Ureterocystoneostomy (UCN) and subureteral collagen injection (SCIN): combined one-stage correction of high-grade bilateral vesicoureteral reflux (VUR) in children.

The treatment of vesicoureteral reflux (VUR) is still a controversial issue. The efficacy of medical treatment appears to be equal to that of operative procedures in avoiding new formation of renal scars. However, there are generally accepted indications for operative procedures including bilateral high-grade VUR, especially in young patients. Ureteral reimplantation (UCN) is the operative treatment of choice in cases with high-grade VUR. Alternatively in cases with lower-grade VUR, injection of bulking agents under the refluxive orifice can be performed. It is also generally accepted that UCN with extravesical preparation of the ureter and the bladder should not be done bilaterally in a one-stage procedure. Postoperative bladder dysfunction may result due to detrimental neurogenic effects. In this study we report on our operative procedure in cases with bilateral high-grade VUR, during which we perform intra/extravesical UCN (mod. Leadbetter-Politano) of the higher-grade refluxive ureter, and (open) subureteral collagen injection (SCIN) of the lower-grade refluxive orifice as a combined one-stage procedure. In this study 50% of the patients had no VUR on either side after the first combined procedure. 15% of the patients showed significant down-grading of VUR of the injected side. These patients underwent a 2nd endoscopic SCIN. 35% of the patients showed no change of VUR of the injected side after the first procedure; these patients underwent reimplantation of this side in another operation. Accordingly, 50% of patients with bilateral high-grade VUR required a 2nd operative procedure under full anesthesia to achieve loss of VUR on both sides. None of the patients showed bladder dysfunction postoperatively. Mean follow-up after the last operative correction was 29.9 months (6 - 84 months).