Vesicoureteral reflux: surgical and endoscopic treatment

The optimal management of vesicoureteral reflux (VUR) is quite controversial. For many years, only antibiotic prophylaxis and open surgery were considered possible options. Since the first descriptions in the early 1980s, endoscopic treatment (ET) has gained popularity and is now considered a valid alternative both to open surgery and antibiotic prophylaxis. Many surgical antireflux techniques have been described in the past 50 years. The general principle of reflux surgery, usually defined as ureteric reimplantation, is elongation of the submucosal ureteral tunnel with creation of a flap-valve mechanism. The antireflux operation can also be carried out laparoscopically, either extravesically or intravesically (pneumovesicum). Open surgery is associated with a high success rate (>95%) regardless of the technique adopted. However, because it is invasive, it is limited to selected cases. Laparoscopic technique is less invasive, but the mean operative time is much longer and results depend significantly on the learning curve. ET involves injecting material endoscopically into the submucosal space under the ureteric orifice. It is associated with a good success rate (about 80% after one injection). Advantages of this minimally invasive treatment include repeatability and the fact that postoperative complications are rare. With a second injection, after few months if needed, the success rate of ET approaches that of open surgery. Our 20-year experience in ET is described in detail in this paper, as this technique has changed the management algorithm for VUR dramatically.