 3 years. Voiding cystourethrogram documented a 98.3% (173 of 176 renal units) success rate. Sixteen children (18%) experienced nonfebrile clinically symptomatic cystitis episodes and 3 children (3%) experienced one febrile episode each. Telephone parental survey of overall surgical experience revealed a 94% very satisfied, 2% satisfied, and 3% dissatisified rate.

CONCLUSIONS

Cross-trigonal ureteroneocystostomy is a safe and effective technique that is virtually complication free and has high parental satisfaction. The results of this study provide a baseline for comparison of non-operative treatment of reflux as well as laparoscopic and endoscopic techniques.

Complications of pregnancy in women after reimplantation for vesicoureteral reflux

The physiological changes of the urinary tract during pregnancy place women at increased risk of urological problems during that time. To evaluate how patients after ureteral reimplantation fared during this high risk period we contacted 67 women who had undergone ureteroneocystostomy with a minimum of 15 years of followup. Only those who underwent an operation for primary vesicoureteral reflux were included. Of the women 30 had been pregnant with 64 total pregnancies. During pregnancy 17 of the 30 women (57 per cent) had 1 or more urinary tract infections and 5 (17 per cent) had 1 or more episodes of pyelonephritis. There were 8 spontaneous abortions and 1 severe ureteral obstruction requiring cutaneous drainage until after delivery. There appears to be an increased risk of urinary infection and fetal loss in pregnant women who have undergone ureteral reimplantation as children. More frequent urinary screening and aggressive therapy during pregnancy are recommended in this high risk group.

Delayed spontaneous resolution of high grade vesicoureteral reflux after reimplantation

Significant (grade III/V or greater, International Reflux Study) postoperative vesicoureteral reflux was noted in 4 children who underwent technically satisfactory ureteral reimplantation. All patients had moderate to severe preoperative ureteral dilatation necessitating ureteral tapering in 3 of the 8 ureters reimplanted. Reoperation was considered in all 4 children but a conservative approach was used, with subsequent spontaneous resolution of the reflux 19 to 55 months after reimplantation. We conclude that even high grade reflux after satisfactory reimplantation can resolve spontaneously.