Comparison of Cohen and Lich-Gregoir ureteral reimplantation in the surgical management of primary unilateral vesicoureteral reflux in children

SUMMARY OBJECTIVE Vesicoureteral reflux (VUR) represents one of the most significant risk factors for acute pyelonephritis in children. Various intravesical and extravesical techniques have been described for the surgical correction of VUR. The aim of our study was to compare the results of open intravesical and extravesical procedures for unilateral primary VUR in children. METHODS Between January 2012 and August 2018, 38 children with primary VUR who underwent open ureteral reimplantation surgery were retrospectively reviewed. The Cohen (intravesical) and the Lich-Gregoir (extravesical) approach were grouped as groups A and B, respectively. The groups were compared for age, gender, preoperative reflux grade, presence of lower urinary tract symptoms, operation time, discomfort and pain, analgesic requirements, duration of hematuria, postoperative complications, and hospital stay. All the parameters were statistically compared. RESULTS There were 38 patients in this study. Group A had 18 patients, and group B had 20 patients. The mean operative time was significantly shorter in group B than in group A. The mean hospital stay was also shorter in group B. The urethral foley stay period was 4.7±0.9 days 2±0 days (p = 0.000*), respectively, for group A and B. Macroscopic hematuria was seen in group A. The objective pain scale was worse after intravesical surgery. Analgesic requirements were higher in group A (p =0.131). CONCLUSION Intravesical and extravesical ureteroneocystostomy methods are equally successful and feasible in the treatment of primary unilateral VUR. The Cohen technique is associated with a longer and more painful hospital stay, gross hematuria, and longer operative time, compared to the Lich-Gregoir technique.

RESUMO OBJETIVO O Refluxo Vesicoureteral (RVU) representa um dos mais importantes fatores de risco para pielonefrite aguda em crianças. Diversas técnicas intra e extravesicais já foram descritas para a correção cirúrgica do RVU. O objetivo do nosso estudo é comparar os resultados de procedimentos extravesicais e intravesicais abertos para o tratamento de RVU primário unilateral em crianças. METODOLOGIA Entre janeiro de 2012 e agosto de 2018, 38 crianças com RVU primário foram submetidas a cirurgia aberta de reimplante ureteral. Esses casos foram retrospectivamente revisados. As abordagens de Cohen (intravesical) e Lich-Gregoir (extravesical) foram agrupadas nos grupos A e B, respectivamente. Os grupos foram comparados quanto à idade, sexo, grau de refluxo pré-operatório, presença de sintomas no trato urinário inferior, tempo de operação, desconforto e dor, necessidade de analgésicos, duração de hematúria, complicações pós-operatórias e tempo de internação. Todos os parâmetros foram comparados estatisticamente. RESULTADOS No total, 38 pacientes foram incluídos neste estudo. O grupo A teve 18 pacientes e o grupo B, 20. O tempo médio de operação foi significativamente menor no grupo B do que no grupo A. O tempo médio de internação também foi menor no grupo B. O tempo de uso do foley uretral foi de 4,7 ± 0,9 dias e 2±0 dias (p = 0,000*) , respectivamente, para o grupo A e B. Hematúria macroscópica foi observada no grupo A. A pontuação na escala objetiva de dor foi pior após a cirurgia intravesical. A necessidade de analgésicos foi maior no grupo A (p = 0,131). CONCLUSÃO As técnicas extravesicais e intravesical de ureteroneocistostomia são igualmente bem-sucedidas e viáveis para o tratamento de RVU primário unilateral. A técnica de Cohen está associada a um período de internação mais longo e mais doloroso, hematúria e maior tempo operatório, em comparação com a técnica de Lich-Gregoir.

Which intraperitoneal insufflation pressure should be used for less postoperative pain in transperitoneal laparoscopic urologic surgeries?

ABSTRACT Purpose To determine whether using different intraperitoneal insufflation pressures for transperitoneal laparoscopic urologic surgeries decreases postoperative pain. Materials and Methods 76 patients who underwent transperitoneal laparoscopic upper urinary tract surgery at different insufflation pressures were allocated into the following groups: 10mmHg (group I, n=24), 12mmHg (group II, n=25) and 14mmHg (group III, n=27). These patients were compared according to age, gender, body mass index (BMI), type and duration of surgery, intraoperative bleeding volume, postoperative pain score and length of hospital stay. A visual analog scale (VAS) was used for postoperative pain. Results Demographic characteristics, mean age, gender, BMI and type of surgeries were statistically similar among the groups. The mean operation time was higher in group I than group II and group III but this was not statistically significant (P=0.810). The mean intraoperative bleeding volume was significantly higher in group I compared with group II and group III (P=0.030 and P=0.006). The mean length of postoperative hospital stays was statistically similar among the groups (P=0.849). The mean VAS score at 6h was significantly reduced in group I compared with group III (P=0.011). At 12h, the mean VAS score was significantly reduced in group I compared with group II and group III (P=0.009 and P<0.001). There was no significant difference in the mean VAS scores at 24h among three groups (P=0.920). Conclusion Lower insufflation pressures are associated with lower postoperative pain scores in the early postoperative period.