Management of Vesicoureteral Reflux

POINT-COUNTERPOINT Management of Vesicoureteral Reflux Ellen Shapiro, MD,* Brent Snow, MD,† Mark Zaontz, MD‡ *Department of Urology, New York University School of Medicine, New York, NY; †Department of Surgery and Pediatrics, University of Utah School of Medicine, Salt Lake City, UT; ‡Department of Surgery and Pediatrics, Temple University Medical School, Philadelphia, PA Four cases of vesicoureteral reflux are discussed by prominent pediatric urologists. The condition can range from minimal reflux into the distal ureter to massive reflux causing tortuosity of the ureter and hydronephrosis. Treatment options range from medical management to tapering of the ureter with reimplantation. The cross-trigonal technique is popular among pediatric urologists, and the Politano-Leadbetter technique is a very successful technique that has stood the test of time. The extravesical approach to ureteral reimplantation reduces morbidity, shortens hospital stays, reduces medical costs, and maintains the high success rates of the intravesical techniques. Subureteric injection of bulking agents to correct the reflux holds promise as an alternative to open surgery, but presents the challenge of identifying the ideal bulking agent. [Rev Urol. 2003;5(2):121–125] © 2003 MedReviews, LLC Key words: Vesicoureteral reflux • Hydronephrosis • Pyelonephritis • Cross-trigonal repair • Detrusorrhaphy • Subureteric injection esicoureteral reflux occurs as a spectrum from a wisp of reflux into the lower ureter (Grade I) to massive reflux causing tortuosity of the ureter and hydronephrosis (Grade V). Reflux may be asymptomatic or may be associated with pyelonephritis and renal scarring. It may spontaneously resolve or require surgical intervention. Based on the spectrum of the disorder and its clinical consequences, many treatment options have evolved, ranging from medical management to tapering of the ureter with reimplantation. Recently, minimally invasive options such as subureteric injection have been advocated. V VOL. 5 NO. 2 2003 REVIEWS IN UROLOGY 121 Vesicoureteral Reflux continued Dr. Shapiro: Case 1 involves a 5-year-old girl with left Grade III/V vesicoureteral reflux on a voiding cystourethrogram (VCUG) and parenchymal scarring in the mid- and lower pole regions on a DMSA scan has breakthrough infections. Her parents have refused “experimental" procedures, including endoscopic injection. Dr. Snow, how would you manage this case? Dr. Snow: I would proceed with a traditional intravesical approach. Intravesical repairs that utilize the same hiatus include the GlennAnderson and the Cohen cross-trigonal repairs. The traditional repair that creates a new hiatus is the PolitanoLeadbetter repair. The Glenn-Anderson repair is a very simple approach that is easy to do. The ureter is separated from its trigonal attachments and freed from its intramural tunnel. A submucosal tunnel is made to advance the ureter further into the trigone. The ureter is placed in this dure. I recommend using a combination of percutaneous antegrade and endoscopic retrograde approaches. Politano-Leadbetter has been a popular operation for a long time. Again, the ureter is freed from its detrusor attachments, and a new hiatus is created. The ureter is brought outside the bladder through a new hiatus. One must be very cautious not to trap the ureter or other tissue or to perforate the peritoneum and its contents as the ureter is rerouted outside the bladder. The ureter is then brought into the neohiatus and down the new tunnel. The Politano-Leadbetter technique has been very successful and stood the test of time. Dr. Shapiro: Dr. Zaontz, how would you approach this case? Dr. Zaontz: I agree with Dr. Snow that the intravesical techniques are highly successful, but we should consider some more contemporary antireflux strategies that reduce morbidity, Based on the spectrum of the disorder and its clinical consequences, many treatment options have evolved, ranging from medical management to tapering of the ureter with reimplantation. tunnel and then sutured to the adjacent bladder mucosa. The primary disadvantage of this approach is the modest increase in tunnel length, which is a significant limitation in cases with large-caliber ureters. A modification of this technique is to recede the hiatus and close the detrusor posteriorly in order to achieve a longer tunnel. The cross-trigonal technique is popular among pediatric urologists. Again, the ureter is freed from its attachments and advanced across the trigone. This achieves a longer tunnel while using the initial hiatus. The primary limitation of the technique is ureteral access following the proce- 122 VOL. 5 NO. 2 2003 shorten hospital stays, reduce medical costs, and maintain the high success rates that we see with the intravesical techniques. I prefer performing a detrusorrhaphy, which is essentially an extravesical ureteral advancement procedure. This is a modification of the Lich-Gregoir repair of the 1960s without the use of ureteral stents. By definition, the term “detrusorrhaphy" means that the submucosal ureter is exposed. The ureteral orifice is advanced further onto the trigone, and the overlying detrusor is reapproximated to complete the repair. In this procedure, the bladder is approached through a standard Pfannenstiel REVIEWS IN UROLOGY incision, and the bladder mucosa is exposed underneath the surrounding detrusor muscle so that the ureter is attached only at the mucosalureteral junction. After creating a long tunnel length by exposing the mucosa, two vestlike sutures are placed at the 5 and 7 o’clock positions at the ureteral-mucosal junction. The orifice is advanced by pulling the ureter underneath the detrusor muscle toward the bladder neck, creating a longer tunnel. The detrusor is then reapproximated over the ureter. The advantages of this technique are that there are no stents or drains, bladder spasms are minimized because the Foley catheter is typically removed the day following surgery, and the hospital stay is shorter. At our institution we have found that this technique is cost-effective because its success is equivalent to that of intravesical techniques. The added bonus of detrusorrhaphy is the ease of access to the distal ureter, in contradistinction to some of the very commonly performed intravesical techniques such as the Cohen cross-trigonal repair. Dr. Shapiro: Let’s proceed to our second case. A 5-year-old girl with bilateral Grade III reflux and left global atrophy on DMSA scan has breakthrough infections. Dr. Zaontz, would you perform detrusorrhaphy in this patient? Dr. Zaontz: One of the criticisms of the detrusorrhaphy technique for cases of bilateral reflux is the increased risk of postoperative urinary retention because of neural denervation. In my personal series of 41 bilateral detrusorrhaphies, only 1 child developed urinary retention. In 1998, Minevich reported on a series of 123 detrusorrhaphies performed on children with voiding dysfunction, with a 98.3% success rate. Of the 8 patients who Vesicoureteral Reflux had postoperative voiding dysfunction, only 5 went into urinary retention. The longest time interval for intermittent catheterization was 3 weeks. Urinary retention is rare in properly selected children without significant preoperative bladder dysfunction. The technical caveat is to limit the dissection of the extravesical submucosal tunnel in order to decrease the risk of postoperative urinary retention. Dr. Shapiro: Dr. Snow, do you have any further comments? Dr. Snow: In my experience, voiding problems in children following bilateral detrusorrhaphy are fairly common. Therefore, in cases of bilateral reflux, I generally perform open procedures rather than extravesical repairs. Dr. Shapiro: Let’s go on to our third case. A 10-year-old girl has bilateral Grade III reflux and significant bilateral parenchymal scarring on DMSA scan. She has breakthrough urinary tract infections. Her parents have refused open surgery. Dr. Zaontz, what techniques are you going to employ in this case? Dr. Zaontz: Because the family is refusing open surgery we must consider some of the more experimental procedures. I would consider endoscopic bulking agents to correct the reflux. Matouschek in 1981 and O’Donnell and Puri in 1984 popularized the technique commonly known as the “STING" (subureteric injection) using Teflon. The success rates reported in the literature are as high as 92%. The challenge has been to identify the ideal bulking agent. Malizia in 1984 and Aaronson in 1993 reported that Teflon migrates to distant organ sites such as the lung, lymph nodes, and the brain, and forms granuloma. Bovine collagen was the next bulking agent that gained popularity. The problem with collagen is that it has had significantly lower success rates than Teflon, presumably due to the fact that collagen rapidly degrades, resulting in loss of volume and reviewed multicenter outcomes with subureteric injection for reflux. The success rates for Teflon, collagen, Deflux, autologous fat, and Chondrogel were 75%, 60%, 68%, 22%, and 60%, respectively. Three months following the first injection with Chondogrel, the success rates Urinary retention is rare in properly selected children without significant preoperative bladder dysfunction. recurrent reflux. In addition, there is the risk of allergic reaction from the collagen. Some of the other nonautologous injectable agents that have been investigated include silicone, bioglass, polyvinyl alcohol, and Deflux (dextranomer microspheres). Autologous substances used as bulking agents include fat, blood, and human collagen. Most recently, bladder cells and chondrocytes have been investigated. Endoscopic correction of reflux has several benefits. It is a short outpatient procedure, it avoids open surgery, is relatively painless, and is easily repeated. The ideal substance for endoscopic correction must be safe, biocompatible, and nonmigratory. The success rates must approach open surgery, and the results must be reproducible among different centers. There are several agents available for the endoscopic correction of reflux that utilize the same technique. A pediatric panendoscope with an offset lens and 21-gauge needle are employed. The needle is inserted at the 6 o’clock position just below and in front of the ureteral orifice. The needle is advanced submucosally approximately 0.5 cm so it is situated right underneath the orifice. The implant material is injected, raising a volcanic wheal beneath the ureteral orifice. Kershen and Atala have recently for Grades I, II, III, and IV reflux were 100%, 75%, 100%, and 50%, respectively. I am convinced that once a safe material is found with an acceptable long-term success rate, patients with mild to moderate reflux will all be treated endoscopically at the time of diagnosis. This will obviate long-term prophylaxis and repeated invasive radiographic evaluation. Dr. Shapiro: Dr. Snow, are there other innovative techniques that you could offer this young girl with bilateral Grade III reflux? Dr. Snow: Laparoscopy and percutaneous endoscopic approaches hold promise for antireflux surgery. Laparoscopic approaches are based on the extravesical Lich-type repair, where mobilization of the ureter takes place just outside the bladder. An incision is made in the bladder wall, and the bladder epithelium is exposed in a trough-like fashion. The ureter is then laid in this trough, and muscle is closed over the ureter with sutures or staples. The best case for a laparoscopic approach is in older patients, because their recovery may benefit. As far as the endoscopic approach is concerned, we have been developing an endoscopic approach where a trocar is placed into the bladder. It is necessary to suture the bladder up to VOL. 5 NO. 2 2003 REVIEWS IN UROLOGY 123 Vesicoureteral Reflux continued the abdominal wall at the time of trocar placement so that the bladder does not retract from the trocar, resulting in loss of access. Incisions are made across the trigone. This procedure is based on the Gil-Vernet technique for reimplantation, so that the epithelium is raised and then sutures are placed on the medial aspects of the ureter. These sutures are tied in the midline to complete the repair. No ureters refluxed immediately after surgery. However, the results have not been durable. At 6-months follow-up, only 62% of cases were not refluxing. In Japan, the success rate has been slightly better than ours in Salt Lake City. Dr. Shapiro: Let’s proceed with our fourth case. A 4-year-old girl has persistent right Grade III/V vesicoureteral reflux and recurrent infections after Politano-Leadbetter ureteral reimplantations at 2 years of age. The initial VCUG shows bilateral Grade III reflux, and the postoperative voiding study showed persistent Grade III reflux on the right. Before we discuss surgical approaches to the failed reimplant, we need to examine the most common causes for failed reimplant, which are unrecognized voiding dysfunction or disturbed voiding and holding patterns and unrecognized bowel dysfunction. These errors in recognition have a significant effect on our surgical outcomes and on postoperative risk of infection. Dysfunctional voiding may be manifested as the lazy bladder syndrome, which is treated with timed voiding for these infrequent voiders. Bladder instability is another type of voiding dysfunction which responds well to anticholinergic therapy. In females, the VCUG may show a “spinning-top" urethra when there is inappropriate closure of the external urinary sphincter during a detrusor contraction, which leads to high intravesical pressures. These increased intravesical pressures can subsequently lead to diverticula formation and reflux. Therefore, when we see children who present with urinary tract infections, we correct voiding dysfunction and vigorously treat problems with constipation, because they will impact on reflux resolution or the outcome of reflux surgery. Dr. Snow, now that we have addressed bowel and blad- der dysfunction, what surgical techniques would you employ in the management of the patient with the failed reimplant? Dr. Snow: I agree wholeheartedly that the failure of reflux surgery should be considered bladder dysfunction and not technical until bladder dysfunction has been excluded and treated appropriately. Only then should one proceed to reoperative procedures. It is important to consider constructing a longer tunnel and perhaps even an alternative technique. One of the ways to obtain a longer tunnel is to perform a psoas hitch. This is a procedure in which the bladder is hitched to the psoas muscle, providing a very long, stable posterior wall, which will allow a hiatus to be positioned higher in the bladder without kinking. If a minimal procedure was initially selected, a cross-trigonal will achieve the longest tunnel using the original hiatus. The primary disadvantage is related to ureteral access at a later time. Because the contralateral reimplantation was successful, another option would be a transureter- Main Points • Vesicoureteral reflux may be asymptomatic or may be associated with pyelonephritis and renal scarring; it may spontaneously resolve or require surgical intervention. • The Glenn-Anderson and the Cohen cross-trigonal repairs utilize the original hiatus; the Politano-Leadbetter repair creates a new hiatus. • Extravesical ureteral reimplantations reduce morbidity, shorten hospital stays, reduce medical costs, and maintain high success rates. • Detrusorrhaphy, an extravesical ureteral advancement procedure, is a modification of the Lich-Gregoir repair without the use of ureteral stents; bladder spasms are minimized because the Foley catheter is typically not used or removed the day following surgery. • Postoperative urinary retention occurs more commonly when detrusorrhaphy is used for cases of bilateral reflux. • Nonautologous injectable bulking agents that have been investigated include Teflon, bovine collagen, silicone, bioglass, polyvinyl alcohol, and Deflux (dextranomer microspheres). • Autologous substances used as bulking agents include fat, blood, and human collagen; most recently, bladder cells and chondrocytes have been investigated. • Dysfunctional voiding must be treated as part of the medical management of reflux; infrequent voiding is treated with timed voiding, and bladder instability responds well to anticholinergic therapy. 124 VOL. 5 NO. 2 2003 REVIEWS IN UROLOGY Vesicoureteral Reflux oureterostomy with unilateral reflux. Dr. Shapiro: Dr. Zaontz, how would you manage this patient with a failed reimplant? Dr. Zaontz: I would consider endoscopic correction of reflux. What are the advantages? Well, you may be able to avoid open surgery again, and you’re not burning any bridges. If it does not work, you can always proceed with open surgery. This outpatient procedure takes about 15 minutes. The child will be back on the playground the next day. Dr. Shapiro: I would like to thank Drs. Zaontz and Snow for discussing these four interesting cases which demonstrate the spectrum of vesi- coureteral reflux and the controversies related to the management of this common condition. Selected References Aaronson IA, Rames RA, Greene WB, et al. Endoscopic treatment of reflux: migration of Teflon to the lungs and brain. Eur Urol. 1993;23:394–399. Atala A, Kavoussi LR, Goldstein DS, et al. Laparoscopic correction of vesicoureteral reflux. J Urol. 1993;150:748. Atala A, Keating MA. Vesicoureteral reflux and megaureter. In: Walsh PC, Retik AB, Vaughan ED Jr, Wein AJ, eds. Campbell’s Urology. 8th ed. Philadelphia: WB Saunders; 2002:2053–2116. Burno DK, Glazier DB, Zaontz MR. Lessons learned about contralateral reflux after unilateral extravesical ureteral advancement in children. J Urol. 1998;160:995–997. Diamond DA, Caldamone AA. Endoscopic correction of vesicoureteral reflux in children using autologous chondrocytes: preliminary results. J Urol. 1999;162:1185–1188. Kershen RT, Atala A. New advances in injectable therapies for the treatment of incontinence and vesicoureteral reflux. Urol Clin North Am. 1999;26:81–94. Koff SA, Wagner TT, Jayanthi VR. The relationship among dysfunctional elimination syndromes, primary vesicoureteral reflux and urinary tract infections in children. J Urol. 1998;160:1019. Lackgren G, Wahlin N, Skoldenberg E, Stenberg A. Long-term followup of children treated with dextranomer/hyaluronic acid copolymer for vesicoureteral reflux. J Urol. 2001;166:1887–1892. Malizia AA Jr, Reiman HM, Myers RP, et al. Migration and granulomatous reaction after periuretheral injection of polytef (Teflon). JAMA. 1984:251:3277–3281. Matouschek E. Treatment of vesicorenal reflux by transurethral teflon-injection [in German]. Urologe A. 1981;20:263–264. Minevich E, Aronoff D, Wacksman J, Sheldon CA. Voiding dysfunction after bilateral extravesical detrusorrhaphy. J Urol. 1998;160:1004–1006,1038. O’Donnell B, Puri P. Treatment of vesicoureteric reflux by endoscopic injection of Teflon. Br J Med (Clin Res Ed). 1984;289:7–9. Puri P, Granata C. Multicenter survey of endoscopic treatment of vesicoureteral reflux using polytetrafluoroethylene. J Urol. 1998;160:1007–1011, 1038. VOL. 5 NO. 2 2003 REVIEWS IN UROLOGY 125