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Indications and effectiveness of the
open surgery in vesicoureteral reflux
Suzi DEMIRBAG, MD
Department of Pediatric Surgery, Gulhane Military
Medical Academy, Ankara, TURKEY
• Vesicoureteral reflux (VUR) refers to the
retrograde flow of urine from the bladder into
the ureter.
• Reflux results from a congenital anomaly of
the ureterovesical junction (Primary VUR),
• Reflux from high-pressure voiding secondary
to posterior urethral valves, neuropathic
bladder or voiding dysfunction (Secondary
VUR).
• The prevalence of VUR in normal children has
been estimated at 0.4–1.8%
• Prenatally identified by ultrasonography the
prevalence was 16.2 %
• Siblings of children with VUR had a 27.4% risk
for VUR
The main goal
preservation of kidney function
The risk factors
• age
• sex
• reflux grade
• lower urinary tract dysfunction [LUTD]
• anatomic abnormalities
• kidney status
There are different options in the management of VUR,
from
-Observation with or without antibiotics prophylaxis
-Surgical intervention:
-open,
-endoscopic
-laparoscopic approaches.
Factors influencing the decision
• The risk of developing a UTI, and associated
risk factors for UTIs
– such as voiding dysfunction
• Risk of development of new renal scars,
• Chance for spontaneous resolution
Which patients should be selected for
surgery ?
The focus should be on selecting patients for
treatment by identifying those at risk :
• Recurrent Pyelonephritis
• VUR will not spontaneously resolve.
Rate of resolution of VUR
•
•
•
•
•
•
•
age at presentation
gender
grade of the reflux
laterality
mode of clinical presentation
ureteral anatomy
bladder/bowel dysfunction
Open Surgery
• Open ureteral reimplantation is still the gold
standard for surgical treatment.
• Success rates of 95% to 98% with low
complication rates.
Indications for Surgery
Absolute indication for surgical correction is the
• Failure of nonsurgical management
Relative indications include the following:
• High-grade reflux
• Anatomic problems,
– large para-ureteral diverticulum
– ureteral duplication;
• impaired renal growth
Controversial indications include
• Persistent reflux in girls after puberty
• Avoid the need for follow-up VUR evaluation or CAP.
The principles of surgical correction of reflux
•
•
•
•
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Defining the causes of secondary VUR
Sufficient mobilization of the distal ureter
Creation of a submucosal tunnel ( 5 : 1 ratio)
Attention to the entry point of the ureter
Attention to the muscular backing of the
ureter
• Gentle surgery
Open Surgical techniques for VUR
•
•
•
•
Politano-Leadbetter Technique
Glenn-Anderson Technique
Cohen’s Technique
Lich-Gregoir Technique
Laparoscopic ureteral
reimplantation
Robot-assisted laparoscopic
ureteral reimplantation
Advantages
• Cosmetic
• Short hospitalisation
Disadvantages
• Longer op.time
• Need more experience in
laparoscopy
Advantages
 Better view
 Better surgery
Disadvantages:
 Higher op. cost
 Longer op.time
Complications of VUR Surgery
Early Complications:
• Persistant reflux
• Contralateral Reflux
• Obstruction
Late Complications:
• Obstruction
• Recurrent or Persistant Reflux
Conclusion
• Factors that negatively influence resolution:
• Grade of reflux,
• Lower bladder volume or pressure at onset of
reflux,
• Age
• Sex
• Laterality of VUR,
• Anatomical problems,
• Abnormal or scarred kidneys,
• Bladder dysfunction
Conclusion
• The treatment of VUR → decreased rate of
pyelonephritis.
• Open surgery is still the gold standard for VUR
treatment
• There is no difference in the rate of renal
scarring, renal growth, and UTIs in patients
treated medically or surgically for dilating
VUR.
References
1-Austin JC, Cooper CS. Vesicoureteral reflux: who benefits from correction. Urol Clin North Am. 2010 May;37(2):243-52. doi:
10.1016/j.ucl.2010.03.012
2-Fonseca FF, Tanno FY, Nguyen HT. Current options in the management of primary vesicoureteral reflux in children. Pediatr Clin
North Am. 2012 Aug;59(4):819-34. doi: 10.1016/j.pcl.2012.05.012. Epub 2012 Jun 22.
3-Routh JC, Bogaert GA, Kaefer M, Manzoni G, Park JM, Retik AB, Rushton HG, Snodgrass WT, Wilcox DT. Vesicoureteral reflux:
current trends in diagnosis, screening, and treatment. Eur Urol. 2012 Apr;61(4):773-82. doi: 10.1016/j.eururo.2012.01.002. Epub
2012 Jan 11.
4-Tekgül S, Riedmiller H, Hoebeke P, Kočvara R, Nijman RJ, Radmayr C, Stein R, Dogan HS; European Association of Urology. EAU
guidelines on vesicoureteral reflux in children. Eur Urol. 2012 Sep;62(3):534-42. doi: 10.1016/j.eururo.2012.05.059. Epub 2012
Jun 5.
5- Khoury AE, Bagli DJ, Vesicoureteral reflux, Campbell-Walsh Urology, chapter: 122, pages:3267-3309, volume 4, 10th Edition,
Elsevier