Surgical Treatment of Vesicoureteric Reflux

Abstract

Vesicoureteral reflux (VUR) describes the retrograde flow of urine from the bladder into the ureters and upper urinary tract. VUR may lead to pyelonephritis, reflux nephropathy, hypertension and, ultimately, chronic renal disease. Ureteric re-implantation is indicated when conservative management (prophylactic antibiotics, treatment of lower urinary tract dysfunction and surveillance) and/or endoscopic treatment has failed to prevent febrile urinary tract infections or other complications of VUR. Currently, the vast majority of ureteric re-implantations are undertaken by the open approach using an intravesical (Cohen, Glenn-Anderson, Politano-Leadbetter) or extravesical (Lich-Gregoir) technique. Open surgery, by any of these techniques, leads to successful correction of VUR in >95% of cases with a low complication rate. Minimally invasive techniques to correct VUR are described, with laparoscopy or robotic-assisted laparoscopy utilized to recreate the intravesical (vesicoscopic) and extravesical procedures described in open surgery. Increased complications have been reported following minimally invasive repair and, inevitably, operative time is longer than for open surgery. Vesicoscopic surgery is technically challenging due to problems in creating and maintaining pneumovesicum, and the inherently small working space within the bladder. Consequently, the most favored minimally invasive technique currently is the robotic-assisted laparoscopic extravesical ureteric re-implantation (RALUR-EV) based on the Lich-Gregoir technique. Nerve-sparing techniques have been implemented to reduce the incidence of urinary retention noted following bilateral laparoscopic (including robotic-assisted) extravesical ureteric re-implantation. Following a significant learning curve, recent studies show the results of minimally invasive surgery are approaching those of open techniques.