Indications and effectiveness of the open surgery in vesicoureteral reflux - PowerPoint Presentation

Slide1

Indications and effectiveness of the open surgery in vesicoureteral reflux

Suzi DEMIRBAG, MD

Department of Pediatric Surgery, Gulhane Military Medical Academy, Ankara,

TURKEY

Vesicoureteral reflux

(VUR)

refers to the retrograde flow of urine from the bladder into the ureter

.

R

eflux

results from a congenital

anomaly of the ureterovesical junction

(

Primary

VUR)

,

R

eflux

from

high-pressure voiding secondary to posterior urethral valves, neuropathic bladder or voiding dysfunction

(

Secondary

VUR)

.

T

he prevalence of VUR in normal

children has been

estimated

at

0.

4

–

1.8

%

P

renatally

identified by ultrasonography

the

prevalence

was

16

.2

%

Siblings of children with VUR had

a

27

.4

%

risk

for

VUR

The main goal

preservation of kidney

function

The risk factors age sex reflux grade lower urinary tract dysfunction [LUTD]anatomic abnormalities kidney status

T

here are

different

options in the

management

of VUR, from -Observation with or without antibiotics prophylaxis -Surgical intervention

:

-

open

,

-

endoscopic

-

laparoscopic

approaches

.

Factors influencing the

decision

T

he risk of developing a UTI, and associated risk factors for UTIs

such as voiding dysfunction

Risk of development of new renal scars, Chance for spontaneous resolution

Which patients

should

be

selected

for

surgery ?The focus should be on selecting patients for treatment by identifying those at risk :Recurrent Pyelonephritis VUR will not spontaneously resolve.

Rate of resolution of VUR

age at presentation

gender

grade of the reflux

laterality

mode of clinical

presentation ureteral anatomy bladder/bowel dysfunction

Open Surgery

O

pen ureteral

reimplantation

is

still

the gold standard for surgical treatment. Success rates of 95% to 98% with low complication rates.

Indications for Surgery

A

bsolute

indication for

surgical correction is the

F

ailure of nonsurgical management Relative indications include the following:High-grade reflux Anatomic problems,

large

para-ureteral diverticulum

ureteral

duplication

;

impaired renal growth

C

ontroversial

indications include

P

ersistent

reflux in girls after

puberty

A

void

the need for follow-up VUR evaluation or CAP.

The principles of surgical correction of reflux

Defining

the

causes of secondary VUR Sufficient mobilization of the distal ureterCreation of a submucosal tunnel ( 5 : 1 ratio)Attention to the entry point of the ureter Attention

to the muscular backing of the ureter

Gentle

surgery

Open Surgical techniques

for

VUR

Politano-Leadbetter

Technique

Glenn-Anderson

TechniqueCohen’s TechniqueLich-Gregoir Technique

Laparoscopic

ureteral

reimplantation

Advantages

Cosmetic

Short hospitalisationDisadvantagesLonger op.timeNeed more

experience

in

laparoscopy

Robot-assisted laparoscopic ureteral

reimplantation

Advantages

Better

view

Better

surgery

Disadvantages

:

Higher

op.

cost

Longer

op.time

Complications of VUR Surgery

Early

Complications

:

Persistant

refluxContralateral RefluxObstructionLate Complications:ObstructionRecurrent or

Persistant

Reflux

Conclusion

F

actors

that negatively influence

resolution

:

Grade of reflux, Lower bladder volume or pressure at onset of reflux, Age Sex

Laterality

of

VUR,

Anatomical

problems

,

A

bnormal

or scarred

kidneys,

B

ladder

dysfunction

Conclusion

The treatment of VUR

→

decreased

rate of pyelonephritis.

Open

surgery is still the gold standard for VUR treatmentThere is no difference in the rate of renal scarring, renal growth, and UTIs in

patients

treated

medically or surgically for dilating VUR.

References

1-

Austin

JC, Cooper CS. Vesicoureteral reflux: who benefits from correction.

Urol

Clin

North Am. 2010 May;37(2):243-52. doi: 10.1016/j.ucl.2010.03.0122-Fonseca FF, Tanno FY, Nguyen HT. Current options in the management of primary vesicoureteral reflux in children. Pediatr Clin North Am. 2012 Aug;59(4):819-34. doi: 10.1016/j.pcl.2012.05.012.

Epub

2012 Jun 22

.

3-

Routh JC,

Bogaert

GA,

Kaefer

M, Manzoni G, Park JM,

Retik

AB, Rushton HG, Snodgrass WT, Wilcox DT. Vesicoureteral reflux: current trends in diagnosis, screening, and treatment.

Eur

Urol. 2012 Apr;61(4):773-82.

doi

: 10.1016/j.eururo.2012.01.002.

Epub

2012 Jan 11.

4-

Tekgül

S,

Riedmiller

H,

Hoebeke

P,

Kočvara

R, Nijman RJ,

Radmayr

C, Stein R,

Dogan

HS; European Association of Urology. EAU guidelines on vesicoureteral reflux in children.

Eur

Urol. 2012 Sep;62(3):534-42.

doi

: 10.1016/j.eururo.2012.05.059.

Epub

2012 Jun 5.

5-

Khoury

AE,

Bagli

DJ,

Vesicoureteral

reflux

,

Campbell-Walsh Urology,

chapter

: 122, pages:3267-3309,

volume

4,

10th Edition

,

Elsevier