Surgical management of vesicoureteral reflux in pediatric patients

Vesicoureteral reflux (VUR) represents one of the most significant risk factors for acute pyelonephritis in children. The current indications for the surgical correction of VUR depend on the presence or absence of renal scars. If no scars are present, primary ureteral reimplantation is only indicated in high-grade bilateral VUR, whereas in the presence of renal scars surgical correction is indicated in low/high grade reflux at a young age. Since there are numerous techniques for antireflux surgery available, it is the purpose of this article to critically review these techniques with their specific advantages, typical complications and postoperative management. In general, all surgical technique have a high success rate of 92-98%. The extravesical Lich-Gregoir technique is primarily indicated in unilateral VUR. Children with a high-grade VUR, who are under the age of 3 years and boys are prone to the development of postoperative urinary retention and might be considered for intravesical surgical techniques. The Politano-Leadbetter technique is very helpful in correcting bilateral VUR of any grade in one session to create a neo-ostium in an anatomically correct position which is easily accessible for endourological manipulations. The Psoas hitch ureteroneocystotomy is an excellent technique to correct VUR associated with megaureter, or with duplicated ureters, and VUR failures. Endoscopic subureteral injections are primarily reserved for low grade VUR with a one session success rate of >90%. Endoscopic subureteral injections appear to be an alternative to long-term antibiotics in grade I-III VUR. Laparoscopic antireflux surgery has not gained widespread use due to the very long operating times. Contralateral VUR will occur in about 20% of children undergoing unilateral antireflux surgery; risk factors are severe VUR and VUR into a duplicated system. Postoperative follow-up nowadays consists of urinalysis and ultrasonography; voiding cystourethrography is only indicated in case of febrile urinary tract infection. Despite the excellent success rates following antireflux surgery one has to keep in mind that surgery only corrects the anatomical abnormality. The long-term outcome with regard to renal function, posttherapeutic febrile urinary tract infections and arterial hypertension does not differ significantly from the medication group except for those patients with a demonstrated a genetic background. Therefore, the indication for surgery and the surgical technique applied have to be discussed thoroughly and must be associated with a minimal complication rate.