Overview
Definition:
Ureteroneocystostomy is a surgical procedure that involves reimplanting a ureter into the urinary bladder
The Lich-Gregoir technique is a specific type of extravesical ureteroneocystostomy characterized by its direct, tunneled reimplantation of the ureter into the bladder wall without creating an intravesical submucosal tunnel
It is primarily used to correct primary or secondary vesicoureteral reflux (VUR) and to manage distal ureteral obstructions.
Epidemiology:
Vesicoureteral reflux affects approximately 1-3% of children worldwide, with higher incidence in infants and those with a history of urinary tract infections (UTIs)
Primary VUR is the most common indication for ureteroneocystostomy
The Lich-Gregoir technique is a widely adopted method for surgical correction of VUR due to its efficacy and relatively low complication rates.
Clinical Significance:
Ureteroneocystostomy, particularly the Lich-Gregoir technique, is crucial for preventing recurrent UTIs and renal scarring in patients with VUR, thus preserving renal function and avoiding long-term complications such as hypertension and end-stage renal disease
It also addresses distal ureteral strictures that can lead to hydronephrosis and poor renal development.
Indications
Indications For Surgery:
High-grade vesicoureteral reflux (Grade IV-V) on voiding cystourethrogram (VCUG) that is persistent despite antibiotic prophylaxis
Recurrent febrile UTIs in children with VUR
Reflux associated with significant renal scarring or potential for renal damage
Duplex systems with significant reflux in the lower moiety
Distal ureteral obstruction requiring ureteral reimplantation.
Contraindications:
Active UTI at the time of surgery
Severe bladder dysfunction or neurological bladder disease that may compromise the success of the reimplantation
Patient refusal or inability to comply with postoperative care and follow-up
Certain anatomical abnormalities of the bladder or ureter that preclude a successful reimplantation.
Preoperative Evaluation:
Complete history and physical examination focusing on UTI symptoms and renal function
Urinalysis and urine culture to rule out active infection
Renal ultrasound to assess for hydronephrosis and renal parenchymal changes
Voiding cystourethrogram (VCUG) to grade VUR
DMSA scan to assess for renal scarring and function
Urodynamic studies may be indicated in select cases with suspected bladder dysfunction.
Preoperative Preparation
Antibiotic Prophylaxis:
Patients on prophylactic antibiotics for VUR should continue them until surgery
A perioperative broad-spectrum antibiotic (e.g., ampicillin or cephalexin) is administered intravenously just before incision and continued for 24-48 hours postoperatively.
Bowel Preparation:
Routine bowel preparation is generally not required for the Lich-Gregoir technique unless the patient has a history of constipation or other bowel issues
The absence of a bowel segment in the reconstruction reduces the risk of infection transmission.
Anesthesia Considerations:
General anesthesia is typically used
Careful attention to fluid management and monitoring of vital signs is essential
Postoperative pain management strategies should be planned.
Informed Consent:
Detailed discussion with the patient and guardians about the procedure, its benefits, risks (including bleeding, infection, ureteral obstruction, bladder issues, need for reoperation), expected outcomes, and alternatives
Ensuring understanding of the postoperative care regimen is crucial.
Procedure Steps Lich Gregoir
Patient Positioning And Incision:
The patient is placed in a supine position
A transverse or curvilinear suprapubic incision is made, typically 1-2 cm above the pubic symphysis, to gain access to the bladder
In infants and small children, a Pfannenstiel incision may be used.
Bladder Mobilization And Ureteral Dissection:
The bladder is dissected free from the surrounding peritoneum and retractor muscles
The distal ends of the affected ureter(s) are identified and carefully dissected free from the bladder adventitia, preserving their blood supply
Care is taken not to injure the contralateral ureter or major pelvic vessels.
Ureteral Preparation And Insertion:
The ureter is spatulated longitudinally at its tip to facilitate its passage into the bladder
A small incision is made in the bladder wall at a chosen site (typically superolateral) to create an opening for the ureter
The spatulated ureter is then passed through this opening and advanced into the bladder lumen, creating a tension-free, obliquely tunneled anastomosis.
Bladder Closure And Drainage:
The bladder wall incision is closed with absorbable sutures
A Foley catheter is typically inserted into the bladder to decompress it and ensure adequate urinary drainage
A suprapubic catheter may also be placed in select cases
The abdominal incision is closed in layers
A drain is usually not required.
Postoperative Care
Monitoring And Pain Management:
Close monitoring of vital signs, urine output, and abdominal distension
Analgesia is provided using intravenous or oral analgesics as needed
Antiemetics may be administered for nausea and vomiting.
Urinary Drainage:
The Foley catheter is typically kept in place for 5-7 days, or until satisfactory bladder drainage is observed and the patient is comfortable
Gradual dislodction of the catheter is performed
Early mobilization is encouraged once pain is controlled.
Antibiotic Therapy:
Intravenous antibiotics are continued for 24-48 hours postoperatively, followed by oral antibiotics as per institutional protocol to prevent UTIs.
Activity And Diet:
Activity is gradually increased
A regular diet is usually resumed as tolerated once bowel function returns
Patients are advised to avoid strenuous activity and heavy lifting for 4-6 weeks postoperatively.
Complications
Early Complications:
Bleeding from the incision or bladder
Urinary tract infection
Bladder spasms and voiding dysfunction
Retained Foley catheter
Ileus
Wound infection
Hematuria.
Late Complications:
Ureteral obstruction at the reimplantation site
Persistent or recurrent VUR
Bladder outlet obstruction
Stone formation
Ureteral stricture
Bladder diverticulum formation
Recurrent UTIs
Renal scarring progression.
Prevention Strategies:
Meticulous surgical technique with preservation of ureteral blood supply
Accurate placement and tension-free anastomosis
Appropriate use of prophylactic and perioperative antibiotics
Careful management of the Foley catheter
Close postoperative monitoring for signs of obstruction or infection
Patient education on activity restrictions and follow-up.
Prognosis
Success Rates:
The Lich-Gregoir technique has a high success rate, typically ranging from 90-97% in correcting VUR
Success is defined as the absence of VUR on a postoperative VCUG and resolution of UTI symptoms.
Factors Affecting Prognosis:
Grade of VUR preoperatively
Presence of renal scarring or dysfunction
Quality of the bladder and ureteral anatomy
Surgical experience and technique
Postoperative adherence to care and follow-up
Presence of complicating factors such as bladder dysfunction or other congenital anomalies.
Long Term Follow Up:
Regular follow-up appointments are essential
This typically includes periodic renal ultrasounds to monitor for hydronephrosis and renal growth, and voiding cystourethrograms (VCUGs) at 6-12 months postoperatively to confirm resolution of VUR
Long-term follow-up focuses on preventing UTIs and monitoring renal function.
Key Points
Exam Focus:
Lich-Gregoir is an *extravesical* ureteroneocystostomy
Key advantage: avoids entering the bladder lumen directly, reducing infection risk
Commonly used for VUR correction and distal ureteral reimplantation
Differentiate from *intravesical* techniques like Politano-Leadbetter or Glenn-Anderson.
Clinical Pearls:
Ensure adequate ureteral mobilization without compromising vascularity
Spatulate the ureter to prevent stenosis
Create an oblique, tension-free tunnel
Close approximation of the ureter to the bladder mucosa is crucial
Careful attention to bladder closure to prevent urine leakage
Postoperative catheter management is critical for success.
Common Mistakes:
Undermobilizing the ureter leading to tension on the anastomosis
Inadequate spatulation of the ureter causing stenosis
Creating a too-short or too-tight submucosal tunnel
Failure to meticulously close the bladder wall, leading to extravasation
Disregarding signs of postoperative obstruction or infection
Inadequate follow-up leading to missed complications.