VESICO-RENAL REFLUX IN ADULTS
Basic principles ( A )
The aim of the operation is to restore the normal function of the interureteric bar in order to prevent sliding of ureters outwards during voiding.
The standard Cohen operation for children is build to the same purpose : both terminal ureters are laid down side by side in a submucosal groove and stability is held by scar adherences.
In adult women this procedure may fail by shortage of ureters and this building entails a major criticism as impeding further ureter catheterisation.
1) Terminal ureters are freed as far as they move easily within the bladder wall.
2) Both ureteric outlets are joined by submucosal tunnelling. Left and right tunnel legs start from a medan sagittal incision.
3) Both ureteral extemities are sutured end to end on the posterior half of their circumference and the anterior halves are tied to the surrounding mucosa and the underlying muscular layer.
4) Before closing the lateral incisions, the surgeon verifies and strengthens by resuturing if necessary the fibrous underlying contention fascia.
Catheters, sutures and minor details are always preferences of the operating surgeon.
When ureters are too long and fall sock-sagging they may be shortened . Extremity resection implies no healing complication ; on the contrary terminal centimeters are often long time infected and devitalized.( B )
Too short ureters surrounded by a stiff inflammatory sheath are rather uncommon.
This appears at first sight. The surgeon can delimit left and right extension straps from the whole bladder wall thickness to be joined end to end.(C )
Have no fear that the new ureteric outlets remain too closely face to face. Physiological muscle strains replace them automatically in normal position.
In this 177 operated on patients series, were performed as complementary interventions :
16 for stress incontinence
7 for redundant hymeneal fringes
2 for hysterectomy
2 for E.C. Lithotrity
1 for pyelo-ureteric junction syndrome
1 for bladder neck syndrome
1 for urethral diverticula plasty
1 for urethral stricture enlargement