Evolving surgical management of pediatric vesicoureteral reflux: is open ureteral reimplantation still the 'Gold Standard'?

Abstract

Vesicoureteral reflux, the retrograde flow of urine from the bladder into the upper urinary tract, is one of the most common urologic diagnoses in the pediatric population. Once detected, therapeutic options for urinary reflux are diverse, ranging from observation with or without continuous low-dose prophylactic antibiotics to a variety of operative interventions. While a standardized algorithm is lacking, it is generally accepted that management be tailored to individual patients based on various factors including age, likelihood of spontaneous resolution, risk of subsequent urinary tract infections with renal parenchymal injury, and parental preference. Anti-reflux surgery may be necessary in children with persistent reflux, renal scarring or recurrent pyelonephritis after optimization of bladder and bowel habits. Open, laparoscopic/robot-assisted and endoscopic approaches are all successful in correcting reflux and have been shown to reduce the incidence of febrile urinary tract infections.

Keywords: Pediatrics; Ureteral Diseases; Vesico-Ureteral Reflux.

Figure 1. Comparison of clinical and radiographic success of open ureteral reimplantation (14), robotic ureteral reimplantation (26) and Dx/HA injection (33).

Figure 2. EI may be considered first line surgical therapy for most cases of grade II-IV VUR, owing to its ambulatory nature and good clinical success. OUR offers more approaches with high radiographic and clinical success rates, but higher morbidity compared to EI must be considered. RALUR is an option in older children but is typically limited to an extravesical approach.