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Journal of Pediatric Surgery (2010) 45, 806–810

Review articles

Laparoscopic extravesical transperitoneal approachfollowing the Lich-Gregoir technique in the treatment ofvesicoureteral reflux in childrenManuel Lopez⁎, François Varlet

Department of Paediatric Surgery, University Hospital of Saint Etienne, 42270 Saint Etienne, France

Received 24 July 2009; revised 30 October 2009; accepted 4 December 2009

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Key words:Vesicoureteral reflux;Lich-Gregoir technique;Laparoscopy;Children

AbstractIntroduction: Laparoscopy may have a place in the treatment of vesicoureteral reflux (VUR). We reportour initial experience in the treatment of VUR by laparoscopic extravesical transperitoneal approach(LETA) following the Lich-Gregoir technique to describe the evolution and to evaluate the results andbenefits of this technique for these patients.Materials and Methods: Between August 2007 and May 2009, 43 renal units in 30 children (23 femaleand 7 male) with VUR and deterioration of renal function on isotope renography (17 unilateral and 13bilateral) were treated with LETA. The mean age was 52 (range, 15-183) months. Nine patients had adouble total collector system associated with VUR in a lower system. Two of them had a ureterocelewith adequate upper polar rein function, and another had a ureterocele with complete deterioration ofupper polar rein function.Results: The mean surgical time was 70 (38-120) minutes in unilateral and 124 (100-180) minutes inbilateral VUR. All procedures were successfully completed laparoscopically, and the reflux was correctedin all patients. At the same time, 1 heminephrectomy and 2 ureterocele were removed by laparoscopy andendoscopy, respectively. We had 1 ureter leakage 15 days postoperation that underwent a redoreimplantation. In cases of bilateral VUR, 1 patient presented postoperative bladder emptying difficultyand required temporary urethral catheterization postoperatively. The mean hospital stay was 24 hours. Acystogram was performed systematically in all patients at 45 days postoperation; none of them presentedrecurrence of VUR. The follow-up was 11 (range, 2-24) months, without recurrence of VUR.Conclusion: Laparoscopic extravesical transperitoneal approach in the treatment of VUR is a safe andeffective approach even in unilateral, bilateral simultaneous, and double total collector system. Thetechnique results in a shorter hospital stay, less postoperative discomfort, and reduced recovery period,with a low morbidity to resolve the VUR and with success rates similar to the open technique.© 2010 Elsevier Inc. All rights reserved.

Vesicoureteral reflux (VUR) represents one of the most

⁎ Corresponding author.E-mail address: manuel.lopez@chu-st-etienne.fr (M. Lopez).

022-3468/$ – see front matter © 2010 Elsevier Inc. All rights reserved.oi:10.1016/j.jpedsurg.2009.12.003

significant risk factors for acute pyelonephritis in children.Nephropathy with renal scarring is still the most concerningissue in VUR. Surgical correction to eliminate VUR is animportant part of its management [1]. Minimally invasive

Fig. 1 Trocars position.

807LETA for the treatment of VUR in children

technique in the treatment of VUR is being developed as analternative to open surgery. The first report was published in1984 [2,3]. O'Donnell and Puri popularized the classicsubureteric transurethral injection by endoscopy, with lessintervention and discomfort. Most studies would suggest thatthis approach is not as successful as standard repair, with alower success rate [4,5].

Laparoscopic antireflux surgery has never achievedpopular consensus because of the technical difficulty indissection and suturing required; however, efforts have beendirected toward reducing the perioperative morbidity periodand the length of hospitalization.

The minimally invasive surgical approach to VUR diseasewas first described by Atala et al [6] in minipigs, and the firstreport described in humans was in 1994 by Ehrlich et al [7].Since then, different reports of laparoscopic repair have beendescribed. Few pediatric centers have embraced either thelaparoscopic extravesical or vesicoscopic cross-trigonalapproach; and the success rates have been comparable toopen surgery surgical, with less morbidity for patients withVUR [8-10,16,17].

We report our initial experience in the treatment of VURby the laparoscopic extravesical transperitoneal approach(LETA) to describe the evolution and to evaluate the resultsand benefits of this technique for these patients.

Fig. 2 Exposition of the mucosa.

1. Materials and methods

Between August 2007 and May 2009, 43 renal units in 30children (23 female and 7 male) with VUR and deteriorationof renal function on isotope renography were treated withLETA (Lich-Gregoir technique). Seventeen had unilateral(10 left, 7 right) and 13 had bilateral VUR. The mean agewas 52 (range, 15-183) months. Reflux was classified byusing the international classification as grades I to V.Preoperative VUR grade were as follows: 31 renal units weregrade III, 11 were grade IV, and 1 was grade V. Nine had adouble total collector system associated with VUR in a lowersystem. Two of them had a intravesical ureterocele withadequate upper polar function, and one had ureterocele withcomplete deterioration of the upper polar function. In allpatients, a deterioration of renal function on isotoperenography was found, with mean of 34% (19%-40%).Three patients had bilateral hutch diverticulum. Three 3cases of VUR were treated initially by endoscopicsubureteral injection, with recurrence of VUR. The surgicalindication was recurrent acute pyelonephritis under antibioticprophylaxis and deterioration of renal function.

1.1. Operative technique

Laparoscopic extravesical transperitoneal approach wasperformed by the transperitoneal approach. Under generalanesthesia, cystoscopy was used only in patients when the

double collector system was suspected to assess the locationof the ureteral orifices and to check bladder anatomy.

The patient was placed in supine position with the legsapart; a urine catheter was inserted preoperatively. Threeports were used in all cases, 5 mm 30° for the telescope andtwo 3-mm trocars. The surgeon was positioned at the head ofthe patient, with the assistant to the left and the nurse to theright. The monitor was placed at the lower end of the table.The telescope was inserted through the transumbilical trocar;the other two 3-mm trocars were placed at the left and rightlower abdomen under direct vision (Fig. 1). Stay sutureswere used to expose the vesicoureteral junction (VUJ). Twostay sutures were inserted through the abdominal wall andplaced in each side of the bladder to pull it up to the anteriorwall and expose the VUJ. The peritoneum was incised just toidentify the distal ureter that was isolated and dissectedtoward the VUJ. The ureter was mobilized to achievesufficient freedom for a tension-free reimplantation. Usingthe monopolar scissors, the peritoneum was incised toexpose the muscular wall of the bladder and create an

Fig. 3 The ureter was placed in the newly created tunnel.

808 M. Lopez, F. Varlet

optimal lateral tunnel with a length about 4 times the size ofthe ureter (Paquin law). At this moment, the bladder wasfilled partially with physiologic serum to expose and toidentify the mucosa, to avoid the perforation at the momentof detrusorrhaphy (Fig. 2). The detrusor muscle and allmuscle fibbers were cautiously divided down with scissorsuntil the mucosa was exposed. After completing thedissection, another stay suture was inserted through theabdominal wall and placed around the ureter toward the topof the bladder. The ureter was placed in the newly createdtunnel, and the detrusor muscle was reapproximated with 3or 4 separate intracorporeal stitches with nonabsorbablesutures 3-0. At the final stage, the ureter was mobilizedwithout tension to avoid ectasia or ischemia; and the urinecatheter was removed (Fig. 3).

2. Results

Laparoscopic extravesical transperitoneal approach wasfeasible in 30 of 30 patients, and all 43 ureters weresuccessfully reimplanted by laparoscopy. Bilateral caseswere repaired in a single procedure. The mean operative timewas 70 (range, 38-120) minutes in unilateral cases and 124(range, 100-180) minutes in bilateral cases.

At the same time, 2 decompressions of intravesicalureterocele were performed by endoscopy with a 3FBugbee using the cutting current at a level high enoughto ensure a clean puncture, before starting the reimplanta-tion without tailoring.

An upper pole heminephrectomy and partial ureterectomylaparoscopic were associated in a case with intravesicalureterocele and poor function of the upper polar function. In3 cases when the VUR was associated with a paraureteraldiverticulum at the moment of reimplantation, the divertic-ulum was carefully reinforced to provide a secure back wall.

At the beginning of the series, 1 patient presented aureteral leakage 15 days postoperation and underwent a redoprocedure. During surgery, a ureteral perforation was found;and then this complication was treated by redo reimplanta-tion. We reviewed the video tape but did not find thetraumatic cause for this perforation. Probably, this ischemiawas caused by the excessive handling of the ureter or a burnwith the monopolar.

In 1 case of bilateral VUR, the patient presented withpostoperative bladder emptying difficulty requiring 10 daysof temporary urethral catheterization postoperatively. Weanticipated this because the patient had preoperative urinaryretention history.

The average hospital stay was 24 (range, 20-26) hours inall cases. A fluoroscopic voiding cystogram and renalultrasonography were performed systematically in allpatients at 45 days postoperation. The follow-up was aclinical evaluation and ultrasonography control at 3 months,6 months, 1 year, and 2 years. A fluoroscopic voidingcystogram was performed again only in cases of recurrenceof urinary tract infection. Complete resolution of VUR wasidentified in all patients. The Hutch diverticula were resolvedafter surgery. The mean follow-up was 11 (2-24) months; atotal of 43 renal units in 30 patients were asymptomaticwithout urinary tract infection.

3. Discussion

The spectrum of urology pediatric laparoscopy hasundergone a dramatic evolution. Initially used as a diagnostictool, laparoscopic complex and reconstructive procedures arenow performed.

The management of VUR continues evolve. Endoscopiccorrection of VUR is a reasonable alternative to opensurgical reimplantation, particularly in cases with a lowgrade, although long-term results into adulthood remainunknown. In 2008, Callaghan et al [11] presented the factorinvolved in parenteral decision making for surgical correc-tion of VUR and considered that the parents selecting opensurgery consider the success of the procedure mostimportant, and the majority are satisfied with their choiceof treatment. Parents choosing endoscopic correctionconsider the minimally invasive nature of the procedureand the success rate most important, but the outcome mayalter their satisfaction [11]. Different techniques of VURdemonstrating feasibility with pneumovesicoscopic, laparo-scopic, and robotic-assisted techniques are encouraging andhave been reported to be beneficial in terms of decreasedpostoperative pain, shorter hospital stay, and quicker returnto normal activity [12]. Extravesical reimplantation andlaparoscopic Cohen technique are the most commonlyperformed and achieves a high success rate.

The Lich-Gregoir technique was simultaneously devel-oped and described by Lich et al [13] in 1961 and Gregoirand Van regemorter [14] in 1964.

809LETA for the treatment of VUR in children

This technique is an extravesical procedure and has thefollowing advantages: minimal bladder spasm, less morbid-ity because the bladder remains intact, no hematuria, and noanastomosis. In addition, decreased hospital stay with fasterrecovery makes it a potential 1-day surgery [15-18]. TheLich-Gregoir technique is associated with a high successrate, as with the Cohen technique.

In open surgery, the Lich-Gregoir technique reportsincidence of urinary retention for bilateral reimplantationand impaired voiding efficiency. These are the commoncomplications of this technique, ranging from 3% to 20%[19,20]. The cause might be a result of neurovascular injuryduring wound handling and ureteral or bladder dissection[21]. However, in open surgery, Mc Achran and Palmer[16] in 2005 demonstrated that bilateral extravesicalureteroneocystostomy can be performed in selected patientswithout postoperative urinary retention and with uniformhospital discharge in 1 day. In 2008 and 2009, Palmer[17,18] demonstrated that unilateral and bilateral extra-vesical ureteral reimplantation can consistently result insame-day discharge from the hospital without postoperativeurinary retention.

The minimally invasive technique is associated with lessmorbidity owing to less tissue and nerve injury and can behandled simply in an outpatient setting.

Peters [22] in 2004 encountered postoperative voidingdysfunction in his experience of extravesical roboticreimplantation. In our series, we had only 1 patient whopresented postoperative bladder emptying difficulty requir-ing temporary urethral catheterization postoperatively, whichwe had anticipated because the patient had preoperativesevere urinary retention history. In most series, thesecomplications have not been found [8-10].

Casale et al [23] in 2008 reported 41 patients whounderwent nerve-sparing robotic extravesical reimplantationfor bilateral VUR, without episodes of urinary retentiondocumented by bladder scanning.

One of the most common intraoperative complications inlaparoscopic extravesical ureteral reimplantation is ureteralinjury (ischemia) owing to excessive handling of the ureter,but it was only reported in the early series [24]. Unfortu-nately, in our series, we had 1 case at the beginning of series.The patient presented a ureteral leakage 15 days post-operation. At the moment of surgery, a urinary ureteralfistula was found; and then a redo reimplantation was done.We reviewed the video tape but did not find the traumaticcause for this perforation. Probably, this ischemia wascaused by the excessive handling of the ureter or a burn withthe monopolar.

Another probable intraoperative complication is the riskof visceral organ injury and postoperative bowel adhesion.Fortunately, these complications have not been observed inthe literature.

Careful selections of operative candidates are necessary.It is speculated that ureters requiring tapering are unsuitablefor the Lich-Gregoir technique by laparoscopy; however,

Ansari et al [25] in 2006 described an extracorporealtailoring for megaureter to perform laparoscopic extravesicaltransperitoneal ureteral reimplantation with the Lich-Gregoirapproach, with good results.

Based on the results in this preliminary series, theauthors think that LETA following the Lich-Gregoirtechnique for VUR is a safe, effective, and feasibleprocedure with good short-term results. With our currenttechnique, excellent results comparable to those of estab-lished open procedures are achieved, with a low morbidityto resolve the VUR. The technique results in lesspostoperative discomfort, shorter hospital stay, goodcosmetic results, and reduced recovery period.

Laparoscopic extravesical transperitoneal approach fol-lowing the Lich-Gregoir technique is easy even in unilateral,bilateral simultaneous, and double total collector system. Inmost cases, LETA is not associated with bladder dysfunctionas in an open surgery even in bilateral procedures. In fact, webelieve that this procedure is technically reproducible foryoung surgeons in laparoscopic and urologic training. In ourexperience with LETA and with many laparoscopic andurologic procedures to date, our learning curve plateauedafter 6 to 7 cases; and our operative time decreasedsignificantly after 6 cases. We still make a video recordingof all of our procedures not only for use as a learning tool byour residents and fellow, but also to allow the surgeons to becritical of their technique and permit further improvement.Minimally invasive surgery is an alternative to openprocedure and not to medical treatment especially in patientswith nephropathy with renal scarring. We believe that thisprocedure will become an established treatment option.

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