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Surgical management of vesicoureteral reflux in pediatric patients

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Abstract

Vesicoureteral reflux (VUR) represents one of the most significant risk factors for acute pyelonephritis in children. The current indications for the surgical correction of VUR depend on the presence or absence of renal scars. If no scars are present, primary ureteral reimplantation is only indicated in high-grade bilateral VUR, whereas in the presence of renal scars surgical correction is indicated in low/high grade reflux at a young age. Since there are numerous techniques for antireflux surgery available, it is the purpose of this article to critically review these techniques with their specific advantages, typical complications and postoperative management. In general, all surgical technique have a high success rate of 92–98%. The extravesical Lich-Gregoir technique is primarily indicated in unilateral VUR. Children with a high-grade VUR, who are under the age of 3 years and boys are prone to the development of postoperative urinary retention and might be considered for intravesical surgical techniques. The Politano-Leadbetter technique is very helpful in correcting bilateral VUR of any grade in one session to create a neo-ostium in an anatomically correct position which is easily accessible for endourological manipulations. The Psoas hitch ureteroneocystotomy is an excellent technique to correct VUR associated with megaureter, or with duplicated ureters, and VUR failures. Endoscopic subureteral injections are primarily reserved for low grade VUR with a one session success rate of >90%. Endoscopic subureteral injections appear to be an alternative to long-term antibiotics in grade I-III VUR. Laparoscopic antireflux surgery has not gained widespread use due to the very long operating times. Contralateral VUR will occur in about 20% of children undergoing unilateral antireflux surgery; risk factors are severe VUR and VUR into a duplicated system. Postoperative follow-up nowadays consists of urinalysis and ultrasonography; voiding cystourethrography is only indicated in case of febrile urinary tract infection. Despite the excellent success rates following antireflux surgery one has to keep in mind that surgery only corrects the anatomical abnormality. The long-term outcome with regard to renal function, posttherapeutic febrile urinary tract infections and arterial hypertension does not differ significantly from the medication group except for those patients with a demonstrated a genetic background. Therefore, the indication for surgery and the surgical technique applied have to be discussed thoroughly and must be associated with a minimal complication rate.

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References

  1. King LR (2003) The development of the management of vesico-ureteral reflux in the USA. BJU Int 92 [Suppl 1]: 4–6

  2. Arant BS (2001) Vesicoureteral reflux and evidence-based management. J Pediatr 139:620–621

    Article  PubMed  Google Scholar 

  3. Smellie J, Jodal U, Lax H, Mobius TT, Hirche H, Olbing H, Writing Committee International Reflux Study in Children European Branch (2001) Outcome at 10 years of severe vesicoureteric reflux managed medically: report of the International Reflux Study in Children. J Pediatr 139:656–663

    Article  CAS  PubMed  Google Scholar 

  4. Elder JS, Peters CA, Arant BS, Ewalt DH, Hawtrey CE, Hurwitz RS, Parrott TS, Snyder HM, Weiss RA, Woolf SH, Hasselblad V (1997) Pediatric vesicoureteral reflux guideline panel summary report on the management of primary vesicoureteral reflux in children. J Urol 157:1846–1851

    CAS  PubMed  Google Scholar 

  5. Yu TJ, Chen WF (1997) Surgical management of grades III and IV primary vesicoureteral reflux in children with and without acute pyelonephritis as breakthrough infections: a comparative analysis. J Urol 157:1404–1406

    Article  CAS  PubMed  Google Scholar 

  6. Rushton HG (1997) Evaluation of acute pyelonephritis and renal scaring with technetium 99m-dimercaptosuccinic acid renal scintigraphy: evolving concepts and future directions. Pediatr Nephrol 11:108–114

    Article  CAS  PubMed  Google Scholar 

  7. Riedmiller H, Androulakakis P, Beurton D, Kocvara R, Gerharz E (2001) EAU guidelines on pediatric urology. Eur Urol 40:589–599

    Article  CAS  PubMed  Google Scholar 

  8. Capitanucci ML, Silveri M, Mosiello G, Zaccara A, Capozza N, De Gennaro M (2000) Prevalence of hypercontractility in male and female infants with vesico-ureteral reflux. Eur J Pediatr Surg 10:172–176

    CAS  PubMed  Google Scholar 

  9. Willemsen J, Nijman RJ (2000) Vesicoureteral reflux and videourodynamic studies: results of prospective study. Urology 55:939–943

    Article  CAS  PubMed  Google Scholar 

  10. Chandra M, Maddix H (2000) Urodynamic dysfunction in infants with vesicoureteral reflux. J Pediatr 136:754–759

    Article  CAS  PubMed  Google Scholar 

  11. Sillen U, Hellstrom AL, Hermanson G, Abrahamson K (1999) Comparison of urodynamic and free voiding pattern in infants with dilating reflux. J Urol 161:1928–1933

    CAS  PubMed  Google Scholar 

  12. Wille S, Von Knobloch R, Klose KJ, Heidenreich A, Hofmann R (2003) Magnetic resonance urography in pediatric urology. Scand J Urol Nephrol 37:16–21

    Article  PubMed  Google Scholar 

  13. Borthne A, Pierre-Jerome C, Nordshus T, Reiseter T (2000) MR urography in children: current status and future development. Eur Radiol 10:503–511

    CAS  PubMed  Google Scholar 

  14. Smellie J, Barratt TM, Chantler C, Gordon I, Prescod NP, Ransley PG, Woolf AS (2001) Medical versus surgical treatment in children with severe bilateral vesicoureteral reflux and bilateral nephropathy: a randomised trial. Lancet 357:1329–1333

    CAS  PubMed  Google Scholar 

  15. Hjälmas K, Löhr G, Tamminen-Möbius T, Seppanen J, Olbing H, Wikström S on behalf of the International Reflux Study in Children (1992) Surgical results in the International Reflux Study in Children (Europe). J Urol 148:1657–1661

    PubMed  Google Scholar 

  16. Lapointe SP, Barrieras D, Leblanc B, Williot P (1998) Modified Lich-Gregoir ureteral reimplantation: experience of a Canadian centre. J Urol 159:166–1667

    Google Scholar 

  17. Vuckov S, Nikolic H, Kvesic A, Bukvic N (1999) Our experience in the treatment of the vesico-ureteral reflux with Lich Gregoir antireflux surgical procedure. Eur J Pediatr Surg 9:33–36

    CAS  Google Scholar 

  18. Heimbach D, Bruhl P, Mallmann R (1995) Lich-Gregoir anti-reflux procedure: indications and results with 283 vesicoureteral units. Scand J Urol Nephrol 29:311–316

    CAS  PubMed  Google Scholar 

  19. Leblanc B, Williot P (1995) Lich-Gregoir ureteroneocystotomy: experience of a North American pediatric center. Ann Chir 49:685–688

    CAS  PubMed  Google Scholar 

  20. Linn R, Ginesin Y, Bolkier M, Levin DR (1989) Lich-Gregoir anti-reflux operation: a surgical experience and 20 years of follow-up in 149 ureters. Eur Urol 16:200–203

    CAS  PubMed  Google Scholar 

  21. Heidenreich A, Becker T, Hofmann R. Ureteral reimplantation: a comparison of results with the Lich-Gregoir, psoas hitch and Politano-Leadbetter techniques in 196 children. Urol A [Suppl] S40:1.14

  22. Barrieras D, Lapointe S, Reddy PP, Williot P, McLorie GA, Bagli D, Khoury AE, Merguerian PA (1999) Urinary retention after bilateral extravesical ureteral reimplantation: does dissection distal to the ureteral orifice have a role? J Urol 162:1197–1200

    CAS  PubMed  Google Scholar 

  23. Lipski BA, Mitchell ME, Burns MW (1998) Voiding dysfunction after bilateral extravesical ureteral reimplantation. J Urol 159:1019–1021

    Article  CAS  PubMed  Google Scholar 

  24. Siracusano S, Liguori G, D’Aloia G, Trombetta C, Belgrano E (2002) Simplified Politano-Leadbetter’s ureteral reimplantation associated with psoas-hitch technique usinga new clamp. Urology 59:930–931

    Article  PubMed  Google Scholar 

  25. Steffens J, Langen PH, Haben B, Hiebl R, Steffens L, Polsky MS (2000) Politano-Leadbetter ureteroneocystostomy. Urol Int 65:9–14

    Article  CAS  PubMed  Google Scholar 

  26. Dietz HG, Schmidt A, Bader JB, Markus A (1996) The Politano-Leadbetter antireflux plasty. Investigation of complications in 245 children. Eur J Pediatr Surg 6:277–280

    CAS  PubMed  Google Scholar 

  27. Gearhart JP, Woolfenden KA (1982) The vesico-psoas hitch as an adjunct to megaureter repair in childhood. J Urol 127:505–507

    CAS  PubMed  Google Scholar 

  28. Riedmiller H, Becht E, Hertle L, Jacobi G, Hohenfellner R (1984) Psoas-hitch ureteroneocystostomy: experience with 181 cases. Eur Urol 10:145–150

    CAS  PubMed  Google Scholar 

  29. Esen T, Riedmiller H, Walz PH, Hohenfellner R (1987) Plastic surgical correction of megaureter. Urol A 26:189–196

    CAS  Google Scholar 

  30. El-Sherbiny MT, Hafez AT, Ghoneim MA, Greenfield SP (2002) Ureteroneocystotomy in children with posterior urethral valves: indications and outcome. J Urol 168:1836–1839

    Article  CAS  PubMed  Google Scholar 

  31. Chertin B, Puri P (2002) Endoscopic management of vesociureteral reflux: does it stand the test of time? Eur Urol 42:598–606

    Article  PubMed  Google Scholar 

  32. O’Donnell B, Puri P (1984) Treatment of vesicoureteral reflux by endoscopic injection of Teflon. BMJ 289:7–9

    CAS  PubMed  Google Scholar 

  33. Kaplan WE, Dalton DP, Firlit CF (1987) The endoscopic correction of reflux by polytetraflouroethylene injection. J Urol 138:953–955

    CAS  PubMed  Google Scholar 

  34. Schulman CC, Simon J, Pamarat D, Avni FE (1987) Endoscopic treatment of vesicoureteral reflux in children. J Urol 138:950–952

    CAS  PubMed  Google Scholar 

  35. Vereecken RL, Proesmans W (1995) Results of endoscopic treatment for vesico-ureteral reflux. Eur Urol 27:76–79

    CAS  PubMed  Google Scholar 

  36. Puri P (1995) Ten year experience with subureteric Teflon (polytetraflouroethylene) injection (STING) in the treatment of vesico-ureteric reflux. Br J Urol 75:126–131

    CAS  PubMed  Google Scholar 

  37. Herz D, Hafez A, Bagli D, Capolicchio G, McLoire G, Khoury A (2001) Efficacy of endocopic subureteral polydemethylsiloxane injection for the treatment of vesicoureteral reflux in children: a North American clinical report. J Urol 166:1880–1886

    Article  CAS  PubMed  Google Scholar 

  38. Lackgren G, Wahlin N, Sköldenberg E, Stenberg A (2001) Long-term follow-up of children treated with dextranomer/hyaluronic acid colypomer for vesicoureteral reflux. J Urol 166:1887–1892

    CAS  PubMed  Google Scholar 

  39. Puri P, Chertin B, Velayudham M, Dass L, Colhoun E (2003) Treatment of vesicoureteral reflux by endoscopic injection of dextranomer/hyaluronic acid copolymer: prelimary results. J Urol 170:1541–1544

    Article  CAS  PubMed  Google Scholar 

  40. Diamond DA, Caldamone AA, Bauer SB, Retik AB (2003) Mechanisms of failure of endoscopic treatment of vesicoureteral reflux based on endoscopic anatomy. J Urol 170:1556–1559

    Article  PubMed  Google Scholar 

  41. Aaronson IA, Rames RA, Greene WB, Walsh LG, Hasal UA, Garen PD (1993) Endoscopic treatment of reflux: migration of Teflon to the lungs and brain. Eur Urol 23:394–399

    CAS  PubMed  Google Scholar 

  42. Ogan K, Pohl HG, Carlson D, Belman AB, Rushton HG (2001) Parenteral preferences in the management of vesicoureteral reflux. J Urol 166:240–243

    Article  CAS  PubMed  Google Scholar 

  43. Kawauchi A, Fujito A, SOh J, Ukimura O, Mizutani Y, Miki T (2003) Laparoscopic correction of vesicoureteral reflux using the Lich-Gregoir technique: initial experience and technical aspects. Int J Urol 10:90–93

    Article  PubMed  Google Scholar 

  44. Sakamoto W, Nakatani T, Sakakura T, Takegaki Y, Ishi K, Kamikava K, Sugimoto T (2003) Extraperitoneal laparoscopic Lich-Gregoir antireflux plasty in primary vesicoureteral reflux. Int J Urol 10:94–97

    Article  PubMed  Google Scholar 

  45. Aboutaleb H, Bolduc S, Khoury AE, Upadhyay J, Bägli DJ, Farhat W (2003) Polydemethylsolixane injection versus open surgery for the treatment of vesicoureteral reflux in complete duplex systems. J Urol 170:1563–1565

    Article  CAS  PubMed  Google Scholar 

  46. Barrieras D, Lapointe S, Houle H (2003) Is common sheath extravesical reimplantation an effective technique to correct reflux in duplicated collecting systems? J Urol 170: 1545–1547

    Article  PubMed  Google Scholar 

  47. Läckgren G, Wahlin N, Sköldenberg E, Nevéus T, Stenberg A (2003) Endoscopic treatment of vesicoureteral reflux with dextranomer/hyaluronic acid copolymer is effective in either double ureters or a small kidney. J Urol 170:1551–1555

    Article  PubMed  Google Scholar 

  48. Hoening DM, Diamond DA, Rabinowitz R, Caldamone AA (1996) Contralateral reflux after unilateral reimplantation. J Urol 156:196–197

    PubMed  Google Scholar 

  49. Diamond DA, Rabinowitz R, Hoenig D, Caldamone AA (1996) The mechanism of new onset reflux following unilateral ureteroneocystostomy. J Urol 156:665–667

    CAS  PubMed  Google Scholar 

  50. Brandell RA, Broch JW3rd (1993) Ureteral reimplantation: postoperative management without catheters. Urology 42:705–707

    CAS  PubMed  Google Scholar 

  51. Marotte JB, Smith DP (2001) Extravesical ureteral reimplantation for the correction of primary reflux can be done as outpatient procedures. J Urol 165:2228–2231

    Article  CAS  PubMed  Google Scholar 

  52. Duckett JW, Cangiano T, Cubina M, Howe C, Cohen D (1997) Intravesical morphine analgesia after bladder surgery. J Urol 157:1407–1409

    Article  CAS  PubMed  Google Scholar 

  53. El-Ghoneimi A, Deffarges C, Hankhard R, Jean-Eudes F, Aigrain Y, Jacqz-Aigrain E (2002) Intraoperative morphine analgesia is not effective after bladder surgery in children: results of a randomized double-blind study. J Urol 168:694–697

    Article  PubMed  Google Scholar 

  54. Cain MP, Husmann DA, McLaren RH, Kramer SA (1995) Continuous epidural anesthesia after ureteroneocystostomy in children. J Urol 154:791–793

    CAS  PubMed  Google Scholar 

  55. Anderson PD, Dewan PA (2002) Catheter-less Cohen transtrigonal ureteric reimplantation. BJU Int 89:722–725

    Article  CAS  PubMed  Google Scholar 

  56. Duong DT, Parekh DJ, Pope JC, Adams MC, Brock III, JW (2003) Ureteroneocystotomy without urethral catheterization shortens hospital stay without compromising postoperative success. J Urol 170:1570–1573

    Article  PubMed  Google Scholar 

  57. Grossklaus DJ, Pope JC, Adams MC, Brock JW (2001) Is postoperative cystography necessary after ureteral reimplantation? Urology 58:1041–1045

    Article  CAS  PubMed  Google Scholar 

  58. Schwickardi M, Schwickardi A, Heidenreich A, Hofmann R (2000) Long-term follow-up in children with surgically corrected vesicoureteral reflux: what are necessary examinations, what is useless? Eur Urol 37 [Suppl 2]:17

  59. Jodal U, Koskimies O, Hanson E, Löhr G, Olbing H, Smellie J, Tamminen-Möbius T on behalf of the International Reflux Study in Children (1992) Infection pattern in children with vesicoureteral reflux randomly allocated to operation or long-term antibacterial prophylaxis. J Urol 148:1650–1652

    CAS  PubMed  Google Scholar 

  60. Smellie J, Tamminen-Möbius T, Olbing H, Claesson I, Wikstad I, Jodal U, Seppanen U (1992) Five-year study of medical or surgical treatment in children with severe reflux: radiological renal findings. The International Reflux Study in Children. Pediatr Nephrol 6:223–230

    CAS  PubMed  Google Scholar 

  61. Olbing H, Claesson I, Ebel KD, Seppänen U, Smellie J, Tamminen-Möbius T, Wikstad I on behalf of the International Reflux Study in Children (1992) Renal scars and parenchymal thinning in children with vesicoureteral reflux: a five-year report of the International Reflux Study in Children. J Urol 148:1653–1656

    CAS  PubMed  Google Scholar 

  62. Weiss R, Duckett J, Spitzer A on behalf of the International Reflux Study in Children (1992) Results of a randomized clinical trial of medical versus surgical management of infants and children with grades III and IV primary vesicoureteral reflux (United States). J Urol 148:1667–1673

    CAS  PubMed  Google Scholar 

  63. Szlyk GR, Williams SB, Majd M, Belman AB, Rushton HG (2003) Incidence of new renal parechchymal inflammatory changes following breakthrough UTI in patients with vesicoureteral reflux treated with antibiotic prophylaxis: evaluation by99mtechnetium dimercapto-succinic acid renal scan. J Urol 170:1566–1569

    Article  CAS  PubMed  Google Scholar 

  64. Beetz R, Schulte-Wissermann H, Tröger J, Riedmiller H, Mannhardt W, Schofer O, Hohenfellner R (1989) Long-term follow-up of children with surgically treated vesicorenal reflux: postoperative incidence of UTIs, renal scars and arterial hypertension. Eur Urol 16:366–371

    CAS  PubMed  Google Scholar 

  65. Feather SA, Malcolm S, Woolf AS, Wright V, Blaydon D, Reid CJD, Flinter FA, Proesmans W, Devriendt K, Carter J, Warwicker P, Goodship THJ, Goodship JA (2000) Primary nonsyndromic vesicoureteric reflux and its nephropathy is genetically heterogenous, with a locus on chromosome 1. Am J Hum Genet 66:1420–1425

    CAS  PubMed  Google Scholar 

  66. Köhler J, Thysell H, Tencer J, Forsberg L, Hellström M (2001) Conservative treatment and anti-reflux surgery in adults with vesico-ureteral reflux: effect on urinary tract infections, renal function and loin pain in a long-term follow-up study. Nephrol Dial Transplant 16:52–60

    Article  Google Scholar 

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Authors and Affiliations

  1. Department of Urology, University of Köln, 50931 Cologne, Germany

    Axel Heidenreich, Enver Özgur & Gerald Haupt

  2. Department of Urology and Pediatric Urology, Philipps University, 35043 Marburg, Germany

    Tanja Becker

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  1. Axel Heidenreich
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Heidenreich, A., Özgur, E., Becker, T. et al. Surgical management of vesicoureteral reflux in pediatric patients. World J Urol 22, 96–106 (2004). https://doi.org/10.1007/s00345-004-0408-x

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