Open Antireflux Procedures
Open surgical treatment of reflux has been the gold standard. However, surgery is not without risks. The goal of antireflux surgery is to restore the flap-valve mechanism of the UVJ by establishing an adequate submucosal tunnel of intramural ureter. The 2 most commonly used open antireflux procedures are the Cohen technique and the Politano–Leadbetter technique. Some surgeons use the Lich–Gregoir technique. All these procedures, although effective, involve open surgery, prolonged in hospital stay, and are not free of complications, even in the best hands. Although open surgery achieves a success rate of 92% to 98% in grade II to IV VUR, the American Urological Association report on VUR reported persistence of VUR in 19.3% of ureters after reimplantation of ureters for grade V reflux. The rate of obstruction after ureteral reimplantation needing reoperation reported by the American Urological Association in 33 studies was 0.3% to 9.1%.
Cohen Cross-Trigonal Technique
A cystoscopy of the lower urinary tract is first recommended. The patient is then positioned supine with a slight break in the table to raise the hips. A transverse suprapubic skin incision (Pfannenstiel) is made. The subcutaneous tissues are incised and the rectus and pyramidalis muscles are split in the middle to expose the anterior bladder wall. A midline cystostomy is performed vertically. In order to flatten and elevate the posterior bladder wall, a Denis Browne ring retractor is positioned. This brings the trigone and the ueretric orifices into the middle of the operative field. Several moistened swabs are placed inside the dome of the bladder in order to stretch the posterior bladder wall and to expose the trigone. A 3 to 5 Fr. soft feeding tube is inserted into the ureteral orifice, as this helps with the dissection. The catheter is passed up to the kidney and fixed with a stay suture. The ureteric orifice is circumcised and the ureter is dissected out circumferentially (Fig. 66-3A) using a needle cautery tip to aid hemostasis. Lifting the tube helps with dissection. The ureteral dissection continues until the ureter is completely free and the peritoneum is identified. Subsequently, the submucosal tunnel is prepared (Fig. 66-3B). The tunnel is positioned just above the trigone, usually horizontal and crossing the midline of the posterior surface of the bladder. After the site of the new ureteric orifice is selected, the bladder mucosa is lifted from underlying bladder muscles using scissors. Through the opening in the mucosa toward the ureteral hiatus, a right-angled or curved mosquito clamp is positioned in order to grasp the tip of the feeding tube. The feeding tube is then gently pulled through the submucosal tunnel, paying attention not to twist or kink the ureter. This brings the ureter into place (Fig. 66-3C). In cases of bilateral reimplantation, the same procedure can be carried out for the opposite ureter and both ureters can be placed in the same submucosal tunnel. It is better to place the ureter with a higher grade of reflux above the ureter with lower reflux grade, as the upper ureter would normally have a slightly longer tunnel. The anastomosis is performed using fine absorbable sutures leaving the feeding tube in position. The feeding tube is then removed and reinserted into the ureter to make sure that the feeding tube passes smoothly through the submucosal tunnel. It is also important to watch for urinary efflux. The feeding tube is exteriorized through the bladder wall, the rectus muscle, and the skin. The cystostomy is closed in 2 layers using running absorbable sutures. The bladder mucosa is closed using running absorbable sutures. It is not necessary to leave the ureter stented unless there is bladder wall oedema or it is a secondary procedure.
A. The ureteric orifice is circumcised and the ureter is dissected out circumferentially. B. The submucosal tunnel is prepared. C. A right-angled or curved mosquito clamp grasps the tip of the feeding tube and the tip is gently pulled through the submucosal tunnel.
This procedure is another intravesical approach. This technique brings the ureter into the bladder through a new ureteral hiatus superior to the original hiatus. The bladder is opened and the ureters are dissected out in the same way as described above. A right-angle clamp is passed through the UVJ opening from inside to out and the tip of the clamp is used to tent up the posterior wall of the bladder (Fig. 66-4A). The bladder mucosa overlying the tip of the clamp is opened using the needle cautery and a new hiatus is shaped. Through the newly formed hiatus, a right-angle clamp is positioned, the feeding tube in the ureter is then grasped, and the ureter is pulled carefully into the bladder (Fig. 66-4B). The original hiatus is then closed with absorbable sutures and a submucosal tunnel is made. The ureter is positioned in a submucosal tunnel directed toward the bladder neck and sutured to the bladder mucosa (Fig. 66-4C). The feeding tube is then removed and reinserted into the ureter to make sure that the feeding tube passes easily through the submucosal tunnel. There is no need to leave a feeding tube in the ureter. The cystostomy is closed in 2 layers using running absorbable sutures.
A. A right-angle clamp is passed through the UVJ opening from inside to out and the tip of the clamp is used to tent up the posterior wall of the bladder. B. The feeding tube in the ureter is grasped and the ureter is pulled into the bladder. C. The ureter is lying in the submucosal tunnel directed toward the bladder neck.
The success rate for Politano–Leadbetter and Cohen Cross-Trigonal Technique are similar. One advantage of the Politano–Leadbetter is the option to create a neo-ostium in an anatomically adequate position and to create a neo-ostium that is easily accessible for future pyelography and ureteral endoscopy because the ureteral opening of the Cohen procedure is on the opposite side of the bladder. Bowel injury is one of the most feared complications of the Politano–Leadbetter approach, being encountered in approximately 0.5% of cases.
This procedure has been developed from the Lich–Gregoir technique. Success rates are similar to intravesical approaches. The most significant complications associated with the extravesical technique of ureteral reimplantation are ureteral obstruction and urinary retention. Ureteral obstruction occurs in about 2% to 4% of the children. Urinary retention is only associated with bilateral reimplantation and is reported to occur in 8% to 15% of the children due to trauma to the pelvic nervous plexus.
Laparoscopic Ureteral Reimplantation
In recent years, several authors have reported their experience of ureteral reimplantation with laparoscopic extravesical transperitoneal approach as well as pneumovesical approach. This technique results in a shorter hospital stay and less postoperative discomfort compared to open operation. Furthermore, robotic assisted laparoscopic extravesical ureteral reimplantation has shown high success rates similar to open ureteral reimplantation as well as minimal morbidity.
Endoscopic Treatment of Vesicoureteral Reflux
The concept of endoscopic treatment was introduced by Puri and O'Donnell in 1984 as a minimally invasive treatment for VUR following a successful experimental study in piglets. A minimally invasive endoscopic technique for the correction of VUR has become an established alternative to long-term antibiotic prophylaxis and open surgical treatment. The AUA Guideline recently updated the management of primary VUR in children. They extracted data from 131 articles and data from 17,972 patients were included in their analysis. Success rates are 98.1% for open surgical procedures and 83.0% for endoscopic therapy after 1 injection. With the high success rate of endoscopic treatment, the AUA Guidelines included endoscopic treatment in the management options for VUR.
Endoscopic treatment has several advantages over open surgical treatment or long-term antibiotic prophylaxis. In contrast to long-term antibiotic prophylaxis, it offers immediate cure of reflux with a high success rate, its success does not rely on patient or parent compliance and the procedure is virtually free of adverse side effects. In 2001, Deflux® was approved by the Food and Drug Administration (FDA) as an acceptable tissue-augmenting substance for subureteral injection therapy for VUR. Since then, endoscopic treatment has become increasingly popular worldwide for managing VUR, and Deflux® is the most widely used tissue-augmenting substance.
Recently, the Swedish Reflux Trial in Children recruited children between 1 and 2 years old with grade III to IV VUR for a prospective, open, randomized controlled multicenter study. Children were treated in 3 groups, including low-dose antibiotic prophylaxis, endoscopic therapy, and a surveillance group on antibiotics only for febrile UTI. After 2 years, endoscopic treatment results were significantly better than the spontaneous resolution rate or downgrading in the prophylaxis and surveillance groups.
The technique of endoscopic injection of Deflux® is simple and straightforward. The patients should be placed in a lithotomy position. The cystoscope is passed and the bladder wall, the trigone, bladder neck, and both ureteric orifices are inspected. All cystoscopes available for infants and children can be used for this procedure. The bladder should be almost empty before proceeding with injection, since this helps to keep the ureteric orifice flat rather than away in a lateral field. The disposable Puri flexible catheter (STORZ, Catalogue-No-27201) or a rigid metallic catheter can be used for injection. A 1-mL syringe filled with Deflux® is attached to the injection catheter. Under direct vision through the cystoscope, the needle is introduced under the bladder mucosa 2 to 3 mm below the affected ureteral orifice at the 6 o'clock position (Fig. 66-5). In children with grade IV and V reflux with wide ureteral orifices, the needle should be inserted not below but directly into the affected ureteral orifice. The needle is advanced about 4 to 5 mm under the mucosa and the injection started slowly. As the Deflux® is injected, a bulge appears in the floor of the submucosal ureter. Most refluxing ureters require 0.4 to 1.0 mL Deflux® to correct reflux. A correctly placed injection creates the appearance of a nipple on the top which is a slit-like or inverted crescent orifice. If the bulge appears in an incorrect place, for example, at the side of the ureter or proximal to it, the needle should not be withdrawn, but should be moved so that the point is in a more favourable position. The noninjected ureteric roof retains its compliance while preventing reflux. Postoperative urethral catheterization is not necessary. Patients are treated as day cases and a voiding cystourethrogram and ultrasound are performed 6 to 12 weeks after discharge. A follow-up renal and bladder ultrasound are obtained 12 months after endoscopic correction.
Technique of endoscopic subureteric injection: (A) the site of insertion of needle; (B) the needle is advanced 4 to 5 mm before the injection is started; and (C) appearance of the ureteric orifice at completion of injection.
Figure 66-6A shows a VCUG with right-grade IV VUR and left-grade V VUR in an infant. Complete resolution of VUR after endoscopic treatment in the same infant is shown in Fig. 66-6B.
A. VCUG shows right-grade IV VUR and left-grade V VUR in an infant. B. VCUG shows complete resolution of VUR after endoscopic treatment in the same infant.
Procedure-related complications are rare. The only significant complication with this procedure has been failure. There may be initial failure, that is, the reflux is not abolished by the injection, or recurrence, where initial correction is not maintained. About 15% of refluxing ureters require more than 1 endoscopic injection of paste to correct the condition.
Between 2001 and 2010, the authors treated 1551 children with intermediate and high-grade VUR by endoscopic injection of Deflux®. VUR was unilateral in 765 children and bilateral in 786. Renal scarring was detected in 369 (26.7%) of the 1384 patients who had a DMSA scan. Reflux grade in the 2341 ureters was grade II to V in 98 (4.2%), 1340 (57.3%), 818 (34.9%) and 85 (3.6%), respectively. VUR resolved after first, second, and third endoscopic injection of Dx/HA in 2039 (87.1%), 264 (11.3%), and 38 (1.6%) ureters, respectively. Sixty-nine (4.6%) of the 1512 patients who were followed up developed febrile UTIs during a median follow-up of 5.6 years. None of the patients in the series needed reimplantation of ureters or developed any significant complications, confirming the efficacy and safety in the management of intermediate and high-grade VUR.
Endoscopic subureteral injection of Deflux® is an excellent first-line treatment in children with 87% success in high-grade VUR after 1 injection. This 15-minute outpatient procedure is safe and simple to perform, and it can be easily repeated in failed cases.