Pediatric Pharmacology and Therapeutics

Introduction: Historically the Cohen technique has been considered the “gold” standard in the open surgical management of VUR. Th is technique has the inherent end result of placing the ureteric orifi ce across the midline of the trigon and theoretically making future access to the ureteric orifi ce possibly more diffi cult than if they remained lateralized. The Glenn-Anderson technique does not require contralateral placement of the ureteric orifi ce thus likely not complicating future UO access. We compared both techniques in pediatric age group at two separate institutes to assess the feasibility and short-term outcomes.

 

Methodology: Between April 2014 and April 2015, 90 consecutive cases of ureteral reimplantation performed for VUR were retrospectively analyzed in two diff erent hospitals. Surgical complications, length of stay and short-term outcomes were evaluated in an attempt to assess the equivalence or superiority of either procedure. Forty-fi ve cases (75 ureters) group (A) from Queen Rania Children Hospital, King Hussein Medical Center, Amman-Jordan, managed by Cohen procedure. Fortyfive cases, (65 ureters), group (B) from Rocky Mountain Children Hospital at Presbyterian St.Luke's Medical Center, Colorado. All patient had single system ureter without complex anatomies such as ureterocele, duplex collecting systems, or megaureters.

 

Results: Surgical indication in all patients was VUR and VUJ obstruction. All patients in group A were discharged on day 4 to 5 post-operatively while patients in group B were discharged at second-day post-op. Patients age was ranged between 8 months and 10 years while body weight ranged from 9 to 38 Kilograms. All patients in group A had local anesthetic incisional wound infiltration compared to group B who received caudal block and bladder neck and trigonal local anesthesia in addition to the incisional block. Five patients in group A developed urine retention while none in B. Four patients in group A had no resolution but downgrading of their VUR. No patient to date has required further surgical intervention.

 

Conclusion: Glenn-Anderson procedure is a feasible and equivalent technique to Cohen cross-trigonal -ureteral reimplantation. Glenn-Anderson technique theoretically as a result of a more orthotropic ureteric orifi ce placement should allow for easier ureteral access in patients that developed urolithiasis requiring retrograde ureteral access. Length of stay as a measure of postoperative convalescence was superior in the GA technique with all patients being discharged the day aft er surgery. Perhaps the adjunct local wound infi ltration into the bladder neck and trigone played a major role in the ability for earlier discharge? It is not unreasonable to consider this technique as equivalent and potentially superior to others for these reasons. A further prospective study looking at postoperative pain measures and long-term surgical outcomes, as well as the latent need of additional ureteral access procedure, will be necessary to confi rm our initial impressions.