Results of laparoscopic extravesical antireflux operation in vesicoureteral reflux in children

The objective was to improve the results of surgical treatment of vesicoureteral reflux in children, using laparoscopic access. The prospective study was performed in 111 children (137 ureters) with the primary III–IV grade vesicoureteral reflux. The mean age was 34.7 months. The modified laparoscopic antireflux technique was performed on 73 children (91 ureters). We compared the perioperative complications and the medium-term outcome with a group of 38 children (46 ureters) who underwent classical laparoscopic extravesical reimplantation.3 In the modified group, the mean surgery time was 109.8 ± 31.5 minutes for unilateral cases and 176.5 ± 47.6 minutes for bilateral cases; in the classical group, it was 118.6 ± 34.3 and 209.5 ± 51.2 minutes respectively (p > 0.05). Postoperative vesicoureteral reflux had 2 (2.7 %) patients in the main group and 8 (21.1 %) children in the control group (p = 0.002). There was no ureteral obstruction in the both groups. The success rate for ureters was 97.8 % with modified technique versus 82.6 % after classical laparoscopic reimplantation (p = 0.003). Laparoscopic extravesical ureteral reimplantation is a safe and effective surgical procedure. The modified technique may improve the surgical treatment results.

Antireflux-Operation im ersten Lebensjahr, wenn ja, wann und wie? Kontra OP

ZusammenfassungDas Management des vesikoureteralen Refluxes (VUR) im Säuglingsalter bleibt auch weiterhin ein überaus kontrovers diskutiertes Thema in der Kinderurologie. Hohe Spontanmaturationsraten selbst bei dilatierenden Refluxen von bis zu 45 %, der hohe Anteil an Jungen mit hohen Refluxgraden und oft assoziierter Nierenhypoplasie/Nierendysplasie von bis zu 30 % sowie die noch unreife Blasenfunktion kennzeichnen das Krankheitsbild in diesem Alter. Der Reflux per se hat in diesem Kontext eher an Bedeutung verloren. Umso erstaunlicher ist es, dass in letzter Zeit vermehrt Publikationen erscheinen, die eine endoskopische Therapie nicht nur als Alternative bei Durchbruchsinfektionen unter der Langzeittherapie, sondern auch als primäre Alternative zur Chemoprophylaxe empfehlen. Keine der bislang vorliegenden Metaanalysen konnte jedoch eine Evidenz für die Überlegenheit der endoskopischen Therapie gegenüber der Langzeitantibiose im Hinblick auf die Infekthäufigkeit oder die Entstehung neuer Parenchymnarben belegen. Demgegenüber stehen Nachteile dieser Methode wie die Notwendigkeit einer Narkose, die häufige Refluxpersistenz und das Obstruktionsrisiko sowohl postoperativ als auch im Langzeitverlauf. Die klassischen operativen Antireflux-Techniken sollten trotz moderner minimal invasiver Techniken aufgrund der hohen Spontanmaturationsrate und der in diesem Alter noch nicht abgeschlossenen Blasenfunktionsausreifung (sog. immature Blasenfunktion) auch weiterhin routinemäßig nicht zur Anwendung kommen und nur Einzelfällen vorbehalten bleiben

MODIFIED SINGLE-SIDED LAPAROSCOPIC EXTRAVESICAL ANTIREFLUX OPERATION

Introduction. Laparoscopic techniques have been applied to ensure surgical treatment of the vesicoureteral reflux (VUR) in children during the last decades. We present the experience of using the laparoscopic extravesical antireflux standard and ureter-fixed modified surgery.Materials and methods. A multi-center prospective experimental clinical historical cohort two-group study of patients with III–V stage primary VUR. The basic group consisted of 48 children who had a unilateral laparoscopic extravesical surgery when the ureter was fixed according to the developed technique. 44 children who had a surgery according to the standard technique were included into the control group.Results. Complete VUR removal was noted in 100% of patients from the basic group and 81.2% of patients from the control group (р <0.01). Preservation of the megaureter with complete reflux resolution was seen in 1 child only (2.1%) from the basic group who had V stage VUR (p=0.2).Conclusions. Laparoscopic extravesical antireflux is a safe and effective surgery. Distal ureter fixation reduces the rate of VUR recurrences.

Long-Term follow-up of Trigonoplasty Antireflux Operation

Background Open trigonoplasty antireflux operation has been associated with promising results. However, its success in controlling reflux has not been evaluated in the long term. Methods All patients who underwent trigonoplasty for vesicoureteral reflux by one surgeon from 2004 to 2014 were included. Pre-Operative evaluations included direct radionuclide cystography (DRNC) or voiding cystourethrography, urine analysis and culture and abdominal sonography. Urodynamic study and cystoscopy was performed in selected patients. Trigonoplasty was done by a modified Gil-Verent method. The latest available patients’ DRNCs were used to judge for reflux relapse. Results Ninety-one patients, 142 refluxing units; median (range) age, 10.5 (1-45) years; M/F, (11/80) were followed for 18 to 135 months. Reflux resolution rate was 73.6% for patients and 75.4% for refluxing units. Relapse was associated with reflux grade (67% in grade V), ureteral orifice appearance (40% in golf hole/stadium), and patients with a history of pyelonephritis. Multivariable model based on the above variables had less than 10% sensitivity in predicting relapse. Conclusions Trigonoplasty success rate can decrease with long-term follow-up.