A New Endoscopic Ureteral Reimplantation for Primary Vesicoureteral Reflux (Endoscopic Trigonoplasty II)

Abstract

We describe a new technique of endoscopic antireflux surgery. The principle of the procedure is to make a reliable muscular backing and elongate the intramural ureter. We performed this new endoscopic surgery in 8 female patients in whom 4, 1, 8 and 1 refluxing ureters (total 14) were diagnosed with grades I to IV reflux, respectively. The operation consists of 3 steps. Two 5 mm. locking trocars are placed into the bladder. Irrigation is done with 3% D-sorbitol solution and the bladder wall is incised upward along each side of the ureter using a resectoscope to make a 2 to 3 cm. U-shaped bladder flap, including the ureter. Under pneumobladder the incised muscle is sutured to make a muscular bed with a needle holder via the urethra and forceps via the abdominal trocar. The U flap is fixed with 2 distal anchor sutures on the embedded muscular layer and 4 additional sutures are placed to approximate the mucosa of the U-shaped flap and bladder. Mean operative time was 245 minutes. Ureteral injury occurred in 2 patients. A Foley catheter remained indwelling for 3 to 5 days (mean 4.1). Reflux resolved in 12 of the 14 ureters (86%) 12 months postoperatively. Vesicoureteral reflux persisted in 1 case because of insufficient fixation and recurred in 1 because of ureterovesical fistula. The patients were satisfied with better cosmesis and minimal postoperative discomfort. We believe that procedure is feasible for female patients with primary vesicoureteral reflux.