title: Salvage extravesical ureteral reimplantation after failed endoscopic surgery for vesicoureteral reflux.
abstract: OBJECTIVE
  Open intravesical ureteral reimplantation has been reported to be uncomplicated following dextranomer/hyaluronic acid implantation. However, there are no known reports regarding extravesical ureteral reimplantation following dextranomer/hyaluronic acid failure. We reviewed our experience with extravesical ureteral reimplantation after dextranomer/hyaluronic acid failure.
  
  
  METHODS
  We reviewed the charts of 30 patients who underwent extravesical ureteral reimplantation after dextranomer/hyaluronic acid failure. If reflux was initially bilateral and only a unilateral cure was achieved, the cured ureter was not reimplanted. Intraoperative complications, need for stenting or prolonged bladder catheterization, length of hospitalization and radiographic results were noted.
  
  
  RESULTS
  At cystoscopy the dextranomer/hyaluronic acid implants were not seen in half of the patients. In the remaining 15 patients the blebs had moved caudally and/or were seen extravesically at the ureteral hiatus or along Waldeyer's sheath. Unilateral extravesical ureteral reimplantation was performed without difficulty in all patients and there were no intraoperative complications. Stents were left indwelling only in those patients who had undergone dismembered ureteral reimplantation. No patient required prolonged bladder drainage. All patients except 2 who had undergone additional procedures were discharged home within 24 hours postoperatively. There was no evidence of obstruction on postoperative renal sonography, and extravesical ureteral reimplantation was confirmed to be successful in all 24 patients with postoperative voiding cystourethrograms.
  
  
  CONCLUSIONS
  Extravesical ureteral reimplantation can be performed without difficulty following dextranomer/hyaluronic acid implantation. Since extravesical ureteral reimplantation is less morbid and better tolerated than intravesical reimplantation, it is an excellent treatment option for patients with persistent unilateral vesicoureteral reflux following dextranomer/hyaluronic acid implantation. Furthermore, in cases in which vesicoureteral reflux is initially bilateral our data suggest that reimplantation of the successfully treated contralateral ureter can be avoided.
authors.affiliation: Department of Pediatric Urology, Children's Healthcare of Atlanta and Emory University School of Medicine, 5445 Meridian Mark Road, Atlanta, GA 30342, USA.
authors.forename: James M
authors.initials: JM
authors.lastname: Elmore
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Kirsch
authors.forename: Marcos R
authors.initials: MR
authors.lastname: Perez-Brayfield
authors.forename: Hal C
authors.initials: HC
authors.lastname: Scherz
authors.forename: Martin A
authors.initials: MA
authors.lastname: Koyle
mesh_terms: D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D007223:Infant; D008297:Male; D012189:Retrospective Studies; D016879:Salvage Therapy; D017211:Treatment Failure; D014513:Ureter / Q000601:surgery*; D018666:Ureteroscopy; D013520:Urologic Surgical Procedures / Q000379:methods; D014718:Vesico-Ureteral Reflux / Q000601:surgery*