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History
Vesicoureteral reflux (VUR) represents the retrograde flow
of urine from the bladder to the upper urinary tract
Galen and da Vinci:
- First references to VUR by Western medicine
- UVJ as a mediator of unidirectional flow of urine
from the kidneys to the bladder
RELATIVE INDICATIONS :
Presence of massive reflux – gr IV&V
Reflux associated with paraureteral diverticulum
In girls whose reflux persists after they have reached the full somatic
growth potential at puberty.
Parental preference
The principles of surgical correction :
- Exclude secondary reflux
- Adequate ureteral mobilization without tension and protection
of the ureteral blood supply
- A generous submucosal tunnel should be fashioned
- Attention should be directed to prevent angulation and twisting
- Bladder tissues must be handled gently
-attention to muscular backing of ureter to achieve effective anty
refux mechanism.
-creation of submucosal tunnel that satisfy 5:1 ratio of length and
width recommended by Paquin.
-
According to approach :
Intravesical
Extravesical
Combined
According to the position of the sub mucosal
tunnel in relation to the original hiatus :
Suprahiatal
Infrahiatal
Supra hiatal tunnel
Politano-Leadbetter Technique
The principle behind this technique, which was
originally described by Politano and Leadbetter (1958),
is to bring the ureter in through a new hiatus superior
to the original insertion.
A submucosal tunnel is created in the direction of the
trigone, medial to the original orifice.
The advantage of this technique is that a long tunnel
can be created, which is valuable in the higher grades
of reflux.
Infrahiatal
Glenn-Anderson Technique
In 1967 Glenn and Anderson described their technique
of ureteral reimplantation .
By using the same hiatus and advancing the ureter
distally toward the bladder neck, the potential
complications associated with thePolitano-Leadbetter
technique, specifically kinking of the ureter, are
avoided
The distance from the hiatus to the bladder neck limits
the length of the tunnel.
Cohens cross trigonal technique.
Intravesical, infrahiatal procedure
Simple, safe and most commonly used
Good for small capacity bladder
Success > 95%
Problem :
Difficult retrograde catheterization of ureters
Extra vesical procedure.
Lich –Gregoir techique.
The advantage of the extravesical technique is that the
bladder is not opened; thus postoperative hematuria
and bladder spasms are minimized.
The technique is simple to learn.
The main concern with this technique has been the
development of transient voiding inefficiency that is
seen in up to 20% of cases.
Follow up
Discharged on uro-prophylaxis
Monitoring of pt’s
- BP
- renal function
- urine analysis
Follow up USG and urine c/s after 6-12 weeks.
VCUG after 3 mnths
Discontinuation of uroprophylaxis on resolution of
reflux
DMSA after 1yr (not mandatory)
complications
Persistent Reflux.
Early reflux following ureteroneocystostomy is usually not
a significant clinical problem and commonly resolves by 1
year on repeat cystography.
Contralateral reflux
Seen in 5-11%cases
There was no difference noted among the various surgical
techniques, but there was a significant trend toward
development of contralateral reflux with the higher grades
of ipsilateral corrected reflux and correction of reflux in
duplex systems.
Prophylactic bilateral reimplantation for unilateral
reflux, to avoid contralateral reflux, is not warranted
on the basis of the high spontaneous resolution rates.
Obstruction
Due to odema , clot ,twisting or kinking of ureter.
Diagnosis made by USG showing severe HDUN.
PCN or stenting has to be done.
Redo surgery may be required
Endoscopic management
Injection of a bio- compatible bulking agent beneath
intravesical portion of ureter in sub-mucosal tunnel
Elevates the intra-vesical ureter narrowing of lumen
Prevents regurgitation of urine & allows antegrade
flow
ADVANTAGES
OPD based treatment
less morbidity, no mortality
No surgical scar
Success rate almost equivalent to open surgery for
primary reflux.
DISADVANTAGES
Cost
Lower success rate compared to surgery for high
grade reflux,upto 90%.
Agents used for Endoscopic Correction of Vesicoureteral
Reflux
Nonautologous Materials
Polytetrafluoroethylene (PTFE)
Cross-linked bovine collagen
Polydimethylsiloxane
Dextranomer hyaluronic copolymer (Deflux)
Coaptite
Autologous Materials
Chondrocytes
Fat
Collagen
Muscle
Deflux
Dextranomer/Hyaluronic Copolymer (DX/HA) is formed of
crosslinked dextranomer microspheres (80 to 250 μm in
diameter) suspended in a carrier gel of stabilized sodium
hyaluronate.
DX/HA is biodegradable, the carrier gel is reabsorbed, and the
dextranomer microspheres capsulated by fibroblast migration
and collagen ingrowth.
DX/HA loses about 23% of its volume beyond 3 months of
follow-up
The appeal of Deflux is that it is a natural product that is easily
administered without a ratcheted syringe through a smaller-gauge
needle.
It is currently the preferred agent for endoscopic correction in
most centers.
Polytetrafluoroethylene Paste
(Teflon Paste)
Teflon paste is relatively inexpensive; it is viscous and
requires a ratcheted syringe for injection.
Less used now because of concerns regarding distant
migration of the PTFE particles.
Particle size 10-100μm.
Malizia demonstrated in experimental studies that the
particles can migrate to regional lymph nodes and to
distantorgans including the lung and the brain
Polydimethylsiloxane (Macroplastique)
Polydimethylsiloxane (PDS) is a solid silicone
elastomer that has been used as a soft tissue bulking
agent.
The main advantage of PDS is that it is a permanent
material that remains well encapsulated, causing
minimal local inflammatory changes.
PDS has yet to achieve FDA approval for correction of
VUR possibly because of concerns regarding
migration, particularly particles that are smaller than
80 μm,
Laparoscopic Surgical Procedures
Gil-Vernet Procedure
In this procedure the trigonal mucosa is incised
vertically and themtwo ureters are approximated into
the midline with a single submucosal suture.
This procedure has been accomplished
laparoscopically transvesically with limited sucees
Reported success rates of 60%.
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