Extravesical Antireflux Peritoneal Tunnel Technique for the Treatment of Dilated High-Grade Refluxing Ureters

Abstract

INTRODUCTION:The purpose of the study was to assess the effectiveness of a new antireflux technique that uses a peritoneal flap as a tunnel for the treatment of high-grade refluxing ureters. METHODS:This was a prospective, nonrandomized trial involving15 patients with grade 4 or grade 5 vesicoureteral reflux, seen between 1998 and 2004. Their mean age was 41 years (range, 27-58 years). Of the 15 patients, 13 had a past history of ureteroneocystostomy without an antireflux procedure for the treatment of bilharzial ureteral stricture; 2 patients had reflux secondary to neurogenic bladder. A peritoneal flap was used to create an extravesical ureteral tunnel as an antireflux procedure that does not interrupt the ureterovesical junction. The effective tension of the tunnel and its ability to prevent reflux were tested using intraoperative fluoroscopy. Patients were followed at 6 and 12 months with urine cultures, creatinine measurement, voiding cystourethrogram, and renal ultrasound. RESULTS:Voiding cystourethrogram showed that 10 of 12 patients without reflux during the procedure remained free of reflux during follow-up; the remaining 2 patients developed grade 1 and grade 2 reflux. For 3 patients with low-grade reflux during surgery, 2 remained at the same grade and 1 progressed to high grade. There were no major changes in serum creatinine from baseline to follow-up. After surgery, the frequency and severity of urinary tract infections and pyuria were appreciably diminished. There was no evidence of ureteral obstruction. CONCLUSIONS:The new technique was effective in preventing or downgrading reflux in this small number of patients. By creating an extravesical tunnel from a peritoneal flap, the technique avoids interrupting the ureterovesical junction in the dilated unhealthy ureter and fibrosed bladder wall. It could be applied to cases with a severely fibrosed ureter and bladder when other surgical techniques cannot be safely used.UroToday International Journal ® UI J