[A good solution for a bad case].

Area of Science:

• Pediatric Urology
• Minimally Invasive Surgery
• Urologic Imaging

Background:

• Vesicoureteral reflux (VUR) is a common condition in children, often treated with ureteral reimplantation or endoscopic methods.
• Recurrent VUR necessitates re-evaluation of treatment efficacy and anatomical integrity.
• Endoscopic treatment involves bulking agents to augment the ureteral orifice and create a valve mechanism.

Observation:

• A child with VUR experienced persistent reflux despite prior ureteral reimplantation and endoscopic treatment.
• A subsequent cystoscopy revealed an unexpected new orifice within the ureteral reimplantation tunnel.
• This newly identified orifice functioned as a shunt, bypassing the intended repair and maintaining reflux.

Findings:

• The presence of a secondary ureteral orifice within the reimplantation tunnel was the cause of persistent VUR.
• This orifice acted as an unintended conduit, allowing urine to flow retrograde from the bladder to the ureter.
• Successful occlusion of this aberrant orifice with a dextranomer/hyaluronic acid-based injectable gel resolved the reflux.

Implications:

• Highlights the importance of thorough intraoperative and postoperative assessment for iatrogenic or anatomical abnormalities.
• Demonstrates the potential for unexpected anatomical variations to compromise surgical repair of VUR.
• Suggests that repeat endoscopic interventions can be effective in managing complex or recurrent cases of VUR, even with unusual anatomical findings.