1. Indications and effectiveness of the open surgery in vesicoureteral reflux Suzi DEMIRBAG, MD Department of Pediatric Surgery, Gulhane Military Medical Academy, Ankara, TURKEY

2. Vesicoureteral reflux (VUR) refers to the retrograde flow of urine from the bladder into the ureter. Reflux results from a congenital anomaly of the ureterovesical junction (Primary VUR), Reflux from high-pressure voiding secondary to posterior urethral valves, neuropathic bladder or voiding dysfunction (Secondary VUR).

3. The prevalence of VUR in normal children has been estimated at 0.4–1.8% Prenatally identified by ultrasonography the prevalence was 16.2 % Siblings of children with VUR had a 27.4% risk for VUR

4. The main goal preservation of kidney function The risk factors age sex reflux grade lower urinary tract dysfunction [LUTD] anatomic abnormalities kidney status

5. There are different options in the management of VUR, from -Observation with or without antibiotics prophylaxis -Surgical intervention: -open, -endoscopic -laparoscopic approaches.

6. Factors influencing the decision The risk of developing a UTI, and associated risk factors for UTIs – such as voiding dysfunction Risk of development of new renal scars, Chance for spontaneous resolution

7. Which patients should be selected for surgery ? The focus should be on selecting patients for treatment by identifying those at risk : Recurrent Pyelonephritis VUR will not spontaneously resolve.

8. Rate of resolution of VUR age at presentation gender grade of the reflux laterality mode of clinical presentation ureteral anatomy bladder/bowel dysfunction

9. Open Surgery Open ureteral reimplantation is still the gold standard for surgical treatment. Success rates of 95% to 98% with low complication rates.

10. Indications for Surgery Absolute indication for surgical correction is the Failure of nonsurgical management Relative indications include the following: High-grade reflux Anatomic problems, – large para-ureteral diverticulum – ureteral duplication; impaired renal growth Controversial indications include Persistent reflux in girls after puberty Avoid the need for follow-up VUR evaluation or CAP.

11. The principles of surgical correction of reflux Defining the causes of secondary VUR Sufficient mobilization of the distal ureter Creation of a submucosal tunnel ( 5 : 1 ratio) Attention to the entry point of the ureter Attention to the muscular backing of the ureter Gentle surgery

12. Open Surgical techniques for VUR Politano-Leadbetter Technique Glenn-Anderson Technique Cohen’s Technique Lich-Gregoir Technique

13. Laparoscopic ureteral reimplantation Advantages Cosmetic Short hospitalisation Disadvantages Longer op.time Need more experience in laparoscopy Robot-assisted laparoscopic ureteral reimplantation Advantages  Better view  Better surgery Disadvantages:  Higher op. cost  Longer op.time

14. Complications of VUR Surgery Early Complications: Persistant reflux Contralateral Reflux Obstruction Late Complications: Obstruction Recurrent or Persistant Reflux

15. Conclusion Factors that negatively influence resolution: Grade of reflux, Lower bladder volume or pressure at onset of reflux, Age Sex Laterality of VUR, Anatomical problems, Abnormal or scarred kidneys, Bladder dysfunction

16. Conclusion The treatment of VUR → decreased rate of pyelonephritis. Open surgery is still the gold standard for VUR treatment There is no difference in the rate of renal scarring, renal growth, and UTIs in patients treated medically or surgically for dilating VUR.

17. References 1-Austin JC, Cooper CS. Vesicoureteral reflux: who benefits from correction. Urol Clin North Am. 2010 May;37(2):243-52. doi: 10.1016/j.ucl.2010.03.012 2-Fonseca FF, Tanno FY, Nguyen HT. Current options in the management of primary vesicoureteral reflux in children. Pediatr Clin North Am. 2012 Aug;59(4):819-34. doi: 10.1016/j.pcl.2012.05.012. Epub 2012 Jun 22. 3-Routh JC, Bogaert GA, Kaefer M, Manzoni G, Park JM, Retik AB, Rushton HG, Snodgrass WT, Wilcox DT. Vesicoureteral reflux: current trends in diagnosis, screening, and treatment. Eur Urol. 2012 Apr;61(4):773-82. doi: 10.1016/j.eururo.2012.01.002. Epub 2012 Jan 11. 4-Tekgül S, Riedmiller H, Hoebeke P, Kočvara R, Nijman RJ, Radmayr C, Stein R, Dogan HS; European Association of Urology. EAU guidelines on vesicoureteral reflux in children. Eur Urol. 2012 Sep;62(3):534-42. doi: 10.1016/j.eururo.2012.05.059. Epub 2012 Jun 5. 5- Khoury AE, Bagli DJ, Vesicoureteral reflux, Campbell-Walsh Urology, chapter: 122, pages:3267-3309, volume 4, 10th Edition, Elsevier