Editing Pediatrics: Vesicoureteral Reflux (section)

=== Ureteral reimplant ===
* '''The principles of ureteral reimiplant for reflux include the following:'''
*# '''Exclusion of causes of secondary VUR'''
*# Adequate mobilization of the distal ureter without tension or damage to its delicate blood supply
*# '''Creation of a submucosal tunnel that is generous in caliber and satisfies the 5:1 ratio of length to width'''
*# Attention to the entry point of the ureter into the bladder (hiatus), the direction of the submucosal tunnel, and the ureteromucosal anastomosis to prevent stenosis, angulation, or twisting of the ureter
*# '''Attention to the muscular backing of the ureter to achieve an effective anti-reflux mechanism'''
*# Gentle handling of the bladder to reduce postoperative hematuria and bladder spasms
** '''Common to each type of open surgical repair for reflux is the creation of a valvular mechanism that enables ureteral compression with bladder filling and contraction, thus reenacting normal anatomy and function.'''
* '''Ureteral duplication'''
** Approximately 10% of children undergoing antireflux surgery have an element of ureteral duplication. The most common configuration is a complete duplication that results in two separate orifices. This is best managed by preserving a cuff of bladder mucosa that encompasses both orifices. Because the pair typically share blood supply along their adjoining wall, mobilization as one unit with a “common sheath” preserves vascularity and minimizes trauma.
* '''Success rate for ureteroneocystostomy in patients with low-grade primary VUR approaches 100%'''
** '''BBD does not alter surgical resolution rates in children treated with open surgery'''
** '''BBD is associated with increased incidence of UTI after surgery.'''
* '''Follow-Up after Ureteral Reimplant'''
** '''An US is necessary at 6-12 weeks postoperatively'''
*** Ureteral obstruction can be clinically silent, and therefore, the absence of ureteral obstruction must be documented.
*** '''Minimal ureteral dilation and low-grade hydronephrosis on early post-operative ultrasonography is not unusual'''
**** '''Persistence of this dilation > 3 months or its progression should be further investigated'''
** '''Postoperative VCUG can be avoided in patients with:'''
**# '''Low-grade primary reflux initially'''
**# '''Normal preoperative and post-operative US examinations'''
*** Recall that follow-up after endoscopic management includes post-operative antbiotics for 3 months and imaging with US and VCUG
** Children with renal scarring should have their blood pressure measured at every visit with their family physician
* '''Complications of Ureteral Reimplantation'''
** '''Early Complications'''
*** '''Persistent Reflux'''
**** '''Early reflux after ureteroneocystostomy usually is not a significant clinical problem and commonly resolves by 1 year on repeat cystography'''
*** '''De novo contralateral Reflux'''
**** '''Prophylactic bilateral reimplantation for unilateral reflux, to avoid contralateral reflux, is not warranted on the basis of the high spontaneous resolution rates'''
*** '''Obstruction at the anastamosis'''
**** Early after surgery, various degrees of obstruction can be expected of the reimplanted ureter. Edema, subtrigonal bleeding, and bladder spasms all possibly contribute. Mucus plugs and blood clots are other causes.
**** '''Most postoperative obstructions are mild and asymptomatic and resolve spontaneously without requiring additional surgery.''' More significant obstructions are usually symptomatic.
***** Affected children typically present 1 to 2 weeks after surgery with acute abdominal pain, nausea, and vomiting
***** '''In the more significant cases, drainage of the system either by retrograde insertion of a double-J stent or a percutaneous nephrostomy tube may be necessary'''
**** '''Many of these cases resolve without requiring additional surgery'''
** '''Late complications'''
*** '''Obstruction at the anastamosis'''
*** '''Recurrent or Persistent Reflux'''
**** '''Causes (4):'''
****# '''High-grade reflux'''
****# '''Inadequate ratio of tunnel length to ureteral diameter'''
****#* Development of a short tunnel and failure to taper the excessively wide ureter are important factors
****# '''Failure to recognize secondary reflux''', especially associated with neurogenic bladders and PUV bladders.
****# '''Bladder and bowel function''' preoperatively, as well as in all cases of persistent or recurrent reflux.
* '''Laparoscopic approach'''
** Should theoretically provide the success rate and durability of open surgery while avoiding its morbidity.
** Procedures have been attempted laparoscopically (3)
**# Extravesical reimplant
**# Gil-Vernet procedure
**# Cohen cross-trigonal reimplant.