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 ID: 809697
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Slide1
Indications and effectiveness of the open surgery in vesicoureteral reflux
Suzi DEMIRBAG, MD
Department of Pediatric Surgery, Gulhane Military Medical Academy, Ankara,
TURKEY
Slide2Vesicoureteral 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)
.
Slide3T
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
Slide4The main goal
preservation of kidney
function
The risk factors age sex reflux grade lower urinary tract dysfunction [LUTD]anatomic abnormalities kidney status
Slide5T
here are
different
options in the
management
of VUR, from -Observation with or without antibiotics prophylaxis -Surgical intervention
:
-
open
,
-
endoscopic
-
laparoscopic
approaches
.
Slide6Factors 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
Slide7Which 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.
Slide8Rate of resolution of VUR
age at presentation
gender
grade of the reflux
laterality
mode of clinical
presentation ureteral anatomy bladder/bowel dysfunction
Slide9Open Surgery
O
pen ureteral
reimplantation
is
still
the gold standard for surgical treatment. Success rates of 95% to 98% with low complication rates.
Slide10Indications 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.
Slide11The 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
Slide12Open Surgical techniques
for
VUR
Politano-Leadbetter
Technique
Glenn-Anderson
TechniqueCohen’s TechniqueLich-Gregoir Technique
Slide13Laparoscopic
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
Slide14Complications of VUR Surgery
Early
Complications
:
Persistant
refluxContralateral RefluxObstructionLate Complications:ObstructionRecurrent or
Persistant
Reflux
Slide15Conclusion
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
Slide16Conclusion
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.
Slide17References
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