title: Redo ureteroneocystostomy using an extravesical approach in pediatric renal transplant patients with reflux: a retrospective analysis and description of technique.
abstract: OBJECTIVE
  Vesicoureteral reflux and pyelonephritis following transplantation may significantly contribute to renal damage and premature graft loss. We report our retrospective experience with redo ureteral reimplantation of refluxing pediatric renal transplants and describe our surgical technique.
  
  
  METHODS
  We identified 20 children with a diagnosis of symptomatic post-transplant vesicoureteral reflux, of whom 16 underwent redo ureteral reimplantation. Patient characteristics including etiology of end stage renal disease, presenting symptoms, serum creatinine and postoperative followup were documented. The presence or absence of lower urinary tract dysfunction was documented and values between the 2 groups were analyzed for significance.
  
  
  RESULTS
  All 20 patients presented after assessment for a febrile urinary tract infection, and 35% had concurrent lower urinary tract dysfunction. Median interval between transplantation and vesicoureteral reflux diagnosis was 1.3 years, and mean vesicoureteral reflux grade was 3.2. Patients with lower urinary tract dysfunction presented significantly earlier and had a higher postoperative serum creatinine than those without lower urinary tract dysfunction (1.1 vs 1.7 years, p = 0.048). Redo reimplantation was performed in 94% of patients using an extravesical approach with ureteral stent placement. Seven of 16 patients underwent followup voiding cystourethrogram, with 5 demonstrating resolution and 2, both with lower urinary tract dysfunction, exhibiting persistent vesicoureteral reflux. At a mean followup of 3.6 years 25% of patients experienced recurrent pyelonephritis, while 75% were asymptomatic. One instance of anastomotic stricture occurred in a patient with lower urinary tract dysfunction.
  
  
  CONCLUSIONS
  Effective repair of post-transplantation vesicoureteral reflux can be performed using an extravesical technique, facilitated by preoperative ureteral stent placement. Patients with lower urinary tract dysfunction are likely to present earlier after transplantation than those without lower urinary tract dysfunction, and may have an increased risk of persistent vesicoureteral reflux and renal damage despite surgical correction.
authors.affiliation: Department of Urology, Divisions of Pediatric Urology and Nephrology, University of California at San Francisco, San Francisco, California, USA.
authors.forename: Anand
authors.initials: A
authors.lastname: Krishnan
authors.forename: Hubert
authors.initials: H
authors.lastname: Swana
authors.forename: Robert
authors.initials: R
authors.lastname: Mathias
authors.forename: Laurence S
authors.initials: LS
authors.lastname: Baskin
mesh_terms: D002648:Child; D003559:Cystostomy / Q000379:methods*; D005260:Female; D006801:Humans; D016030:Kidney Transplantation / Q000009:adverse effects*; D008297:Male; D012086:Reoperation; D012092:Replantation / Q000379:methods*; D012189:Retrospective Studies; D016896:Treatment Outcome; D014513:Ureter / Q000601:surgery*; D014718:Vesico-Ureteral Reflux / Q000209:etiology* / Q000601:surgery*