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ORIGINAL ARTICLE
Year : 2019  |  Volume : 46  |  Issue : 3  |  Page : 90-94

Persistence and appearance of vesicoureteral reflux/obstruction following open reimplantation for vesicoureteral reflux


1 Department of Urology, JN Medical College, KLE Academy of Higher Education and Research, JNMC Campus; KLES Kidney Foundation, KLES Dr. Prabhakar Kore Hospital and M.R.C, Belagavi, Karnataka, India
2 Department of Urology, JN Medical College, KLE Academy of Higher Education and Research, JNMC Campus, Belagavi, Karnataka, India
3 Department of Urology, KLES Kidney Foundation, KLES Dr. Prabhakar Kore Hospital and M.R.C, Belagavi, Karnataka, India
4 Department of Biotechnology and Microbiology, Karnatak University, Dharwad, Karnataka, India

Date of Web Publication28-Jan-2020

Correspondence Address:
Dr. R B Nerli
Department of Urology, JN Medical College, KLE Academy of Higher Education and Research (Deemed-to-be-University), JNMC Campus, Belagavi - 590 010, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jss.JSS_18_19

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  Abstract 


Introduction: Appearance or persistence of vesicoureteral reflux (VUR) and other obstructive complications after open reimplantation of ureters is well known and up to 7.5% of cases require reoperation. In this study, we have assessed children presenting with recurrent urinary tract infection (UTI) following open reimplantation for VUR. Materials and Methods: We retrospectively collected hospital data of 14 children referred to us for management of recurrent UTIs following open ureteric reimplantation for vesicoureteric reflux from January 2006 to December 2015. Results: Fourteen children presented to our center at a mean age of 31.85 ± 10.17 months. The mean serum creatinine was 0.77 ± 0.26 mg% (range 0.5–1.3). Urine culture was positive in all with Escherichia coli being the most common organism grown on culture. Two children had obstruction at the vesicoureteric junction, and the remaining twelve children had 14 ureteral units with VUR. Two children underwent reimplantation into Boari flap, five underwent open reimplantation, and the remaining seven underwent endoscopic Deflux injection. Repeat voiding cystourethrogram done within 1 year of surgery revealed no VUR in any child. Conclusions: Appearance or persistence of VUR and obstructive complications after open reimplantation surgery is a matter of great concern for the parents of these children as well as the treating pediatric urologists. Appropriately selected open/endoscopic treatment can help in resolving these complications.

Keywords: Endoscopic treatment, postoperative complications, ureteral reimplantation, vesicoureteral reflux


How to cite this article:
Nerli R B, Pujar SV, Ghagane SC, Hiremath MB, Dixit NS. Persistence and appearance of vesicoureteral reflux/obstruction following open reimplantation for vesicoureteral reflux. J Sci Soc 2019;46:90-4

How to cite this URL:
Nerli R B, Pujar SV, Ghagane SC, Hiremath MB, Dixit NS. Persistence and appearance of vesicoureteral reflux/obstruction following open reimplantation for vesicoureteral reflux. J Sci Soc [serial online] 2019 [cited 2020 Aug 11];46:90-4. Available from: http://www.jscisociety.com/text.asp?2019/46/3/90/276993




  Introduction Top


Vesicoureteral reflux (VUR) represents the retrograde flow of urine from the bladder to the upper urinary tract.[1] The true prevalence of VUR is unknown, as many children remain asymptomatic. The prevalence of VUR in normal children has been estimated to be 0.4%–1.8%.[2] The prevalence of VUR is significantly higher in siblings of patients with VUR (46%), children with urinary tract infection (UTI) (30%), infants with prenatal hydronephrosis (16%), and in the presence of urogenital anomalies such as posterior urethral valves (60%), cloaca (60%), and duplex kidney (46%).[3],[4],[5]

Spontaneous resolution of primary reflux is known to be common. This occurs probably due to remodeling of the ureterovesical junction, elongation of the intravesical ureter, and stabilization of bladder voiding dynamics over time. At birth, the likelihood of spontaneous resolution is inversely proportional to the initial grade of reflux; approximately 80% of low-Grade (I and II) reflux will resolve spontaneously versus about 50% of Grade III reflux. Few or approximately 20% of high-Grade (IV and V) reflux will resolve.[6] For older children, resolution depends on both initial grade of reflux, gender, and age at initial diagnosis.[7] Other factors that affect reflux resolution include voiding dysfunction, presence of renal scarring, and occurrence of reflux during bladder filling or emptying. In general, reflux is more likely to resolve in younger patients with low-grade reflux and normal renal ultrasound (US).

Due to the risk of renal scarring, hypertension, and renal failure, the main goal in management is the preservation of kidney function by minimizing the risk of pyelonephritis. However, VUR can present with a wide range of severity, and a substantial proportion of the patients may not need any intervention.[8] A conservative approach is primarily used for the management of persistent low-grade (Grade 1–3) VUR. Surgical correction, either by subureteric injection or open surgery, is recommended in patients with a persistent high-grade reflux (Grade 4–5 reflux) after a period of antibiotic therapy.[9],[10] The advantages of subureteric injection include short hospital stay, surgery without an incision scar and the possibility of being performed as an outpatient procedure. Although there is no consensus about the type of surgery for these patients, open ureteric reimplantation is mostly preferred for patients with higher grade reflux.[3],[11] Endoscopic repair is less successful in patients with high-grade primary VUR, multiple procedures are frequently necessary, and recurrent reflux develops in ≈ 20% of patients.[4],[5],[12],[13] The preference of surgical method should reflect a balance of morbidity and efficacy.

Ureteric reimplantation has been associated with a very high success rate of 98.1%.[14] Although ureteric reimplantation is an invasive method of treatment, the rate of complications has not been studied. Suer et al.[15] reported on a study to evaluate and grade the severity of operative complications in children undergoing open surgery for VUR. In all, 383 children who underwent ureteric reimplantation between 2002 and 2011 were included in the study. The mean (standard deviation [SD]) age was 46 ± 25 months, and the mean (SD) follow-up was 49.4 ± 27.8 months. The mean (SD) hospitalization time was 4.7 ± 1.6 days. Complications occurred in 76 (19.8%) children; 34 (8.9%) were modified Clavien classification system Grade I, 22 (5.7%) were Grade II, and 20 (5.2%) were Grade III. Society of Fetal Urology Grade 3–4 hydronephrosis, obstructing megaureters, refractory voiding dysfunction, and a duplex system were statistically significant predictors of complications on univariate analysis. In this study, we have assessed children presenting with recurrent UTI following open reimplantation for VUR.


  Materials and Methods Top


This study was undertaken with approval obtained from the university/institutional ethical committee. We retrospectively collected demographic, operative, and follow-up data of 14 children referred to us for management of recurrent UTIs following open ureteric reimplantation for vesicoureteric reflux from January 2006 to December 2015. Data related to detailed history, prenatal ultrasonography findings (if available), age at ureteric reimplantation, postoperative follow-up, and complications were collected.

Similarly, data related to the children's urine analysis, urine culture, renal US, and radiographic voiding cystourethrogram (VCUG) done at our center were also collected. All VCUGs demonstrating VUR were graded according to the international reflux study classification system. Intravenous urogram, computed tomography (CT), and radioisotope studies if done were similarly collected and analyzed. Associated dysfunctional voiding in any of these children was classified by a validated symptom score,[16] two uroflowmetry tests at strong desire to void and residual urine volume.


  Results Top


During the 10-year study period, a total of 14 children underwent open ureteric reimplantation at a mean age of 18.07 ± 8.54 months (range 5–30) at a center elsewhere for VUR and were referred to our center for further management of recurrent UTI. The children group included six male and eight females. The indications for surgery as noted from the discharge notes included recurrent UTI in 9%, deterioration of renal function on radioisotope studies in 2%, and high-grade reflux in the remaining 3%. Three of these fourteen children underwent bilateral reimplantation. Twelve of these children had Grade IV/V reflux, whereas two children had Grade III reflux. Eight of these children had undergone unilateral Leadbetter Politano, two B/L Leadbetter Politano, two unilateral Cohens, one bilateral Lich Gregoire, and one Glen Anderson's open antireflux surgery. All these 14 children had recurrent episodes of UTI following reimplantation.

All of these children were referred for further management of recurrent UTIs to our center. The mean age of these children at presentation to our center was 31.85 ± 10.17 months (range 15–46). The mean serum creatinine was 0.77 ± 0.26 mg% (range 0.5–1.3). Urine examination revealed pyuria and bacteriuria in all. Urine culture was positive in all with  Escherichia More Details coli being the most common organism grown on culture. Ultrasonography [Figure 1] revealed dilated pelvicalyceal system with dilated ureters on the same side of reimplantation in 12 children and on the opposite nonoperated side in two children.
Figure 1: Ultrasonography (USG) shows a dilated pelvicalyceal system on the right side

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CT imaging revealed that the two children who had undergone Cohens reimplantation had developed ureteric obstruction at the reimplantation site, with urinary stasis in ureter and pelvis [Figure 2]. VCUG revealed Grade IV/V VUR on the operated side in the seven children and Grade III VUR on the contralateral side in two children who underwent unilateral reimplantation. Of the three children who underwent bilateral reimplantation, two developed bilateral reflux (Grade III/IV) [Figure 3] and one developed unilateral reflux (Grade III). All these children were treated with appropriate antibiotics based on urinary culture reports. Three children had associated symptoms of [Figure 4] dysfunctional elimination with mean voiding scores of 19.4 and were put on a conservative regimen of fluids, appropriate antibiotics, and stool softeners. All children improved with conservative treatment.
Figure 2: Magnetic resonance urogram shows a dilated pelvicalyceal system and ureter on the right side

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Figure 3: Micturating cystourethrogram shows bilateral reflux, right-side Grade V, and left-side Grade III

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Figure 4: Plain X-ray abdomen shows multiple gas shadows, suggesting dysfunctional elimination

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The two children who had undergone Cohen's reimplantation underwent open antireflux reimplantation into a Boari flap as the ureters were short after trimming of the narrow segment. The three children who had earlier undergone bilateral reimplantation were treated by endoscopic submucosal injection of Deflux. Of the remaining nine children, five patients underwent open Leadbetter Politano repair, and four underwent endoscopic submucosal injection of Deflux. With a mean follow-up of 56.42 ± 31.70 months, all the children were free of UTI and urinary examination revealed no pyuria. Ultrasonography done in follow-up period on multiple occasions showed no persistence of dilated ureters/pelvicalyceal system. Repeat VCUG done [Figure 5] within 1 year of surgery revealed no VUR in any child. None of the children undergoing endoscopic treatment needed extra sessions of injections.
Figure 5: Repeat voiding cystourethrogram done 1 year after surgery reveals no reflux

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  Discussion Top


Prevention of febrile UTI or pyelonephritis is one of the primary goals of surgical management for VUR. Surgical cure of VUR reduces the occurrence of pyelonephritis although it has not been proven to reduce renal injury. Patients with recurrent pyelonephritis and/or persistent reflux benefit most from surgery.[17] Decisions for surgical repair are individualized and based on patient's age, health, reflux grade, clinical course, compliance, renal scarring, and parental preference.[2]

American Urological Association (AUA) recommendations for treatment were first published in 1997, by the pediatric VUR guidelines panel of the AUA.[18] Factors included in these recommendations were patient age at presentation, grade of reflux, unilateral versus bilateral reflux, persistent reflux on follow-up, and presence or absence of renal scarring. In general, surgical intervention was recommended in patients who were older at initial presentation, and had dilating, bilateral, or persistent reflux, and renal scarring. Following Food and Drug Administration approval of Deflux ® as a bulking agent for the treatment of VUR Grades 1–4, the 2010 AUA guidelines were revised to include endoscopic treatment of reflux for patients with febrile breakthrough UTI.[11] Relative indications for surgical correction include high-grade reflux, low probability of spontaneous resolution, renal scarring, recurrent pyelonephritis, and breakthrough febrile UTI while on continuous antibiotic prophylaxis and parental preference.[2]

Options for surgical repair of VUR include open, laparoscopic, robot-assisted laparoscopic and endoscopic techniques. Open repairs prevent reflux by increasing the length of the intravesical ureter, facilitating compression of the ureter against the detrusor muscle during bladder filling. Commonly performed open surgical techniques include Lich-Gregoir, Politano-Leadbetter, Glen-Anderson, and Cohen procedures. In expert hands, the success rate for ureteric reimplantation/ureteroneocystostomy in children with low-grade primary VUR approaches 100%. As a result of these outstanding outcomes, many experts question the need for postoperative invasive imaging. Most agree that a sonogram and urine examination is necessary at 6–12 weeks postoperatively. In a large study by Barrieras et al.,[19] there was a significant difference between children who had undergone surgery for low-grade primary VUR (99% resolution) versus those with high-grade reflux (94%) at 1 year after surgery.

Early complications following ureteral reimplantation/ureteroneocystostomy include persistent reflux, contralateral reflux, and ureteric obstruction. Similarly, long-term complications include ureteric obstruction and recurrent/persistent reflux. Suer et al.[15] reported on 247 girls and 136 boys who underwent open ureteric reimplantation with a mean follow-up of 49.42 ± 27.85 months. Complications occurred in 76 (19.8%) children during the 30-day postoperative period. Minor complications occurred in 14.6% of the children (8.9% Grade I, 5.7% Grade II). The most common infection in the minor complication group was febrile UTIs. Interventions were necessary in 5.2% (3.4% Grade IIIa and 1.8% Grade IIIb) mostly due to urinary retention, hydronephrosis, and obstruction. No Grade IV and V complications occurred during the postoperative period.

VUR appearing or persisting after open vesicoureteral reimplantation represents a disappointing problem both for the pediatric urologists and families, as spontaneous resolution is not frequent and repeated open surgery may represent a challenging procedure. Persistent VUR may be due to technical faults, such as a large atonic ureter or a short submucosal tunnel. Ideally, a length/width ratio of 5/1 is indeed recommended to assure an antireflux mechanism. The presence of voiding dysfunction such as a poorly compliant bladder or inadequate emptying can also affect the results of open surgery.

In our series, two children who had undergone Cohen's reimplantation developed obstruction at vesicoureteric junction. These children underwent reimplantation into a Boari flap as it was difficult to dissect out the terminal portion of the ureter. Five other children underwent open Leadbetter Politano reimplantation. Redo reimplantation is technically more challenging and requires careful attention to detail and meticulous surgical technique.[1] Dissection of the ureter and extensive mobilization are required to achieve an adequate submucosal tunnel. Careful dissection of the ureter is best accomplished by a combination of extravesical and intravesical mobilization as needed. If the ureter is shorter, a psoas hitch can be used to facilitate the creation of the antireflux mechanism. Other techniques to consider for the short ureter include the Boari flap, in which a flap extending from the dome to the anterior wall of the bladder based on the posterior wall can be rotated proximally. The flap should be wide enough to allow creation of a submucosal tunnel and tubularization of this flap. In the short ureter, a nipple valve can be created in association with a short submucosal tunnel. The nipple valve is particularly useful in dilated ureters and is fashioned by spatulating the ureter and folding it back onto itself.[1]

In our series, a total of seven children (9 ureteral units [UU]) underwent endoscopic treatment with Deflux, and none of them had recurrence of VUR at the end of 1 year on VCUG. This strongly supports the idea that endoscopic treatment with Deflux could be used in settings such as failed open reimplantation. Kumar and Puri [20] reported their experience with endoscopic Teflon injection in 31 children with persistent high-grade VUR after failure of reimplantation of ureters. VUR was successfully corrected in 27 ureters after a single injection. They opined that submucosal Teflon injection was simple and effective day care procedure for the correction of VUR after failure of reimplantation of ureters. Similarly, Capozza et al.[21] assessed the feasibility of endoscopic treatment of VUR after a failed ureteral reimplantation in 28 patients. VUR was bilateral in 11 patients, for a total of 39 UU treated. The endoscopic treatment was performed 1–7 years after surgery (average 2.5 years). Success was achieved in 22/28 patients (78.5%) and in 30/39 UU (76.9%) after failed ureteral reimplantation.


  Conclusions Top


Appearance or persistence of VUR and obstructive complications after open reimplantation surgery is a matter of great concern for the parents of these children as well as the treating pediatric urologists. Appropriately selected open/endoscopic treatment can help in resolving these complications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Suer E, Ozcan C, Mermerkaya M, Gokce MI, Gulpinar O, Telli O. Can factors affecting complication rates for ureteric re-implantation be predicted? Use of the modified Clavien classification system in a paediatric population. BJU Int 2014;114:595-600.  Back to cited text no. 15
    
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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