Extravesical nondismembered ureteroplasty with detrusorrhaphy: a renewed technique to correct vesicoureteral reflux in children

Development and Validation of a Scoring System for Assessment of Clinical Failure after Pediatric Robot-Assisted Laparoscopic Extravesical Ureteral Reimplantation: A Multi-Center Study

We aimed to develop and validate a scoring system as an objective assessment tool for predicting clinical failure after pediatric robotic extravesical ureteral reimplantation. Data for this multi-institutional retrospective cohort was obtained from two tertiary referral hospitals. We defined clinical failure as incomplete radiographic resolution or post-operative febrile UTI. Patients were stratified into low, intermediate, and high-risk groups according to the score. External validation was performed using the model projected to the external validation cohort. An amount of 115 renal units in the development cohort and 46 renal units in the validation cohort were analyzed. The prediction score was calculated with weighted points to each variable according to their regression coefficient as age (year) + BMI + BBD times 10 + VUR grade times 7 + console time (h) + hospital stay times 6. The C-index of our scoring system was 0.850 and 0.770 in the development and validation cohorts, respectively. Clinical failure was significantly different among risk groups: 0% (low-risk), 3.3% (intermediate-risk), and 22.2% (high-risk) (p = 0.004) in the development cohort. A novel scoring system using multiple pre- and intra-operative variables provides a prediction of children at risk of failure after robotic extravesical ureteral reimplantation.

Ureteral reimplantation after deflux failure for vesicoureteral reflux in renal transplant

PURPOSE

To evaluate the outcomes of ureteral reimplantation (UR) after failure of endoscopic treatment for symptomatic vesicoureteral reflux (VUR) in renal transplant recipients.

METHODS

We conducted a monocentric retrospective study that included all renal transplant recipients with failure of Deflux™ as first-line treatment of VUR from January 2007 to December 2020. Failure of Deflux™ was defined by: VUR on retrograde cystography and at least one acute pyelonephritis of the renal graft. The preferred surgical treatment was native ureteropyelostomy (NPUS) in the recent years. If the native ureter could not be used, ureteroneocystostomy (UNC) was performed. The primary outcome was the clinical efficacy of UR defined as the absence of acute graft pyelonephritis during follow-up.

RESULTS

Out of 1565 kidney transplantations, 119 (7.6%) had symptomatic VUR treated with bulking agent. 35 (29.4%) had Deflux™ failure and were addressed to UR: 21/35 (60%) NPUS and 14/35 (40%) UNC. The median estimated blood loss, operative time, and length of stay were 120 mL, 90 min, and 7 days, respectively. After a median follow-up of 7.1 (IQR 4.1-9.8) years, UR was clinically successful in a total of 32 patients (91.4%): 20 (95.2%) and 12 (85.7%) patients in the NPUS and UNC groups, respectively (p = 0.55). Three (8.5%) high-grade complications have been reported. No nephrectomy of native kidney was required in the NPUS group.

CONCLUSIONS

After failure of Deflux™ for VUR of renal graft, surgical treatment with native ureteropyelostomy or ureteroneocystostomy is associated to a high success rate and few high-grade complications.

Preoperative Bladder Bowel Dysfunction Is the Most Important Predictive Factor for Postoperative Urinary Retention After Robot-Assisted Laparoscopic Ureteral Reimplantation via An Extravesical Approach: A Multi-Center Study

Introduction: Postoperative acute urinary retention (pAUR) is a known occurrence after robot-assisted laparoscopic ureteral reimplantation via an extravesical approach (RALUR-EV). We hypothesized that the risk factor of pAUR after RALUR-EV might be similar to that of pAUR after open reimplantation. We aimed at performing a retrospective multi-institutional study to evaluate the risk factors for pAUR after RALUR-EV. Materials and Methods: Perioperative data collected from two tertiary referral hospitals included demographics and perioperative variables such as bladder bowel dysfunction (BBD) status, vesicoureteral reflux (VUR) grade, and laterality. pAUR was defined as the need for urethral catheter replacement after removal of the initial postoperative catheter. Univariate and multivariate analyses were performed to identify risk factors for pAUR. Results: A total of 117 patients with 174 renal units from the 2 hospitals were enrolled in this study. The median age at the time of surgery was 5 (0.3-19) years. Bilateral RALUR-EV was performed in 57 (48.7%) cases. pAUR rate was 3.4% in all patients and 7.0% in 57 patients with bilateral VUR. All four cases of pAUR occurred after bilateral surgery. Univariate analysis showed age (p = 0.037), weight (p = 0.039), height (p = 0.040), and bilaterality (p = 0.037) as risk factors of pAUR. In a multivariate analysis, BBD was the only significant risk factor of pAUR (p = 0.037). Conclusion: Urinary retention after RALUR-EV occurred less frequently when compared with the previously reported open surgery series. pAUR was seen only in bilateral cases in our series. Preoperative history of BBD, but not male gender or length of surgical time, was the only risk factor of pAUR after RALUR-EV.

Vesicoureteral antireflux surgery with Lich-Gregoir technique without vesical drainage: Long-term results

OBJECTIVE

To describe our long-term experience with patients with vesicoureteral reflux (VUR) who underwent conventional surgery without postoperative bladder drainage.

MATERIAL AND METHODS

Retrospective review of 45 patients surgically treated by extravesical Lich-Gregoir's ureterovesical reimplantation without postoperative bladder drainage between 2010 and 2013.

RESULTS

37 women (82.2%) and 8 men (17.8%). 28 patients with unilateral reflux, and 17 patients with bilateral reflux with a total of 62 operated kidneys. The mean age at surgery was 6 years (2 to 11 years). The main cause of surgical indication was the persistence of reflux in patients older than 6 years (73.3%); with grade III VUR (75.6%) being the most frequent. The mean surgical time was 44minutes (35-70) for unilateral reimplantation, and 70minutes (53-98) for bilateral ones. All patients presented spontaneous urination in the immediate postoperative period, without pain, no hematuria, full incontinence, and without a bladder balloon. None required bladder catheter placement, and hospital discharge was indicated between 7 and 36hours postoperatively (mean 11h). All continued with spontaneous micturitions, without postvoid residual or voiding dysfunction during the 5-year follow-up.

CONCLUSION

The thorough selection of the patients, the detailed surgical gestures, the bladder emptying without instrumentation of the urethra, together with a correct use of analgesics and early ambulation allowed excellent outcomes obtained in these patients managed with a short hospital stay and without bladder drainage, also demonstrating the safety of the procedure at 5 years of follow-up.

Avoiding routine postoperative voiding cystourethrogram: Predicting radiologic success for endoscopically treated vesicoureteral reflux

INTRODUCTION

Variability in the success rates for the endoscopic correction of vesicoureteral reflux (VUR) has prompted a debate regarding the use of routine postoperative voiding cystourethrogram (VCUG). This study examines the predictive performance of intraoperative mound morphology (IMM) and the presence of a postoperative ultrasound mound (PUM) on radiologic success, as well as investigates the role of using these two predictive factors as a composite tool to predict VUR resolution after endoscopic treatment.

METHODS

This retrospective study included children with primary VUR who underwent endoscopic correction with a double hydrodistension-implantation technique (HIT) and dextranomer/hyaluronic acid copolymer. IMM was assessed intraoperatively. The presence of a PUM and VUR resolution were assessed by postoperative ultrasound (US) and VCUG, respectively. Radiologic success was defined as VUR resolution.

RESULTS

A total of 70 children (97 ureters) were included in the study. The overall radiologic success rate was 83.5%. There was no statistically significant association between radiologic success and IMM (85.2% with excellent and 87.5% with "other" morphology; p=0.81). The sensitivity and specificity of PUM for radiologic success in this study was 98% and 71%, respectively, while the sensitivity and specificity of the combined prediction model were 81.9% and 85.7%, respectively.

CONCLUSIONS

We objectively demonstrated that IMM was a poor predictor of radiologic success and should be used with caution. In addition, the performance of a combined prediction model was inferior to the presence of a PUM alone. As such, selective use of postoperative VCUG may be guided solely by the presence of a PUM.

Extravesical approach in paraureteral bladder diverticulum: a case report

Bladder diverticulaeare herniations of bladder mucosa through fibers of the detrusor muscle. We present the extravesical approach to a case of paraureteral bladder diverticulum in a six-year-old boy who had a history of recurrent urinary infection. In case of recurrent urinary complaints, the possibility of presence of a bladder diverticulum should be kept in mind. Voiding cystourethrogram is helpful for the differential diagnosis of the bladder diverticulum. Excision by extravesical approach of the paraureteral bladder diverticulum is a good choice.

Evaluation of a process-of-care model for open intravesical ureteral reimplantation in children from a contemporary health care perspective

INTRODUCTION

Surgical management of patients with vesicoureteral reflux consists of both open and minimally invasive approaches. Open approaches are associated with postoperative hospitalization and stays of 2 to 3 days, dependent on the type of procedure; alternately, when endoscopic correction is performed, it is a same-day procedure. Changes in health care policy emphasize reduction in cost while maintaining and improving quality of care. We sought to evaluate the impact of a "1-night cost-saving process-of-care" model for open surgical correction of vesicoureteral reflux in children on quality of care, which was defined as a return to the emergency room (ER)/office or readmission to the hospital within 2 days of discharge.

MATERIALS AND METHODS

An institutional review board-approved retrospective chart review of all open ureteral reimplantations for uncomplicated vesicoureteral reflux from January 2009 through January 2013 was performed. Children who underwent ureteral stent placement and those who did not have a caudal anesthetic were excluded from the study. Length of postoperative stay, ER records, hospitalizations, and office records were reviewed to assess for presentation to the ER/office or readmission to the hospital within 2 days of discharge.

RESULTS

During the 4-year study period, 92 children (23 males, 69 females) underwent open ureteral reimplantation-there were 83 (89.1%) discharges on the first postoperative day; 9 (9.8%) on the second postoperative day; and 1 (1.1%) on the third postoperative day. One patient presented to the ER within 2 days of discharge, and 4 patients presented to the ER/office or were readmitted > 2 days after discharge.

CONCLUSION

Use of a caudal anesthetic, earlier catheter removal, a knowledgeable nursing team, and parental education allowed us to decrease the length of stay to 1 night in 82 of 92 patients (89.1%). These procedural changes allowed for a decrease in hospital stay comparable with and potentially shorter than robotic-assisted laparoscopic approaches. Additionally, these changes did not seem to increase the risk of early (≤ 2 days of discharge) presentation to the ER/office or readmission.

Laparoscopic extravesical transperitoneal approach following the lich-gregoir procedure in refluxing duplicated collecting systems: initial experience

INTRODUCTION

Vesicoureteral reflux (VUR) represents one of the most significant risk factors for acute pyelonephritis in children. Nephropathy with renal scarring is still the most concerning issue in VUR. Surgical correction to eliminate VUR is an important part of its management and this need is increasing for duplicated collecting systems (DCS). Laparoscopy may have a place in the treatment of VUR. We report our initial experience in the treatment of refluxing DCS by laparoscopic extravesical transperitoneal approach (LETA) following Lich-Gregoir technique. The aim of this study was to describe the evolution and evaluate the results and benefits of this technique.

MATERIALS AND METHODS

Between August 2007 and January 2010, 60 renal units in 43 children with VUR and deterioration of renal function on isotope renography were treated with LETA following the Lich-Gregoir procedure. Twelve patients had refluxing DCS in a lower polar system; three of them had bilateral VUR. Three cases of refluxing DCS were associated to obstruction. Two of them presented an ectopic ureterocele with adequate split renal function and another had an ectopic ureterocele with complete deterioration of upper polar renal function. Their mean age was 36 months (range: 15-80 months).

RESULTS

The mean surgical time was 90 minutes (38-140 minutes) in unilateral and 144 minutes (120-200 minutes) in bilateral VUR including cystoscopy. All procedures were successfully completed laparoscopically and the reflux was corrected in all patients. One-stage laparoscopic heminephroureterectomy with excision of ureterocele and ureteric reimplantation was done in 1 case, and ureterocele excision and ureteric reimplantation by LETA were done in 2 cases. The mean hospital stay was 27 hours. A cystogram was performed systematically in all patients at 45 days postoperatively; none of them presented recurrence of VUR. The follow-up period was 11 months (range: 2-24 months), without recurrence of VUR.

CONCLUSION

LETA following the Lich-Gregoir procedure in refluxing DCS is a safe and effective approach even in unilateral, bilateral simultaneous, and split renal function in duplicated systems. When refluxing DCS is associated with obstruction and total deterioration of upper polar function, heminephroureterectomy with excision of ureterocele and ureteric reimplantation can be safely and effectively performed in a single-stage laparoscopic procedure, which minimizes the hazards of traditional open surgical reconstruction. A shorter hospital stay, decreased postoperative discomfort, reduced recovery period, and a low morbidity to resolve VUR in DCS are the benefits of this technique, with success rates similar to the open technique.

Laparoscopic extravesical transperitoneal approach following the Lich-Gregoir technique in the treatment of vesicoureteral reflux in children

INTRODUCTION

Laparoscopy may have a place in the treatment of vesicoureteral reflux (VUR). We report our initial experience in the treatment of VUR by laparoscopic extravesical transperitoneal approach (LETA) following the Lich-Gregoir technique to describe the evolution and to evaluate the results and benefits of this technique for these patients.

MATERIALS AND METHODS

Between August 2007 and May 2009, 43 renal units in 30 children (23 female and 7 male) with VUR and deterioration of renal function on isotope renography (17 unilateral and 13 bilateral) were treated with LETA. The mean age was 52 (range, 15-183) months. Nine patients had a double total collector system associated with VUR in a lower system. Two of them had a ureterocele with adequate upper polar rein function, and another had a ureterocele with complete deterioration of upper polar rein function.

RESULTS

The mean surgical time was 70 (38-120) minutes in unilateral and 124 (100-180) minutes in bilateral VUR. All procedures were successfully completed laparoscopically, and the reflux was corrected in all patients. At the same time, 1 heminephrectomy and 2 ureterocele were removed by laparoscopy and endoscopy, respectively. We had 1 ureter leakage 15 days postoperation that underwent a redo reimplantation. In cases of bilateral VUR, 1 patient presented postoperative bladder emptying difficulty and required temporary urethral catheterization postoperatively. The mean hospital stay was 24 hours. A cystogram was performed systematically in all patients at 45 days postoperation; none of them presented recurrence of VUR. The follow-up was 11 (range, 2-24) months, without recurrence of VUR.

CONCLUSION

Laparoscopic extravesical transperitoneal approach in the treatment of VUR is a safe and effective approach even in unilateral, bilateral simultaneous, and double total collector system. The technique results in a shorter hospital stay, less postoperative discomfort, and reduced recovery period, with a low morbidity to resolve the VUR and with success rates similar to the open technique.

Bilateral extravesical ureteral reimplantation in toilet-trained children: short-stay procedure without urinary retention

OBJECTIVES

We have previously reported on the ability of toilet-trained children to undergo bilateral extravesical ureteral reimplantation with a 1-day hospitalization and without urinary retention using a critical pathway and modification of the surgical technique. The objective of this study was to determine whether additional refinement of the critical pathway and surgical technique could continue to result in 1-day hospitalization and possibly an outpatient procedure, without urinary retention, in toilet-trained children.

METHODS

We evaluated all toilet-trained children undergoing bilateral extravesical ureteroneocystostomy, with a critical pathway for preoperative education, operative management, and postoperative care. A modified technique was used that limits ureteral dissection, ureteral mobilization, and detrusor dissection to as distally as possible such that a 5:1 ratio of tunnel length to ureteral diameter can be accomplished. Patients followed a strict postoperative critical pathway, and parents received extensive preoperative and postoperative education. A child was required to fulfill 5 strict criteria to be discharged from the hospital.

RESULTS

A total of 84 patients underwent bilateral extravesical ureteral reimplantation. Of the 84 patients, 64 were girls and 20 were boys. The age range was 1.9-12.8 years (mean 4.6). The first 78 patients were discharged on the first postoperative day as planned. The next 6 patients in this series were discharged the same day as surgery as planned, using the modification of the critical pathway. All patients were able to spontaneously void postoperatively without any instances of acute or chronic urinary retention, acute urinary tract infection, or rehospitalization.

CONCLUSIONS

The results of this study further support our initial findings that bilateral extravesical ureteral reimplantation can be performed in toilet-trained children after a 1-day hospitalization without postoperative urinary retention. In the present study, this was also accomplished as an outpatient procedure.

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.

Robert Lich, Jr., M.D.: innovator in pediatric and adult urology

PURPOSE

Dr. Robert Lich, Jr. (1909 to 1987) advanced the foundation of knowledge in many areas in the field of urology. He is best known for his contributions to our understanding and management of vesicoureteral reflux.

MATERIALS AND METHODS

We reviewed the many articles published by Dr. Robert Lich, Jr., focusing on his work with vesicoureteral reflux. We describe the contributions made by a pioneering urologist who helped advance the foundation of knowledge concerning the etiology of vesicoureteral reflux and its surgical management. We discuss his novel ideas within the framework of surgical techniques of his time, and relate personal experiences from his colleagues and his wife.

RESULTS

Doctor Lich was a pioneer in adult and pediatric urology. He is remembered most for his innovative ureteral reimplant technique for the surgical management of vesicoureteral reflux.

CONCLUSIONS

Doctor Lich enriched the fields of adult and pediatric urology through a lifelong pursuit of scientific investigation and refinement of surgical practice. It is appropriate to review his innovative contributions to the management of vesicoureteral reflux as we experience yet another paradigm shift in our understanding and management of this condition.

[Primary vesicoureteral reflux and extravesical ureteral reimplantation in chidren]

PURPOSE

to assess the results of the Lich-Gregoire procedure in the treatment of primary vesicoureteral reflux (VUR).

MATERIALS AND METHODS

In a 2.5-year period, 141 children with primary VUR underwent a vesicoureteral reimplantation using the Lich-Gregoire procedure in 101 patients (158 ureters) and the Cohen procedure in 48 patients (68 ureters). Patients were evaluated retrospectively in a non randomized fashion and data were recorded about: age, indications for surgery, days with the bladder catheter, length of stay, and short and long-term complications.

RESULTS

The control average time was 1.71 years (from 8 months to 3.5 years). A) Early complications. No obstruction was seen in this series. Five children (8.6 of the bilaterally simultaneously operated) showed urinary retention, but only three needed replacement of the bladder catheter and only one of them needed temporary clean intermittent catheterization. Nausea, vomiting, pain and hematuria were sporadic and limited in time. B) Late complications. The long-term results were good (95%). Seven ureters (4.4%) had persistent VUR and 3 children (6.7% of the unilateral cases) had contralateral VUR. Only 3 ureters needed a new surgical treatment (2%) for persistent ipsilateral VUR. Short and long-term complications, days with bladder catheter and length of stay in the hospital were significantly smaller in the group of patients operated with Lich-Gregoire procedure than in patients operated with the Cohen technique.

CONCLUSIONS

The Lich-Gregoire procedure is a technique associated with shorter postoperative hospitalization and less discomfort, pain and hematuria than the intravesical technique. Both techniques were effective in correcting VUR. Extravesical reimplantation can cause transitory bladder dysfunction in a small percentage of the bilateral cases.

BILATERAL EXTRAVESICAL URETERAL REIMPLANTATION IN TOILET TRAINED CHILDREN: IS 1-DAY HOSPITALIZATION WITHOUT URINARY RETENTION POSSIBLE?

PURPOSE

Bilateral extravesical ureteral reimplantation has been associated with urinary retention. We developed a critical pathway and modification of surgical technique to determine whether the bilateral extravesical procedure could be performed in toilet trained children with patients discharged home after a 1-day hospitalization and without urinary retention.

MATERIALS AND METHODS

A total of 50 consecutive toilet trained children were evaluated after undergoing bilateral extravesical ureteral reimplantation using a modified technique that limits ureteral dissection, ureteral mobilization and detrusor dissection to as distally as possible so that a 5:1 ratio of tunnel length to ureteral diameter can be accomplished. No surgical dissection occurs in proximity to the obliterated umbilical artery, nor is the artery ligated. Patients follow a strict postoperative critical pathway, and parents receive extensive preoperative and postoperative education. A child is required to fulfill 5 strict criteria to be discharged from the hospital.

RESULTS

Patient age ranged from 1.9 to 12.8 years (mean 4.9), with 37 girls and 13 boys participating. All patients were discharged home on postoperative day 1. All patients were able to void postoperatively without any instances of urinary retention. None of the children had acute urinary tract infections or required rehospitalization. All patients had radiographic resolution of the vesicoureteral reflux on postoperative voiding cystourethrogram.

CONCLUSIONS

To our knowledge this is the first study to demonstrate that bilateral extravesical ureteroneocystostomy can be performed in selected patients without postoperative urinary retention and with uniform hospital discharge in 1 day. The critical pathway and limited dissection extravesical approach are essential for this success.

[Primary vesicoureteral reflux treatment in childhood: comparsion of two systematic review]

Many medical practices are being carried out unawares of their efficiency, or of their actual impact on the health of the patients, therefore it is necessary to consider the support of professional recommendations with scientific evidence.

THE PRIMARY OBJECTIVE

To perform a systematic review (SR) of the therapeutic management of primary VUR in pediatric urology.

MATERIAL AND METHODS

A systematic review has been performed, including scientific evidence-based medicine criteria, of the articles published in all of the available databases. Inclusion criteria concerning basic quality of the articles were considered essential, as well as exclusion criteria to be able to reject the articles.

RESULTS AND DISCUSSION

Subsequently, and following the critic reading of greater than 320 articles, statistical study of the grouped data was performed according to the type of treatment and to the benefits contributed by each treatment, and also to their undesirable effects. Finally we have made a comparison between our results and recent Cochrane Systematic Review. The following Conclusions were drawn from the results obtained and from the analysis of the texts. Both medical and surgical treatment present with similar effectiveness concerning resolution of grades I, II and III of VUR, and the former one is the recommended initial treatment following diagnosis. Endoscopic treatment is exactly as effective as open surgery for grades I, II and III with fewer undesirable effects secondary. There are no differences concerning the efficacy of the different injected substances. Not enough evidences exist for degrees IV and V that may recommend or advise against any of the treatments. In any degree of VUR, open surgical treatment is superior as far as medical treatment is concerned only regarding the number of acute pyelonephritis episodes during followup. This conclusion cannot be applied on endoscopic treatment.

Simplified Technique for Laparoscopic Extravesical Ureteral Reimplantation in the Porcine Model

BACKGROUND AND PURPOSE

Laparoscopic intravesical and standard Lich-Gregoir repair have been reported but are technically challenging. Herein, we present our experience with a simplified laparoscopic reimplantation of the ureter to correct vesicoureteral reflux (VUR).

MATERIALS AND METHODS

Bilateral VUR was created cystoscopically in six minipigs, as confirmed by a static cystogram 6 weeks later. The laparoscopic extravesical correction of VUR was performed utilizing a full-thickness cystotomy. The ureter was transposed inside the bladder, and a full-thickness bladder closure was performed. No attempt was made to cover the ureter with urothelium. No stents or catheters were utilized postoperatively. Three months after reimplantation, the animals were evaluated with serology, a static cystogram, an intravenous urogram (IVU), and gross pathologic and histopathologic examination.

RESULTS

The postoperative cystograms confirmed no reflux in all the reimplanted ureters and residual grade 1 to 3 reflux in the non-reimplanted ureters. All pigs voided normally and were completely continent. Cystoscopic evaluation revealed complete epithelialization over the reimplanted ureter. One surgical complication occurred: the ureter was incorporated into the bladder closure and became obstructed. The IVU in all other pigs demonstrated patent ureters with prompt function.

CONCLUSIONS

Laparoscopic reimplantation of the ureter utilizing this modified Lich-Gregoir approach corrected reflux in all animals. The full-thickness bladder incision and intravesical transposition of the ureter greatly simplifies the laparoscopic procedure. This laboratory experience encourages further clinical evaluation in the pediatric population with VUR.

Vesicoureteral reflux: surgical approaches

The treatment of vesicoureteral reflux has evolved over the past half-century from primarily surgical to nonoperative treatments. Although the benefits of surgical correction versus medical management are debated, the surgical techniques that have evolved are highly effective in correcting vesicoureteral reflux. Recently, the US Food and Drug Administration has approved an injectable implant of dextranomer/hyaluronic acid copolymer for use in children, making the endoscopic treatment of reflux a potential alternative to open surgical correction. This article reviews the different surgical techniques,postoperative management, and complications, as well as the various implants used in the endoscopic correction of vesicoureteral reflux and their outcomes.

RESULTS OF TAPERED URETERAL REIMPLANTATION FOR PRIMARY MEGAURETER: EXTRAVESICAL VERSUS INTRAVESICAL APPROACH

PURPOSE

Extravesical ureteroneocystostomy is an accepted technique for the surgical treatment of vesicoureteral reflux. However, many surgeons continue to use an intravesical technique when extensive ureteral tailoring is required in the case of primary megaureter. We present our experience and outcomes with these techniques.

MATERIALS AND METHODS

A retrospective cohort study was performed of all patients who underwent tapered ureteral reimplantation between 1990 and 2002. Patient demographics, surgical technique and outcomes were recorded. Patients with ureteral dilatation secondary to bladder or urethral pathology were excluded from study. A successful postoperative outcome was defined as improved hydronephrosis and no vesicoureteral reflux.

RESULTS

A total of 53 patients with 65 megaureters were identified. Mean patient age at surgery was 4.9 years and mean followup was 3.8 years. Primary obstructive megaureter was present in 31 renal units, while refluxing megaureter was present in 34. An excisional tapering technique was performed in all cases. An extravesical reimplantation was performed in 29 renal units and an intravesical reimplantation in 36. The success rate was 86% for intravesical and 76% for extravesical reimplantation. The success rate was 90% for obstructive megaureters and 74% for refluxing megaureters. Success rate for patients with voiding dysfunction was 93% with an intravesical approach but only 50% with an extravesical approach.

CONCLUSIONS

Extensive ureteral tailoring with an extravesical ureteral reimplantation may be performed safely and effectively for primary obstructive megaureter. Patients with voiding dysfunction or preoperative vesicoureteral reflux may benefit from an intravesical ureteral reimplantation.

Laparoscopic Extravesical Reimplantation for Postpubertal Vesicoureteral Reflux

BACKGROUND AND PURPOSE

Postpubertal vesicoureteral reflux is a rare occurrence. In the adolescent group, its repair can be a challenging open procedure. We present our preliminary experience with laparoscopic extravesical ureteral reimplantation for postpubertal vesicoureteral reflux.

PATIENTS AND METHODS

Six female patients with a mean age of 18.7 years presented with recurrent urinary tract infection secondary to vesicoureteral reflux. The indications for treatment were febrile urinary tract infection, recurrent pyelonephritis, renal scarring, and breakthrough urinary tract infection. The reflux was unilateral in all patients at the time of treatment, but one patient had previously experienced bilateral reflux and had persistent left-sided reflux following subureteral injection of Durasphere. This patient underwent bilateral laparoscopic extravesical ureteral reimplantation.

RESULTS

The mean operative times for the unilateral and bilateral procedures were 1.75 hours and 3.75 hours, respectively. The average length of stay in the hospital was 36 hours; five patients went home in <24 hours. The mean time to resumption of full activity was 8 days. All six patients had resolution of vesicoureteral reflux, as shown by radiographic studies, with a mean follow-up of 11.4 months.

CONCLUSION

Laparoscopic extravesical ureteral reimplantation for postpubertal vesicoureteral reflux has excellent outcomes with minimal postoperative morbidity. Long-term radiographic follow-up is needed.

Ureteral reimplantation for vesicoureteral reflux: comparison of minimally invasive extravesical with transvesical and conventional extravesical techniques

OBJECTIVES

To analyze and compare the different ureteral reimplantation techniques to clarify the decision making for surgical treatment of vesicoureteral reflux.

METHODS

From July 1995 to December 2000, 218 patients underwent antireflux surgery. The first 92 cases (143 ureters) were performed with the transvesical technique of Cohen (group 1), the next 37 cases (49 ureters) with the conventional extravesical technique (group 2), and the last 89 cases (113 ureters) with the new minimally invasive technique (group 3). The surgical time, length of hospital stay, postoperative side effects, frequency of pain control, and voiding cystogram findings to ensure the cessation of reflux for all patients were retrospectively analyzed.

RESULTS

The success rates were similar among the different procedures. All patients in group 1 required a suprapubic cystostomy, and three had blood clot retention. Four patients in group 2 had bladder inefficiency. The surgical time ranged from 139 to 181 minutes in group 1, 58 to 94 minutes in group 2, and 40 to 61 minutes in group 3. The length of hospital stay ranged from 2.8 to 5.5 days in groups 1 and 2, and no hospital stay was needed in group 3. The frequency of analgesic administration was significantly less in group 2 compared with group 1; however, no analgesia was required in group 3.

CONCLUSIONS

The results from our comparison show that the minimally invasive technique can be used as a simple and highly effective interventional procedure with less morbidity for the patient.

Bladder spasm in children after surgery for ureteric reimplantation

The primary aim of this study was to prospectively investigate whether there was an association between the duration of post-operative catheterisation and the incidence of bladder spasm in children following ureteric reimplantation surgery. A secondary aim was to investigate whether other surgical and post-operative factors had an effect on the incidence of bladder spasm.

Is Common Sheath Extravesical Reimplantation an Effective Technique to Correct Reflux in Duplicated Collecting Systems?

PURPOSE

We evaluate the outcome vesicoureteral reflux (VUR) in duplicated collecting systems compared to single collecting systems corrected using an extravesical detrusorrhaphy approach.

MATERIALS AND METHODS

We reviewed the records of 266 patients (422 ureters) treated for VUR using an extravesical approach between 1991 and 2001. Inclusion criteria were primary reflux in single (201 patients, 125 bilateral) or duplicated collecting systems (65, 31 bilateral) in patients not undergoing other concomitant surgery with at least 1 year of postoperative followup. The indication for surgical intervention was unresolved reflux (greater than 4 years) in more than 70% of patients. Postoperative evaluation included a voiding cystourethrogram at 3 months and 12 months if reflux was unresolved at 3 months. Also ultrasound was performed at 6 weeks or earlier if clinically indicated and 12 months.

RESULTS

Group 1 (duplicated collecting systems) and group 2 (single collecting systems) were comparable for age, sex distribution and reflux grade distribution. Overall success rate at 3 and 12 months was 94.7% and 98.9% for group 1, and 95.1% and 98.5% for group 2, respectively. The difference in success rate at 3 and 12 months was not statistically significant (p >0.05). Of note in both groups postoperative VUR was contralateral in more than 40% of cases. Postoperative hydronephrosis (Society for Fetal Urology grade 1, 2 or 1 increment in grade from preoperative status) was observed in 5.3% and 7.3% of ureteral units at 6 weeks in groups 1 and 2, respectively (p >0.05). At 12 months less than 1% of ureteral units exhibited low grade residual hydronephrosis. No high grade postoperative hydronephrosis was observed in either group, and there were no intraoperative complications. Postoperative urinary retention occurred in 4.7% and 4% of patients in groups 1 and 2, respectively (p >0.05).

CONCLUSIONS

Common sheath extravesical reimplantation is highly effective in treating VUR. The common sheath extravesical reimplantation for duplicated collecting systems is as effective in nonduplicated systems and is associated with minimal perioperative morbidity.

The long-term outcome of bilateral Cohen ureteric reimplantation under a common submucosal tunnel

OBJECTIVE

To analyse the results of bilateral Cohen reimplantation under a common submucosal tunnel, over an 18-year period.

PATIENTS AND METHODS

We retrospectively examined 102 children (35 boys and 67 girls, median age 5.5 years, range 0.5-13.5) who underwent bilateral antireflux ureteric reimplantation from 1983 to 2000 with a modified Cohen technique, re-implanting both ureters under a common submucosal tunnel in the mid-trigonal area, to treat primary vesico-ureteric reflux (VUR, 99 patients) or obstructive megaureter (three). The mean (range) follow-up was 10.6 (2-18) years.

RESULTS

The operation was successful in 198 of 204 (97%) ureters. One patient had vesico-ureteric stenosis in one ureter and was re-operated successfully. In two ureters in two different patients there was transient stasis after surgery caused by oedema within the tunnel, which gradually resolved. Two ureters in two other patients had reflux after surgery, which resolved spontaneously after 12 and 24 months, respectively. A 6-month old baby had anuria after surgery because of acute compression of both ureters within a narrow tunnel; this patient was re-operated, the tunnel widened and the obstruction resolved. None of 82 patients who had reached school age by the time of their last follow-up showed signs of voiding dysfunction.

CONCLUSIONS

The modified bilateral Cohen reimplantation with both ureters under a common submucosal tunnel offers very good long-term results in curing VUR or obstructive megaureter. Crossing one ureter upon the other within the tunnel does not predispose to long-term obstruction. From these results we recommend it as a reliable technique for surgically treating bilateral VUR or obstructive megaureter.

Subureteral polydimethylsiloxane injection versus extravesical reimplantation for primary low grade vesicoureteral reflux in children: a comparative study

PURPOSE

We compare the outcome of extravesical ureteral reimplantation to endoscopic polydimethylsiloxane (Macroplastique, Uroplasty, Inc., Minneapolis, Minnesota) subureteral injection for primary low grade vesicoureteral reflux in children.

MATERIALS AND METHODS

Between 1997 and 2000, 180 patients underwent polydimethylsiloxane injection (74, 108 ureters) or extravesical ureteral reimplantation (106, 166 ureters) for low grade vesicoureteral reflux. Low grade reflux was defined as grades I to III. Outcome analysis included success rates, de novo hydronephrosis, voiding efficiency, urinary tract infections and complications.

RESULTS

Mean patient age at surgery for the injection and surgery groups was 60 and 77 months, and mean followup was 12 and 15 months, respectively. Of the patients who underwent single injection 80.6% were cured of reflux at 3 months and 91.6% were cured at last followup. Success rate after reimplantation was 95.8% at 3 months which improved to 98.8% 1 year later. The success rate was significantly different between the injection and reimplantation groups at 3 and 12 months (p <0.01). Postoperative complications in the reimplantation group included transient urinary retention after bilateral surgery in 2 patients (3.3%), suprapubic fluid collections in 2 and wound seroma in 1. No complications occurred in the polydimethylsiloxane group.

CONCLUSIONS

Extravesical ureteral reimplantation has near perfect success with a low but definite complication rate. Polydimethylsiloxane offers high success rates for reflux in an ambulatory setting with no short-term complications. Currently, endoscopic polydimethylsiloxane injection is our preferred mode of therapy for low grade vesicoureteral reflux in children when surgical correction is indicated.

EXTRAVESICAL URETERAL REIMPLANTATIONS FOR THE CORRECTION OF PRIMARY REFLUX CAN BE DONE AS OUTPATIENT PROCEDURES

PURPOSE

Extravesical ureteral reimplantations are thought to be less morbid compared with traditional intravesical techniques. We believe a shorter length of stay can be achieved in children undergoing extravesical reimplantation for the correction of primary reflux without experiencing a reduction in quality of care.

MATERIALS AND METHODS

During a 16-month period 2 boys and 42 girls underwent extravesical ureteral reimplantation and received similar postoperative care by a single pediatric urologist (D. P. S.). These children were 1 to 14 years old (mean age 4.7) and underwent reimplantation for correction of primary vesicoureteral reflux due to breakthrough urinary tract infections, moderate/high grade reflux and parental desire. Unilateral and bilateral reimplantations were done in 21 and 23 children, respectively, and 9 underwent reimplantation of duplex systems. Each child received 0.25 to 0.5% marcaine locally instead of caudal at termination of the surgical procedure. Criteria for patient discharge home included sufficient urine output, toleration of a liquid diet, adequate pain control with oral analgesics and "parental readiness." Renal and bladder ultrasound was obtained no earlier than 1 month following surgery. Postoperative cystograms were obtained in any child with a febrile urinary tract infection or at parental request. Charts were reviewed for demographics, operative procedures, postoperative intravenous analgesic doses, catheter requirements and length of stay, defined as hours from surgery to discharge home. Surgical outcomes were analyzed specifically for perioperative complications and resolution of reflux on postoperative cystograms.

RESULTS

The length of stay for all children ranged from 5 to 30 hours (average plus or minus standard deviation 13.3 +/- 6.8). Of the children 31 (70.5%) were discharged home the same day while the remaining 13 (29.5%) went home the next day. When comparing the outpatient surgical group to those hospitalized for 1 night, there were no significant differences in age, operative times and technique (unilateral versus bilateral). Children discharged home the same day required significantly fewer doses of intravenous analgesics (1.7 +/- 0.23 versus 2.7 +/- 0.36, p = 0.025). Intravenous narcotics were primarily used in the recovery room and ketorolac tromethamine was administered on the surgical ward. Seven children were discharged home with urethral catheters due to urinary tract infection in 1, transient urinary retention in 4 and surgeon preference in 2. Those patients discharged home with an indwelling catheter had a significantly longer length of stay (hours) compared to those without catheters (20.3 +/- 8.3 versus 12.0 +/- 5.6, p = 0.026). The child discharged home with a catheter due to urinary tract infection was rehospitalized 2 days later and received 48 hours of intravenous antibiotics. Postoperative cystograms revealed resolution of reflux in 12 of 13 children (92.3%). One child with preoperative bilateral high grade reflux had unilateral reflux on postoperative cystogram. Followup of 41 children at 3 to 19 months (mean 9.1) revealed no other significant complications.

CONCLUSIONS

In our experience extravesical ureteral reimplantation for the correction of primary reflux can be done on an outpatient basis in the majority of children without an increase in morbidity. Pain management and catheter placement significantly influence length of stay in children undergoing extravesical ureteral reimplantation.

Extravesical ureteral reimplantations for the correction of primary reflux can be done as outpatient procedures

PURPOSE

Extravesical ureteral reimplantations are thought to be less morbid compared with traditional intravesical techniques. We believe a shorter length of stay can be achieved in children undergoing extravesical reimplantation for the correction of primary reflux without experiencing a reduction in quality of care.

MATERIALS AND METHODS

During a 16-month period 2 boys and 42 girls underwent extravesical ureteral reimplantation and received similar postoperative care by a single pediatric urologist (D. P. S.). These children were 1 to 14 years old (mean age 4.7) and underwent reimplantation for correction of primary vesicoureteral reflux due to breakthrough urinary tract infections, moderate/high grade reflux and parental desire. Unilateral and bilateral reimplantations were done in 21 and 23 children, respectively, and 9 underwent reimplantation of duplex systems. Each child received 0.25 to 0.5% marcaine locally instead of caudal at termination of the surgical procedure. Criteria for patient discharge home included sufficient urine output, toleration of a liquid diet, adequate pain control with oral analgesics and "parental readiness." Renal and bladder ultrasound was obtained no earlier than 1 month following surgery. Postoperative cystograms were obtained in any child with a febrile urinary tract infection or at parental request. Charts were reviewed for demographics, operative procedures, postoperative intravenous analgesic doses, catheter requirements and length of stay, defined as hours from surgery to discharge home. Surgical outcomes were analyzed specifically for perioperative complications and resolution of reflux on postoperative cystograms.

RESULTS

The length of stay for all children ranged from 5 to 30 hours (average plus or minus standard deviation 13.3 +/- 6.8). Of the children 31 (70.5%) were discharged home the same day while the remaining 13 (29.5%) went home the next day. When comparing the outpatient surgical group to those hospitalized for 1 night, there were no significant differences in age, operative times and technique (unilateral versus bilateral). Children discharged home the same day required significantly fewer doses of intravenous analgesics (1.7 +/- 0.23 versus 2.7 +/- 0.36, p = 0.025). Intravenous narcotics were primarily used in the recovery room and ketorolac tromethamine was administered on the surgical ward. Seven children were discharged home with urethral catheters due to urinary tract infection in 1, transient urinary retention in 4 and surgeon preference in 2. Those patients discharged home with an indwelling catheter had a significantly longer length of stay (hours) compared to those without catheters (20.3 +/- 8.3 versus 12.0 +/- 5.6, p = 0.026). The child discharged home with a catheter due to urinary tract infection was rehospitalized 2 days later and received 48 hours of intravenous antibiotics. Postoperative cystograms revealed resolution of reflux in 12 of 13 children (92.3%). One child with preoperative bilateral high grade reflux had unilateral reflux on postoperative cystogram. Followup of 41 children at 3 to 19 months (mean 9.1) revealed no other significant complications.

CONCLUSIONS

In our experience extravesical ureteral reimplantation for the correction of primary reflux can be done on an outpatient basis in the majority of children without an increase in morbidity. Pain management and catheter placement significantly influence length of stay in children undergoing extravesical ureteral reimplantation.

Are postoperative studies justified after extravescial ureteral reimplantation?

PURPOSE

We evaluated the usefulness of postoperative imaging studies after extravesical ureteroneocystostomy and identified patient subsets in which these studies are necessary.

MATERIALS AND METHODS

Records of 438 patients who had undergone extravesical ureteroneocystostomy from 1991 to 1997 were reviewed retrospectively. Study inclusion criterion was primary reflux with at least 1 year of postoperative followup. Grades I to III reflux were defined as low, and grades IV and V were defined as high. All patients were on prophylactic antibiotics. Evaluation included ultrasound and a voiding cystourethrogram 3 months postoperatively, and if reflux persisted the studies were repeated at 12 months.

RESULTS

A total of 438 patients (723 renal units) underwent extravesical ureteral reimplantation. At 3 months the procedure was successful in 93.2% of ureters (91.3% patients), and at 12 months the success rate increased to 97.9% of ureters (95.4% patients). There were 49 renal units in 38 cases that were refluxing at 3 months, 11 of which were contralateral. At 12 months reflux resolved spontaneously in 20 of 38 ipsilateral and 8 of 11 contralateral ureters. Of the remaining 18 ipsilateral units reflux was high grade preoperatively in 12 and persisted postoperatively in 4. There was a statistically significant difference in the success rate at 1 year between high (94%) versus low (99%) grade reflux (p = 0.007). Age and preoperative bladder function did not significantly affect the success rates but males had a lower success rate. Hydronephrosis was noted in 7.2% of ureters at 6 weeks and in only 0.005% at 12 months.

CONCLUSIONS

Extravesical reimplantation is successful in treating vesicoureteral reflux. Postoperative voiding cystourethrogram should be reserved for high grade reflux. Limiting these studies will help reduce patient discomfort and the cost of treatment.

Surgical management of vesicoureteral reflux

Vesicoureteral reflux (VUR) is a urologic condition in which there is a retrograde flow of urine from the bladder through the ureter back up to the upper urinary tract. The condition may be classified as primary or secondary and is more often identified in Caucasian females. The primary goal in the management of VUR is the prevention of pyelonephritis and subsequent renal scarring.

Urinary retention after bilateral extravesical ureteral reimplantation: does dissection distal to the ureteral orifice have a role?

PURPOSE

We evaluated the outcome and incidence of urinary retention after bilateral detrusorrhaphy using 2 modifications of the original Lich-Gregoir procedure.

MATERIALS AND METHODS

We evaluated the charts of 220 patients who underwent correction of bilateral vesicoureteral reflux using the extravesical approach from January 1991 to December 1997. Inverted Y detrusorrhaphy was performed in 154 patients and the advancing suture modification was done in 66.

RESULTS

The success rate using the advancing suture technique was 92.4 and 95.4% at 3 and 12 months, respectively. The Y detrusorrhaphy technique was successful in 91.6 and 97.4% of cases at 3 and 12 months, respectively. The difference in the techniques was not statistically significant. Urinary retention developed in 8.4% of the patients who underwent Y detrusorrhaphy compared to 15.2% of those who underwent the advancing suture technique (not statistically significant). However, patients with grades IV and V reflux, children younger than 3 years and boys had significantly (p <0.05) higher postoperative retention rates of 24.6, 35.6 and 20.3%, respectively, when all 220 patients were considered.

CONCLUSIONS

Each modification of the original Lich-Gregoir technique is highly effective for treating bilateral vesicoureteral reflux and each is associated with a low rate of temporary urinary retention. Although there seems to be a lower incidence of retention with the Y detrusorrhaphy technique, this was not statistically significant. Because of the higher incidence of urinary retention in young children, boys and/or patients with high grade reflux, we recommend that physicians consider a longer period of catheterization regardless of the technique chosen.

Lower ureteral reconstruction

Lower ureteral reconstruction is commonly performed in instances of congenital anomalies and ureteral injury. Keys to a successful outcome are an understanding of ureteral anatomy, familiarity with the principles of tissue handling, and the knowledge of various techniques of repair. This article presents some important and useful reconstructive techniques that can be considered in the management of patients with congenital anomaly or lower ureteral injury.

Voiding dysfunction after bilateral extravesical detrusorrhaphy

PURPOSE

Extravesical detrusorrhaphy has been successful for correcting unilateral vesicoureteral reflux, although its use in bilateral ureteral reimplantation has been questioned because of a reportedly high incidence of significant postoperative voiding dysfunction. We reviewed the incidence of voiding dysfunction after bilateral extravesical detrusorrhaphy during the last 5 years.

MATERIALS AND METHODS

From 1990 to 1995, 123 patients with a mean age of 5.8 years (231 refluxing renal units) underwent bilateral extravesical detrusorrhaphy. Patients requiring anticholinergic therapy or intermittent catheterization at surgery were excluded from study, although in 6 who were included voiding dysfunction had previously resolved.

RESULTS

Grades I and II vesicoureteral reflux persisted in 1 and 3 renal units, respectively, representing a 98.3% success rate. There was no postoperative upper urinary tract obstruction. Postoperatively voiding dysfunction developed in 8 patients (6.5%), including 2 with a history of voiding dysfunction. In 3 cases (2.5%) irritative voiding symptoms controlled with oxybutynin chloride resolved 2, 4 and 24 months postoperatively, respectively. In 5 patients (4%) temporary incomplete bladder emptying and/or urinary retention required outpatient Foley catheter drainage or intermittent catheterization for 2 to 21 days.

CONCLUSIONS

Bilateral extravesical detrusorrhaphy is a highly successful procedure with a low incidence of significant voiding dysfunction. Should this condition develop, in our experience it is transient and of minimal morbidity. We found an increased rate of postoperative voiding dysfunction in younger patients as well as in those with a history of resolved voiding dysfunction.

Incidence of contralateral vesicoureteral reflux following unilateral extravesical detrusorrhaphy (ureteroneocystostomy)

PURPOSE

The development of contralateral vesicoureteral reflux following different types of unilateral antireflux surgery has been reported to be as high as 22%. We review our recent experience with unilateral extravesical detrusorrhaphy in regard to the incidence of postoperative contralateral vesicoureteral reflux.

MATERIALS AND METHODS

Between 1990 and 1995, 72 children underwent unilateral extravesical detrusorrhaphy. Of 73 refluxing renal moieties (1 patient had reflux in both moieties of a completely duplicated kidney) reflux grade was II in 35 (48%), III in 25 (34%), IV in 11 (15%) and V in 2 (3%). Common sheath reimplantation for complete ipsilateral duplication was performed in 16 patients.

RESULTS

One patient had grade I postoperative ipsilateral vesicoureteral reflux resulting in a success rate of 98.6%. In 4 patients (5.6%) contralateral vesicoureteral reflux developed, and was grade II in 3 and grade I in 1. In all patients contralateral reflux resolved at 16, 17, 18 and 31 months of followup. No additional surgery was required in any patient. There was no association between the incidence of contralateral vesicoureteral reflux, and patient age, gender, preoperative ipsilateral reflux grade and presence of ipsilateral duplication.

CONCLUSIONS

Unilateral extravesical detrusorrhaphy is a highly successful procedure with a low incidence of postoperative contralateral vesicoureteral reflux. Should reflux develop, it is of low grade with a significant rate of spontaneous resolution.

Extravesical ureteral reimplantation: results in 128 patients

PURPOSE

We evaluated the results of extravesical ureteral reimplantation in children.

MATERIALS AND METHODS

We reviewed the records of 128 children (174 ureters) who underwent ureteral reimplantation via extravesical techniques. Primary vesicoureteral reflux was the most common diagnosis (73 patients).

RESULTS

The extravesical technique produced a successful result in all patients (no reflux or obstruction). The 2 complications included postoperative urosepsis and transient urinary retention.

CONCLUSIONS

Extravesical ureteral reimplantation is a reliable procedure with predictable results comparable to those of more traditional intravesical techniques.