Search

Pronounced ureteral obstruction following an antireflux operation is an uncommon but often difficult problem to manage. Based on a limited experience we have found that triangular flap ureteroplasty is a worthwhile means of repeat reimplantation of the obstructed ureter and perhaps provides a better alternative than transureteroureterostomy.

The results of antireflux operations in 41 cases of primary and 9 cases of secondary vesicoureteral reflux in adults are presented. Reflux was eliminated in all cases and there were no postoperative complications. Most patients had a long history of urinary tract infection preoperatively, which was eliminated in 64.1 per cent of the cases after surgical correction of the reflux. A relapse of infection occurred in 30.8 per cent of these cases. Chronic pyelonephritis remains active in 5.1 per cent of the cases. There were 6 patients with serum creatinine levels higher than 1.8mg. per cent who underwent a successful antireflux procedure without an increase of serum creatinine levels. An antireflux operation should be preferred over long-term conservative management in most cases of symptomatic vesicoureteral reflux in adults less than 50 years old.

Four of 8 cases that represent unusual and infrequent complications of the transvesicle Politano-Leadbetter ureteral reimplantation technique are reported. Approximately 90 per cent of ureteral reimplantations for vesicoureteral reflux may be done satisfactorily as a transvesical procedure but combining it with an extravesical approach of the ureter when necessary or indicated will serve to correct any conceivable congenital, acquired or iatrogenic lesion of the lower ureteral segment. The extravesical approach should be used if there is any difficulty in performing the procedure transvesically or if the patient has undergone previous attempts at antireflux operation. Obstructive complications may occur in either the early or late postoperative period. When discovered, surgical correction is usually indicated. We strongly advocate strict adherence to the surgical technique involved and meticulous postoperative followup of these patients.

Early removal of the vesical catheter after routine ureteroneocystostomy in children was not associated with any increase in surgical complications but significantly shortened hospitalization, reduced the incidence of nosocomial infections and significantly lessened morbidity.

Reflux occurs into unused ureters in patients with urinary diversion and renal tranplantation, and into the ipsilateral ureter in patients with renal agenesis or dysplasia. Efflux may prevent reflux in patients with normal ureterovesical anatomy. If urine begins to flow down the ureter again the reflux may cease. Thus, in patients undergoing urinary tract reconstruction, undiversion should be done before an antireflux operation is performed. Reimplantation can be done after undiversion on a normal capacity bladder if the reflux persists.

We analyzed renal growth and development of renal scars in 754 children with primary and 169 with secondary vesicoureteral reflux. The incidence of a small kidney was 15.5 per cent in the primary and 24.1 per cent in the secondary groups. About three-fourths of the small kidneys remained small from the first examination through followup. Catch-up renal growth was only exceptional. New scars or progression of previous scarring was observed in 7.4 and 30 per cent of the primary and secondary groups, respectively. Factors that promote formation of new scars are high grade vesicoureteral reflux, recurrent urinary tract infections and abnormal bladder function that results in high pressure reflux. We emphasized the importance of precise examination of the lower urinary tract. An early antireflux operation should be performed on children with severe reflux or recurrent urinary tract infections. (J. Urol, part 2, 140:1097-1100, 1988)

Vesicoureteral reflux ceased after eradication of a reservoir of infection in 6 patients. In each case the reflux was mild, the ureter with reflux was not markedly dilated and no ureter had a golfhole orifice. A reservoir of infection should be sought for in adults with chronic or recurrent urinary tract infection and reflux. If it is found and eliminated ureteral reimplantation can be withheld while the patient is followed closely. However, if infection, reflux and associated pyelonephritis persist reimplantation may be necessary.

Gross vesicoureteral reflux with infection can retard renal growth. Resumption of renal growth or even accelerated growth has been reported after successful surgical repair of reflux in children. No published reports examining the effect on physical growth are available. The preoperative and postoperative physical growth curves were examined in 35 consecutive pediatric patients undergoing ureteroneocystostomy for reflux. The significant (average 81 per cent) increase in the postoperative physical growth percentile is presented and discussed.