•The success of endoscopic treatment of VUR are as follows:

–Grades I and II: 78.5 %

–Grade III: 72 %

–Grade IV: 63 %

–Grade V: 51 %

•Endoscopic treatment of VUR can be repeated up to three times and this increases the overall success rate to 85 %.

•The most common complications following endoscopic treatment of VUR:

–Transient ureteral obstruction

–Urinary tract infection

–The success rates at 1 year are significantly lower than initial success rates

8.8.4Surgical Management

Surgical Treatment of VUR

•Open antireflux surgery

–An extravesical approach

–The Lich-Gregoire repair

–Extravesical detrusorrhaphy (Hodgson-Zaontz)

–An intravesical approach

–The Cohen cross-trigonal technique

–The Politano-Leadbetter procedure

–The Glenn-Anderson repair

•Laparoscopic antireflux operation

•Robotic assisted antireflux operation

•Endoscopic antireflux surgery

•The aim of open, laparoscopic and robotic assisted antireflux operations is reconstruction of the ureterovesical junction to create a lengthened submucosal tunnel for the ureter, which functions as a one-way valve preventing backflow of urine into the ureter as the bladder fills.

•There are several surgical techniques to achieve this:

–Open antireflux surgery

• An extravesical approach

–The Lich-Gregoire repair

–Extravesical detrusorrhaphy (Hodgson-Zaontz)

•An intravesical approach

–The Cohen cross-trigonal technique

–The Politano-Leadbetter procedure

–The Glenn-Anderson repair

–Laparoscopic antireflux operation

–Robotic assisted antireflux operation

–Endoscopic antireflux surgery

•The accepted indications for surgical treatment of VUR include the following:

–Breakthrough febrile UTIs despite adequate antibiotic prophylaxis

–Severe reflux (grade V or bilateral grade IV) that is unlikely to spontaneously resolve, especially if renal scarring is present

–Mild or moderate reflux in females that persists as the patient approaches puberty, despite several years of observation

–Poor compliance with medications or surveillance programs

–Poor renal growth or function or appearance of new scars

•The intravesical approach to correct VUR depends on the followings:

–Cystoscopy is performed and the bladder and ureteral openings are defined.

–The bladder is opened anteriorly via a low abdominal incision.

–The affected ureter or ureters if bilateral VUR is present are dissected and separated from their attachments to the bladder muscle and connective tissue.

–When enough length of the ureter is separated, the ureter is pulled across the trigone through a submucosal tunnel.

–The ureteric opening is sutured at the end of the tunnel to create the necessary 5:1 ureter length-to-diameter ratio.

•These are the basic principles of the Cohen cross-trigonal technique to treat VUR.

•This is the most popular intravesical technique used to treat VUR (Fig. 8.48).

•The Politano-Leadbetter procedure:

–The principle is similar to the Cohen technique

–The ureter is dissected completely free of its attachments and passed through a new muscular hiatus created higher on the bladder wall.

Fig. 8.48 A micturating cystourethrogram showing no VUR after anti-reflux surgery

–The ureter is then passed down through a submucosal tunnel, and the orifice is sutured to the mucosa at its original hiatal position.

•The Glenn-Anderson repair creates a new ureteral hiatus more distal to the original hiatus.

•Extravesical approach:

–This was developed in an effort to avoid the time and morbidity associated with the cystotomy and ureteral anastomosis required for intravesical repair.

–It is particularly useful in patients with unilateral reflux.

–The Lich-Gregoire repair:

•The bladder is approached via the retroperitoneum.

•The ureter is dissected from the detrusor muscle, but the orifice is left intact.

•A narrow furrow in the detrusor muscle is created, down to but not disrupting the mucosa, extending cephalad from the ureteral orifice.

•The distal ureter is then laid into this furrow and the detrusor closed over it.

•One complication of the extravesical approach is postoperative urinary retention, which generally resolves spontaneously.

•Rare reports of permanent voiding dysfunction and retention in patients undergoing bilateral extravesical procedures have led some

surgeons to use this technique only for unilateral VUR.

•Extravesical detrusorrhaphy (Hodgson-Zaontz):

–Following the initial dissection, the ureter is dissected extravesically down to the ureterovesical junction.

–The terminal ureter is dissected free from perivesical tissues except its attachment to the bladder mucosa which should remain intact.

–Electrocautery is used to incise the bladder muscle down to the mucosa for a 5-cm arc around the ureterovesical junction.

–The lateral edges of the incision are undermined to create a trough that will form a new bed for the ureter.

–It is important not to open the mucosa of the bladder.

–The ureter is then telescoped into the bladder so it courses within a long subepithelial tunnel.

–Neither a ureteral stent nor a perivesical drain is needed.

–An indwelling Foley catheter is left overnight.

•Laparoscopic and robotic assisted repair of VUR may be possible alternatives to open ureteral reimplantation.

•Post-operative follow-up:

–Continue prophylactic antibiotics

–A postoperative renal ultrasonography in 1–2 months.

–A nuclear cystography in 3 months

–Perform interval renal ultrasonography annually for 3 years

–After confirming resolution of VUR, discontinue antibiotic prophylaxis.

•Complications due to reimplantation of the ureters occur in less than 1 % of cases, and include the followings:

–Gross hematuria

–Bleeding in the retroperitoneal space

–Infections

–Ureteral obstruction

–Injury to adjacent organs

–Persistent reflux

–Recurrent UTIs despite antireflux surgery

•Gross hematuria:

–Gross hematuria after ureteral reimplantation is common.