Lich-Gregoir Ureteral Reimplantation with Fixation of Ureter during Detrusorraphy as a Reliable Outpatient Anti-reflux Procedure

Abstract

Purpose: We report our experience with a Lich-Gregoir reimplantation (LGR) technique that included fixation of the ureter during detrusorraphy to preserve the integrity of the newly created submucosal tunnel, performed as an outpatient anti-reflux procedure.

Methods: Ninety-seven children (mean age: 7.9 years) with primary VUR underwent LGR between 1995 and 2008. Twenty-one had bilateral VUR, 8 had ureteral duplication, 9 had megaureter, and 13 had previous subureteric injections. Through a Pfannenstiel incision the ipsilateral ureter was mobilized up to the ureterovesical junction without disturbing ureterotrigonal integrity. A 3–5 cm detrusorotomy was extended from the ureterovesical junction towards the umbilicus, the ureter was placed on the mucosa, and detrusorraphy was performed with a loosely running 3/4-0 polyglactin suture that passed through the detrusor on one side of the incision, taking a 1–2 mm “bite” of the ureteral adventitia, and detrusor on the other side. Postoperative ultrasonograms and voiding cystograms (VCUG) were obtained at 1 and 3 months, respectively. Children were then followed up for clinical symptoms of urinary tract infection with annual ultrasonograms.

Results: The mean operative time was 56 min. Eighty-one percent of the children were treated as outpatients. Transient voiding difficulties occurred in 2 children with a bilateral procedure. Reflux was cured in 116 ureters (98%) with a mean follow-up of 58 months (range: 6–128). Ipsilateral obstruction was not evident during ultrasound surveillance.

Conclusions: LGR is an outpatient procedure with a high success rate and a low morbidity. Integrity of the newly created submucosal tunnel is important for long-term success, which may be facilitated by our modified detrusorraphy technique.

Key words

vesicoureteral reflux - surgery - outpatients - technique

References

• 1 Lich RJ, Howerton LW, Davis LA. Recurrent urosepsis in children.  J Urol. 1961;  86 554-558
• 2 Gregoir W. Le traitement chirurgical du reflux vesico-ureteral congenital.  Acta Chir Belg. 1964;  63 431-439
• 3 Zaontz MR, Maizels M, Sugar EC. et al . Detrusorraphy: extravesical ureteral advancement to correct vesicoureteral reflux in children.  J Urol. 1987;  138 947-949
• 4 Barrieras D, Lapointe S, Reddy P. et al . Urinary retention after bilateral extravesical ureteral reimplantation: does dissection distal to the ureteral orifice have a role?.  J Urol. 1999;  162 1197-1200
• 5 David S, Kelly C, Poppas DP. Nerve sparing extravesical repair of bilateral vesicoureteral reflux: description of technique and evaluation of urinary retention.  J Urol. 2004;  172 1617-1620
• 6 McAchran SE, Palmer JS. Bilateral extravesical ureteral reimplantation in toilet trained children: is 1-day hospitalization without urinary retention possible?.  J Urol. 2005;  174 1991-1993
• 7 Palmer JS. Extravesical ureteral reimplantation: an outpatient procedure.  J Urol. 2008;  180 1828-1831
• 8 Ashley R, Vandersteen D. Mini-ureteroneocystostomy: a safe and effective outpatient treatment for unilateral vesicoureteral reflux.  J Urol. 2008;  180 1621-1625
• 9 Ashley R, Vandersteen D. Outcome analysis of mini-ureteroneocystostomy versus dextranomer/hyaluronic acid copolymer injection for unilateral vesicoureteral reflux.  J Urol. 2008;  180 1611-1614
• 10 Barrieras D, Lapointe S, Reddy PP. et al . Are postoperative studies justified after extravesical ureteral reimplantation?.  J Urol. 2000;  164 1064-1066
• 11 Elmore JM, Scherz HC, Kirsch AJ. Dextranomer/hyaluronic acid copolymer for vesicoureteral reflux: success rates after initial treatment failure.  J Urol. 2006;  175 712-715
• 12 Puri P, Mohanan N, Menezes M. et al . Endoscopic treatment of moderate and high grade vesicoureteral reflux in infants using dextranomer/hyaluronic acid.  J Urol. 2007;  178 1714-1717
• 13 Elder JS, Diaz M, Caldamone AA. et al . Endocopic therapy for vesicoureteral reflux: a meta-analysis. I. Reflux resolution and urinary tract infection.  J Urol. 2006;  175 716-722
• 14 Saperston K, Smith J, Putman S. et al . Endoscopic subureteral injection is not less expensive than outpatient open reimplantation for unilateral vesicoureteral reflux.  J Urol. 2008;  180 1626-1630
• 15 Schwentner C, Oswald J, Lunacek A. et al . Lich-Gregoir reimplantation causes less discomfort than Politano-Leadbetter technique: results of a prospective randomized, pain scale-oriented study in a pediatric population.  Eur Urol. 2006;  49 388-395
• 16 Onol SY, Onol FF, Inal H. et al . Lich-Gregoir ureteral reimplantation of the ureter with fixation during detrusorraphy as a reliable and effective procedure.  Urology. 2006;  68 ((Suppl. 5A)) 158-159
• 17 Elmore JM, Kirsch AJ, Perez-Brayfield MR. et al . Salvage extravesical ureteral reimplantation after failed endoscopic surgery for vesicoureteral reflux.  J Urol. 2006;  176 1158-1160
• 18 Tamminen-Mobius T, Brunier E, Ebel KD. et al . Cessation of vesicoureteral reflux for 5 years in infants and children allocated to medical treatment. The International Reflux Study in Children.  J Urol. 1992;  148 1662-1666
• 19 Hjalmas K, Lohr G, Tamminen-Mobius T. et al . Surgical results in the International Reflux Study in Children (Europe).  J Urol. 1992;  148 1657-1661
• 20 Weiss R, Duckett J, Spitzer A. Results of a randomized clinical trial of medical versus surgical management of infants and children with grades III and IV primary vesicoureteral reflux (United States). The International Reflux Study in Children.  J Urol. 1992;  148 1667-1673
• 21 Elder JS, Peters CA, Arant Jr BS. et al . Pediatric Vesicoureteral Reflux Guidelines Panel summary report on the management of primary vesicoureteral reflux in children.  J Urol. 1997;  157 1846-1851

Correspondence