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Open Versus Endoscopic Surgery in the Treatment of Vesicoureteral Reflux
0022-i:347/88/14 22--0499$02. 00 iO THE JOURNAL
UROLOGY
Copyrigh-~ © 1989 by ArvlERICAl..Y URCLOGICAL ASSOCIAT}ON,
OPEN VERSUS ENDOSCOPIC SURGERY IN THE TREATMENT OF VESICOURETERAL REFLUX STEPHEN BROWN From the Department of Paediatric Surgery, Royal Belfast Hospital for Sick Children, Belfast, Northern Ireland
ABSTRACT
Surgical reimplantation of the ureters was compared to subureteral injection of polytetrafluoroethylene (Polytef) in the treatment of primary vesicoureteral reflux. Reflux was eliminated successfully in 98 per cent of the 76 ureters treated by reimplantation and in 70 per cent of the 40 ureters treated endoscopically. Although the surgical morbidity of endoscopic surgery appears to be less than that of open surgery, the patients undergoing endoscopic surgery required more hospital admissions, more anesthetics and more micturating cystourethrograms than did those in the reimplantation group. It is concluded that subureteral polytetrafluoroethylene injection does not represent a satisfactory substitute for reimplantation. (J. Ural., part 2, 142: 499-500, 1989) Although the emphasis in the management of vesicoureteral reflux has always been on the generally satisfactory outcome of conservative treatment, 1 it has equally been accepted that in certain circumstances a surgical approach is justified. Like all surgical techniques the procedure should be attended with as little morbidity as possible consistent with successful treatment of the condition. A number of techniques have been described for reimplanting the ureters, 2 - 4 all of which have been shown to be effective u,c,uv'~"" the morbidity of open surgery is common.5 The technique of subureteral polytetrafluoroethylene injection (Sting) introduced in 1984 by O'Donnell and Puri6 brought the hope that this morbidity could be reduced substantially without compromising the efficacy of the treatment. However no direct comparisons have been drawn between the 2 methods of surgical management.
2, see table). Of the 77 patients in the study 39 had failed to improve after a period of medical treatment lasting at least 1 year (29 in group 1 and 10 in group 2). All patients received prophylactic antibiotics for 3 weeks after treatment and thereafter only as indicated by urine culture. A micturating cystourethrogram and an excretory urogram or ultrasound scan were performed 1 year after reimplantation, Patients undergoing the Sting were maintained on proantibiotics until the reflux stopped. A micturating cystourethrogram and ultrasound scan were performed 4 to 6 months after the procedure. If reflux persisted injection was repeated as many as 3 times. An ultrasound scan and micturating cystourethrogram also were repeated after each Sting. RESULTS
The results of the treatment are shown in the table. In the reimplantation group 98 per cent of the ureters were treated successfully compared to 70 per cent of those in the Sting group, a stastically significant difference (p <0.001). In group 2, 25 of the 28 successful results were achieved with 1 or 2 injections, although in all unsuccessful cases a third injection was given. The grade of reflux did not influence the outcome of the procedure. More micturating cystourethrograms were performed in the Sting group (average compared to the reimplantation group (p Indeed if only the postoperative cys(average e,v,,rn,"ucn,..,_, then 51 reimplantation patients had whereas 26 Sting had 63 cystograms, a d1tter,enc:ethat is highly V"h"'"'""~''-'"" ~v,v,,v~ The 26 children
MATERIALS AND METHODS
All patients undergoing "u"'l':!'"'"u management of primary vesicoureteral reflux between 1982 and 1986 were included in the study. Patients with reflux secondary to outflow obstruction, duplex ureters or a neuropathic bladder were excluded. design the was not controlled, A retrospective group of reimplantation operations was compared to a prospective study of the The technique used was described and Puri. 6 The effected ureter was visualized c11uv:,;_;,up,u,,uv a fine needle was instrument mucosa was inferomedial border of the ureteral orifice, tU1UU!V'CC11Ylt,Ht: paste WaS pertion of 0.2 to OA ml. beneath the terminal portion of formed to produce a the ureter such that the of the ureteral orifice was changed from circular to crescentic. A total of 79 ureters in 53 patients v,ere reimplanted, using the Cohen advancement technique 4 and in 42 ureters of 27 patients the Sting procedure was performed. Three patients were lost to foHowup and, therefore, the study included 51 patients (76 ureters) in the reimplantation group (group 1) and 26 patients (40 ureters) in the Sting group (group 2). The surgical approach was based on the severity of reflux, failure of conservative treatment with persistent symptoms and established or progressive renal scarring. All decisions about treatment approach were made by the author. Although the 2 groups were not formally matched, they were similar when compared by age and sex (see table). Severe reflux (grade III or worse 7 ) was present in 86 of the 116 ureters (58 in group 1 and 28 in group 2), and pyelonephritic scarring was present in 64 of the 116 kidneys (36 in group 1 and 28 in group
¥WCCe~CCHV
Characteristics of patients and results of treatment Sting (26 pts.)
Reimplantation (51 pts.)
Pt. sex and age (yrs,):
499
~'{ 1_ 2 2-5 5- 8 3+ Grade of reflux and presence of pyelonephritic scars:
I/II III
~v Scars No. corrected/Total No. reflux ureters(%)
3:23 3 2 12 6 3
12 10
14 4 28 75/76 (98)
* Of the remaining 12 ureters reflux had improved in 5.
6:45 9 5
22 11 4
18 15 40 3 36 28/40 (70)*
500
BROWN
in the Sting group had a total of 57 separate visits to the hospital, each involving an anesthetic, whereas only 1 hospitalization and anesthetic were required for each of the children in the reimplantation group. The Sting was considered successful if the micturating cystourethrogram at 4 to 6 months showed no reflux. However, it is now recognized that reflux can recur up to a year after the injection. The entire group will have to undergo further examination at a later date. Continued surveillance also will be necessary to exclude the possibility of a foreign body response in the bladder, 8 although none of the children in this series has shown such a complication to date. DISCUSSION
Surgical correction of vesicoureteral reflux is undertaken either because conservative treatment has failed, or because the severity of the reflux or symptoms make it imperative to control the reflux with reasonable haste. Therefore, it is important that the procedure used has a high degree of reliability. Such a degree of reliability has always been present with surgical reimplantation, which is particularly important in patients who have already undergone a period of conservative treatment, with all of the uncertainty that this may cause. Subureteral polytetrafluoroethylene injections can only be seen as a rival to reimplantation if they are shown to be as successful. The reported success of 80 per cent by Puri and O'Donnell5 and the 70 per cent success in this series are not significantly different from the results achieved by expectant treatment. 1 Although reimplantation is attended with greater morbidity than endoscopic treatment, the increased number of
micturating cystourethrograms required in the Sting group represents a significant source of trauma for the patients. Furthermore, although all Sting procedures were performed on an outpatient basis, each child may require as many as 3 visits to the hospital and 3 separate anesthetics. On the basis of this study, the author does not regard subureteral polytetrafluoroethylene injection as having any significant advantages over expectant treatment. When intervention is indicated reimplantation remains the procedure of choice. REFERENCES 1. Normand, I. C. S. and Smellie, J.: Vesicoureteric reflux: the case
2.
3. 4. 5.
6. 7.
8.
for conservative management. In: Reflux Nephropathy. Edited by J. Hodson and P. Kincaid-Smith. New York: Masson Publishing Co., chapt. 28, p. 281, 1979. Politano, V. A. and Leadbetter, W. F.: An operative technique for the correction of vesicoureteral reflux. J. Urol., 79: 932, 1958. Glenn, J. F. and Anderson, E. E.: Distal tunnel ureteral reimplantation. J. Urol., 97: 623, 1967. Cohen, S. J.: Ureterzystoneostomie: eine neue Antirefluxtechnik. Akt. Urol., 6: 1, 1975. Puri, P. and O'Donnell, B.: Endoscopic correction of grades IV and V primary vesicoureteric reflux: six to 30 months followup in 42 ureters. J. Ped. Surg., 22: 1087, 1987. O'Donnell, R. and Puri, P.: Treatment of vesicoureteric reflux by endoscopic injection of Teflon. Brit. Med. J., 289: 7, 1984. Report of the International Reflux Study Committee: Medical versus surgical treatment of primary vesicoureteral reflux. Pediatrics, 67: 392, 1981. Woodard, J. R. and Rushton, H. G.: Reflux uropathy. Ped. Clin. N. Amer., 34: 1349, 1987.
UROLOGY
Copyrigh-~ © 1989 by ArvlERICAl..Y URCLOGICAL ASSOCIAT}ON,
OPEN VERSUS ENDOSCOPIC SURGERY IN THE TREATMENT OF VESICOURETERAL REFLUX STEPHEN BROWN From the Department of Paediatric Surgery, Royal Belfast Hospital for Sick Children, Belfast, Northern Ireland
ABSTRACT
Surgical reimplantation of the ureters was compared to subureteral injection of polytetrafluoroethylene (Polytef) in the treatment of primary vesicoureteral reflux. Reflux was eliminated successfully in 98 per cent of the 76 ureters treated by reimplantation and in 70 per cent of the 40 ureters treated endoscopically. Although the surgical morbidity of endoscopic surgery appears to be less than that of open surgery, the patients undergoing endoscopic surgery required more hospital admissions, more anesthetics and more micturating cystourethrograms than did those in the reimplantation group. It is concluded that subureteral polytetrafluoroethylene injection does not represent a satisfactory substitute for reimplantation. (J. Ural., part 2, 142: 499-500, 1989) Although the emphasis in the management of vesicoureteral reflux has always been on the generally satisfactory outcome of conservative treatment, 1 it has equally been accepted that in certain circumstances a surgical approach is justified. Like all surgical techniques the procedure should be attended with as little morbidity as possible consistent with successful treatment of the condition. A number of techniques have been described for reimplanting the ureters, 2 - 4 all of which have been shown to be effective u,c,uv'~"" the morbidity of open surgery is common.5 The technique of subureteral polytetrafluoroethylene injection (Sting) introduced in 1984 by O'Donnell and Puri6 brought the hope that this morbidity could be reduced substantially without compromising the efficacy of the treatment. However no direct comparisons have been drawn between the 2 methods of surgical management.
2, see table). Of the 77 patients in the study 39 had failed to improve after a period of medical treatment lasting at least 1 year (29 in group 1 and 10 in group 2). All patients received prophylactic antibiotics for 3 weeks after treatment and thereafter only as indicated by urine culture. A micturating cystourethrogram and an excretory urogram or ultrasound scan were performed 1 year after reimplantation, Patients undergoing the Sting were maintained on proantibiotics until the reflux stopped. A micturating cystourethrogram and ultrasound scan were performed 4 to 6 months after the procedure. If reflux persisted injection was repeated as many as 3 times. An ultrasound scan and micturating cystourethrogram also were repeated after each Sting. RESULTS
The results of the treatment are shown in the table. In the reimplantation group 98 per cent of the ureters were treated successfully compared to 70 per cent of those in the Sting group, a stastically significant difference (p <0.001). In group 2, 25 of the 28 successful results were achieved with 1 or 2 injections, although in all unsuccessful cases a third injection was given. The grade of reflux did not influence the outcome of the procedure. More micturating cystourethrograms were performed in the Sting group (average compared to the reimplantation group (p Indeed if only the postoperative cys(average e,v,,rn,"ucn,..,_, then 51 reimplantation patients had whereas 26 Sting had 63 cystograms, a d1tter,enc:ethat is highly V"h"'"'""~''-'"" ~v,v,,v~ The 26 children
MATERIALS AND METHODS
All patients undergoing "u"'l':!'"'"u management of primary vesicoureteral reflux between 1982 and 1986 were included in the study. Patients with reflux secondary to outflow obstruction, duplex ureters or a neuropathic bladder were excluded. design the was not controlled, A retrospective group of reimplantation operations was compared to a prospective study of the The technique used was described and Puri. 6 The effected ureter was visualized c11uv:,;_;,up,u,,uv a fine needle was instrument mucosa was inferomedial border of the ureteral orifice, tU1UU!V'CC11Ylt,Ht: paste WaS pertion of 0.2 to OA ml. beneath the terminal portion of formed to produce a the ureter such that the of the ureteral orifice was changed from circular to crescentic. A total of 79 ureters in 53 patients v,ere reimplanted, using the Cohen advancement technique 4 and in 42 ureters of 27 patients the Sting procedure was performed. Three patients were lost to foHowup and, therefore, the study included 51 patients (76 ureters) in the reimplantation group (group 1) and 26 patients (40 ureters) in the Sting group (group 2). The surgical approach was based on the severity of reflux, failure of conservative treatment with persistent symptoms and established or progressive renal scarring. All decisions about treatment approach were made by the author. Although the 2 groups were not formally matched, they were similar when compared by age and sex (see table). Severe reflux (grade III or worse 7 ) was present in 86 of the 116 ureters (58 in group 1 and 28 in group 2), and pyelonephritic scarring was present in 64 of the 116 kidneys (36 in group 1 and 28 in group
¥WCCe~CCHV
Characteristics of patients and results of treatment Sting (26 pts.)
Reimplantation (51 pts.)
Pt. sex and age (yrs,):
499
~'{ 1_ 2 2-5 5- 8 3+ Grade of reflux and presence of pyelonephritic scars:
I/II III
~v Scars No. corrected/Total No. reflux ureters(%)
3:23 3 2 12 6 3
12 10
14 4 28 75/76 (98)
* Of the remaining 12 ureters reflux had improved in 5.
6:45 9 5
22 11 4
18 15 40 3 36 28/40 (70)*
500
BROWN
in the Sting group had a total of 57 separate visits to the hospital, each involving an anesthetic, whereas only 1 hospitalization and anesthetic were required for each of the children in the reimplantation group. The Sting was considered successful if the micturating cystourethrogram at 4 to 6 months showed no reflux. However, it is now recognized that reflux can recur up to a year after the injection. The entire group will have to undergo further examination at a later date. Continued surveillance also will be necessary to exclude the possibility of a foreign body response in the bladder, 8 although none of the children in this series has shown such a complication to date. DISCUSSION
Surgical correction of vesicoureteral reflux is undertaken either because conservative treatment has failed, or because the severity of the reflux or symptoms make it imperative to control the reflux with reasonable haste. Therefore, it is important that the procedure used has a high degree of reliability. Such a degree of reliability has always been present with surgical reimplantation, which is particularly important in patients who have already undergone a period of conservative treatment, with all of the uncertainty that this may cause. Subureteral polytetrafluoroethylene injections can only be seen as a rival to reimplantation if they are shown to be as successful. The reported success of 80 per cent by Puri and O'Donnell5 and the 70 per cent success in this series are not significantly different from the results achieved by expectant treatment. 1 Although reimplantation is attended with greater morbidity than endoscopic treatment, the increased number of
micturating cystourethrograms required in the Sting group represents a significant source of trauma for the patients. Furthermore, although all Sting procedures were performed on an outpatient basis, each child may require as many as 3 visits to the hospital and 3 separate anesthetics. On the basis of this study, the author does not regard subureteral polytetrafluoroethylene injection as having any significant advantages over expectant treatment. When intervention is indicated reimplantation remains the procedure of choice. REFERENCES 1. Normand, I. C. S. and Smellie, J.: Vesicoureteric reflux: the case
2.
3. 4. 5.
6. 7.
8.
for conservative management. In: Reflux Nephropathy. Edited by J. Hodson and P. Kincaid-Smith. New York: Masson Publishing Co., chapt. 28, p. 281, 1979. Politano, V. A. and Leadbetter, W. F.: An operative technique for the correction of vesicoureteral reflux. J. Urol., 79: 932, 1958. Glenn, J. F. and Anderson, E. E.: Distal tunnel ureteral reimplantation. J. Urol., 97: 623, 1967. Cohen, S. J.: Ureterzystoneostomie: eine neue Antirefluxtechnik. Akt. Urol., 6: 1, 1975. Puri, P. and O'Donnell, B.: Endoscopic correction of grades IV and V primary vesicoureteric reflux: six to 30 months followup in 42 ureters. J. Ped. Surg., 22: 1087, 1987. O'Donnell, R. and Puri, P.: Treatment of vesicoureteric reflux by endoscopic injection of Teflon. Brit. Med. J., 289: 7, 1984. Report of the International Reflux Study Committee: Medical versus surgical treatment of primary vesicoureteral reflux. Pediatrics, 67: 392, 1981. Woodard, J. R. and Rushton, H. G.: Reflux uropathy. Ped. Clin. N. Amer., 34: 1349, 1987.