Actas Urol Esp.

2013;37(10):630---633

Actas Urológicas Españolas

www.elsevier.es/actasuro

ORIGINAL ARTICLE

Laparoscopic surgery of vesicoureteral reflux: An experience in

42 patients with the Lich-Gregoir extravesical technique夽
O.A. Castillo a,b,∗ , R. Zubieta c , R. Yañez a

a
Unidad de Urología y Centro de Cirugía Robótica, Clínica INDISA, Santiago, Chile
b
Facultad de Medicina, Universidad Andrés Bello, Santiago, Chile
c
Unidad de Urología, Hospital Exequiel González Cortés, Santiago, Chile

Received 7 March 2013; accepted 12 April 2013

Available online 23 November 2013

KEYWORDS Abstract
Vesico-ureteral Introduction: Vesico-ureteral reflux (VUR) is a common congenital anomaly of the urinary tract
reflux; in the pediatric population, existing controversy regarding its management. Patients selected
Ureteral for treatment options are offered from endoscopic injection of substances sub-ureteral to
reimplantation; ureteral reimplantation surgery.
Laparoscopy; Objective: To evaluate the use of the laparoscopic surgical technique for the treatment of
Endoscopy vesico-ureteral reflux, with an analysis of the procedure, results and complications.
Materials and methods: We evaluated a series of 50 ureteral units in 42 patients, who undergo-
ing laparoscopic transperitoneal ureteral reimplant, using the classic technique of Lich-Gregoir
detrusorrafia.
Results: The mean operative time was 74 min. There were neither intraoperative nor immediate
postoperative morbidities. At longer follow-up VUR was cured in all cases.
Conclusions: Laparoscopic surgery is an effective alternative in the surgical treatment of vesico-
ureteral reflux, with results comparable to open surgery techniques and over sub-ureteral
injection techniques.
© 2013 AEU. Published by Elsevier España, S.L. All rights reserved.

PALABRAS CLAVE Cirugía laparoscópica del reflujo vesicoureteral: experiencia en 42 pacientes con la
Reflujo técnica extravesical de Lich-Gregoir
vesicoureteral;
Neoimplante Resumen
ureteral; Introducción: El reflujo vesicoureteral (RVU) es una anomalía congénita de la vía urinaria fre-
Laparoscopia; cuente en la población pediátrica, existiendo controversia con respecto a su manejo. A los
Endoscopia pacientes que son seleccionados para tratamiento quirúrgico se les ofrecen diversas opciones,
desde la inyección endoscópica de sustancias subureteral hasta la cirugía de neoimplante
ureteral.

夽 Please cite this article as: Castillo OA, Zubieta R, Yañez R. Cirugía laparoscópica del reflujo vesicoureteral: experiencia en 42 pacientes

con la técnica extravesical de Lich-Gregoir. Actas Urol Esp. 2013;37:630---633.

∗ Corresponding author.

E-mail address: octavio.castillo@indisa.cl (O.A. Castillo).

2173-5786/$ – see front matter © 2013 AEU. Published by Elsevier España, S.L. All rights reserved.
Laparoscopic surgery of vesicoureteral reflux 631

Objetivo: Evaluar la utilización de la técnica quirúrgica laparoscópica para el tratamiento del

reflujo vesicoureteral, realizando un análisis del procedimiento, resultados y complicaciones.
Material y métodos: Se evalúa una serie de 50 unidades vesicoureterales en 42 pacientes inter-
venidos por vía laparoscópica transperitoneal mediante la técnica clásica de detrusorrafia de
Lich-Gregoir.
Resultados: El tiempo operatorio medio fue de 74 min. No se observaron complicaciones
intraoperatorias ni postoperatorias inmediatas. En el seguimiento prolongado hubo curación
demostrada del RVU en todos los casos.
Conclusiones: La cirugía laparoscópica es una alternativa efectiva en el tratamiento quirúrgico
del RVU con resultados comparables a las técnicas de cirugía abierta y superiores a las técnicas
de inyección subureteral.
© 2013 AEU. Publicado por Elsevier España, S.L. Todos los derechos reservados.

Introduction Operative technique

Vesicoureteric reflux (VUR) is the most frequent urological
disorder in children affecting 1% of them. VUR has been
reported in 25---40% of children with urinary infection.1 It is
well known the relationship between vesicoureteric reflux,
urinary tract infection and renal damage. In 3---25% of chil-
dren and in 10---15% of adults, reflux nephropathy is the cause
of terminal renal failure.2,3
Since Hutch proved in his classical study the relationship
between VUR with urinary tract infection and renal damage,
the management of VUR has been classified into conserva-
tive and surgical treatment.4 Conservative therapy is mainly
based on that VUR often resolves over the time, as long
as adequate antibiotic prophylaxis to prevent urinary tract
infection is maintained, and that morbidity or complications
associated with the VUR can be controlled medically.5
Surgical treatment of VUR has been well established
for several decades. Ureteral reimplants procedures, open,
intra- and extravesical (Lich-Gregoir, Politano-Leadbetter,
Cohen), are highly successful (92---98%) and with minimal
complications.6,7 Several improvement efforts have been
undertaken to reduce perioperative morbidity and hospital
stay maintaining success rate. Minimally invasive tech-
niques, such as sub- and intra-ureteral endoscopic injection
of bulking agents (Deflux, Vantris, Macroplastique)8 and
laparoscopic extravesical ureteral reimplantation (highly
laborious), have demonstrated to be effective in meeting
the goals.9,10
The feasibility of laparoscopic extravesical ureteral reim-
plantation has been proven for the first time in animal
model.11---13 In 1994, this demonstration was followed by
2 publications about clinical experience in small series of
patients.9,14 Since then, few centers have carried out this
procedure.15,16 The arguments against it are that it is a pro-
cedure highly demanding and with large technical difficulty.
In order to reconsider and promote this surgical approach
we have analyzed our surgical technique, results and
complications.
Preoperative phase: under general anesthesia, urine
catheter is inserted routinely (caliber of the catheter varies
with the age of children). The patient is placed in supine
position with arms on the flanks.
Pneumoperitoneum and trocars ports: 8---12 mm Hg pneu-
moperitoneum is created with umbilical Veress needle
insertion. Four ports are used in all cases for 5 mm trocars:
0◦ telescope in umbilical port, and instrumental trocars in
suprapubic port and flank ports (Figure 1).
Ureteral dissection: after initial inspection of abdominal
cavity, patient is placed in light Trendelenburg position to
displace the bowel loops cephalad. Thus, guide structures
that will limit our initial section (iliac vessels, vas defer-
ens or rounded ligament and medial umbilical ligament) can
be seen through peritoneum. Slight rotation of patient to
opposite side of refluxing ureter can be performed if neces-
sary. To look for distal ureter, transverse incision of parietal
peritoneum is performed within the following boundaries:
proximally, crossing the ureter with iliac vessels and dis-
tally with iliac vessels, and distally crossing the ureter with
round ligament or vas deferens. Incision is prolonged to the
bladder entry. Bladder is filled with 50---150 cc of saline solu-
tion. Detrusor muscle is cautiously sectioned with monopolar

Materials and methods

42 children, who underwent laparoscopic extravesi-

cal transperitoneal approach by Lich-Gregoir technique, Figure 1 Position of the 4 ports of 5 mm trocars for laparo-
between May 1995 and September 2001 comprise our series scopic ureteral reimplantation.
632 O.A. Castillo et al.

coagulation scissors, in the area immediately above bladder-

ureteral junction, until the mucosa is exposed.
In order to improve the distal ureter exposure, ureter is
retracted laterally toward trocar flank with a vascular tape.
After completing the dissection, detrusor muscle is sutured
over the ureter with 3 or 4 separate intracorporeal stitches
with polyglycolic acid sutures 3-0. It is important to avoid
leaving a narrow meatus or portion of the tunnel opened to
prevent pseudodiverticulum formation.
Postoperative care and control: routinely, urethro-vesical
catheter is removed 2 days after surgery. Intravenous antibi-
otic treatment is administrated within the first 24 h after
surgery; it is followed by oral antibiotic treatment until
Foley catheter is removed. Ultrasound monitoring is done
after one month after, and urethrocystography at 6 months.

Results

We have carried out 50 laparoscopic transperitoneal ureteral

reimplants in 42 children, 32 girls and 10 boys, aged from
9 months to 13 years old (average age 5.8 years). Surgical
indications were VUR grade III or higher and medical treat-
ment failure (Figs. 2 and 3). All patients had a history of
repeated urinary infection. Of 42 patients 3 showed VUR
grade V, 3 others VUR grade IV and the remaining patients
VUR grade III. Eight patients had bilateral VUR. Two patients
with unilateral VUR showed double ureters.
Operative time varied from 60 to 120 min (mean:
74 min). Hospital stay was 2---7days (mean: 96 h). There were
no immediate postoperative complications. A girl devel-
oped cardiorespiratory arrest of unknown cause that was
completely recovered without late sequelae at sixth postop-
erative day. In long-term follow-up, VUR disappearance was
demonstrated in all cases (mean follow-up time: 31 months).
In one case, postoperative contralateral VUR grade I was
Figure 2 Voiding cystography showing left unilateral severe
reflux.
Figure 3 Preoperative cystography showing bilateral severe
reflux.
shown and the child is maintained with conservative man-
agement (under observation). Renal damage progression was
observed in a boy with reflux grade VI. Neither impairment
of bladder emptying nor secondary hydronephrosis occurred
in any case of bilateral correction.
Discussion
Any classic vesicoureteral reflux surgery technique shows
high efficiency with low morbidity. Classic or open Lich-
Gregoir procedure frequently used in Europe is not widely
accepted among American urologist. In our environment,
Lich-Gregoir technique reports a resolution rate of VUR close
to 95%,17 similar to those reported in the large series in
which success rates vary from 95% to 98% in VUR grade I---IV,
and is around 80% in VUR grade V. The success achieved
with open technique has been replicated by laparoscopic
approach (with complete resolution of VUR in all cases).
In our series a patient showed contralateral VUR grade I
resolved with conservative management. In open surgery
series, VUR grade I has been reported in 5% of the patients.1
In accordance with other authors,18 this technique is not
contraindicated in patients with double ureters. Thus, in
our series, 2 patients with double-ureters were successfully
treated with laparoscopic approach. Moreover, we consider
that this is the technique of choice for the conjoint reim-
plantation of the double ureters in their common sheath.
In open surgery, the Lich-Gregoir technique reports inci-
dence of urinary retention for bilateral reimplantation in
8.4---15.2% of the cases.19 In this sense, several authors
claim against bilateral reimplantation because postopera-
tive voiding efficiency may be impaired. However, in our
series this complication has not been observed because
bladder requires less dissection and mobilization. With this
technique it is not necessary to move the ureter and its
Laparoscopic surgery of vesicoureteral reflux
Table 1 Advantages and disadvantages of the Lich-
Gregoire laparoscopic technique.
Comparative advantages of laparoscopic Lich-Gregoire
Technical proven efficiency
Minimal ureteral manipulation
Lower risk of meatal stenosis
Easy dissection of the tunnel
Eventual management of meatus size (string) in same
position
Eventual ease of endoscopic tutors techniques
Reproducible
Mucosa breakage does not matter
Comparative disadvantages of laparoscopic Lich-Gregoire
Transperitoneal approach
Likely paraureteral diverticulum if poor tunnel closure
Likely ureteral stenosis if narrow tunnel
meatus when endoscopic subureteral injection of bulk-
ing agent fails, representing a technical advantage over
transvesical approaches (Table 1).
The success rates of endoscopic techniques for per-
imeatal injection is correlated with reflux grade: 78.5% in
VUR grade I---II; 72% in grade III; 63% in grade IV and only
51% in grade V. 77.1% of cases are resolved in the first
injection; however, the success rate decreases in following
sessions (from 68% in the second to 34% in the third injec-
tion). The success rate achieved with single systems is 73%
meanwhile in duplicated systems it is only 50%.20 No severe
complications have been described, and 0.5% of obstruction
risk has been reported.21 Although this technique represents
a low-invasive alternative (mean success rate: 80---85%), the
results of our laparoscopic technique are fully comparable.
Conclusion
Laparoscopic surgery is an effective alternative in the sur-
gical treatment of vesico-ureteral reflux in children. In our
opinion, this series is one of the most extensive published.
Conflict of interests
The authors declare that they have no conflict of interest.
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