Salvage Endoscopic Correction of High-Grade Vesicoureteral Reflux After Unsuccessful Cross-Trigonal Ureteral Reimplantation

Abstract

Introduction: Persistent vesicoureteral reflux (VUR) after reimplantation of ureters requiring reoperation has been reported in up to 7.5% of cases. This video demonstrated a successful endoscopic salvage option for correction of persistent, high-grade VUR after a bilateral cross-trigonal ureteral reimplantation. Methods: A 19-month-old female with a double collecting system and a ureterocele underwent a Cohen cross-trigonal ureteral common sheath reimplantation. A year later, she presented with persisting right-sided grade 5 VUR. We corrected her reflux with salvage endoscopic injection of dextranomer/hyaluronic Acid (Dx/HA). Results: The major challenge in this case was the ureteral orifice axis post-Cohen cross-trigonal ureteral reimplantation, which was nearly perpendicular to the axis of the urethra-cystoscope axis. We used a 4F whistle-tip catheter, which was inserted into the right ureter. The rigidity of this catheter allowed us to torque the ureter to reduce the angulation and allowed the cystoscope to be inserted into the dilated refluxing ureter. Four injections of Dx/HA were performed in the intramural part of the ureter and one at the ureteral orifice location. A final injection was placed below the ureteral tunnel just proximal to the orifice. A voiding cystourethrogram three months postimplantation confirmed the resolution of the reflux. Conclusion: This video demonstrated a successful endoscopic salvage option for correction of persistent, high-grade VUR after a bilateral cross-trigonal ureteral reimplantation. We recommend using a ureteric catheter to align the reimplanted ureter with the urethra-cystoscope axis, followed by insertion of the cystoscope into the ureter for the first intramural injection of Dx/HA. No competing financial interests exist. Runtime of video: 7 mins 54 secs