Is Urinary Reflux Surgery the Gold Standard for Vesicoureteral Reflux?

Vesicoureteral reflux (VUR) is a condition of reverse urine flow. It can improve with time, but some people do require urinary reflux surgery.

Your kidneys filter your blood and send urine to your bladder through tubes called ureters. These tubes connect to your bladder through a one-way, flap-like valve.

This valve is supposed to allow urine to enter your bladder without backflow into your ureters. When the valve doesn’t function properly and your urine reverses its flow, this is known as vesicoureteral reflux (VUR).

VUR is often present at birth, though it can go undiagnosed for a long time and can affect adults. Approximately 1% to 3% of children have the condition. It can improve with age in children, but sometimes urinary reflux surgery is necessary.

Urinary reflux surgery is a procedure that stops urine from backflowing into your ureters. Two main options are available for VUR: ureteral reimplantation or endoscopic injection.

Ureteral reimplantation

Ureteral reimplantation repairs the connection between your bladder and ureter. It can involve minor repairs to the tissue flaps or a complete reattachment of your ureter to a new position on your bladder.

Ureteroneocystostomy, for example, is a type of ureteral reimplantation used in both children and adults. It involves going into your bladder for VUR repair and is also known as intravesical ureteric reimplantation.

A doctor may instead opt for extravesical ureteric reimplantation. This doesn’t involve entering your bladder and is considered less invasive.

A 2022 systematic review and meta-analysis found extravesical and intravesical methods (meaning outside or inside the bladder, respectively) were equally effective in correcting VUR but had individual pros and cons.

A doctor will help you decide which option makes the most sense for your individual needs.

Endoscopic injection

Endoscopic injection, also known as endoscopic surgery, involves placing a “bulking agent” into the area where your ureter meets your bladder. The injection creates a bulge in your bladder tissue that serves as a replacement valve mechanism.

Endoscopic injection does involve general anesthesia, but most people can go home the same day.

Overall, urinary reflex surgery has a good chance of correcting VUR. But each procedure has its positives and potential negatives, as discussed in a 2021 research paper .

Pros of ureteral reimplantation

• It has the highest resolution rate.
• It can be done with robotic assistance, laparoscopically, or traditionally.
• It’s a well-established method with more than 40 years of use.
• You have low risk of postoperative complications.

Cons of ureteral reimplantation

• It’s considered an invasive procedure that may require multiple days in a care facility.
• Robotic assistance can be more costly and not available everywhere.
• Intravesical methods involve increased postoperative pain and a longer hospital stay.
• Extravesical methods may increase your risk of postoperative urine retention and require longer urinary catheterization.
• It can take up to 6 weeks to resume your normal activities.

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Pros of endoscopic injection

• You can often go home on the same day.
• You may return to regular activities within days.
• It’s considered the least invasive.
• It’s effective for difficult-to-treat situations.

Cons of endoscopic injection

• It has a lower resolution rate.
• Its success rate can vary significantly based on your patient age, the stage of VUR, the injection technique used, etc.
• It may cause inflammation due to a foreign body reaction to the bulking agent.
• It’s a newer procedure. Long-term data is lacking on how effective injectable agents are.
• The cost is similar to ureteral reimplantation.

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The success rate of ureteral reimplantation surgery, regardless of type, is greater than 90% up through RUV grade 4.

Endoscopic injection’s resolution rate is between 71% and 83%, depending on the technique.

The cost of urinary reflux surgery varies widely based on the procedure, the use of robotics, surgeon qualifications, and technique.

In 2017, for example, a review found that robot-assisted ureteral reimplantation costs were around $13,000, compared with traditional ureteral reimplantation at approximately $8,500.

Medicare indicates, based on national 2022 averages, ureteroneocystostomy costs run between $3,759 and $6,565. Those are only the costs for the doctor’s fee and the fee for the facility, though.

Those costs don’t include initial tests or examinations, hospitalization, medications, or many of the other fees that are a part of your final bill.

Costs of endoscopic injection are similar, topping out at around $8,600 .

Insurance

Private insurance coverage for urinary reflux surgery varies depending on your policy and how medically necessary the procedure is for your condition.

It’s not unheard of for private insurance companies to push back if they feel less invasive options are reasonable for your diagnosis.

RUV grade 1, for example, is considered a mild form of RUV. It’s often first treated with antibiotic therapy, and you may never need surgery. The healthcare team may need to provide additional evidence as to why surgery is the preferred option in this case.

Aetna, a common insurance carrier, will only consider endoscopic injections as “necessary” when conservative treatments have failed.

Medicare may pay up to 80% of urinary reflux surgery for either endoscopic injection or ureteral reimplantation.

Ureteral reimplantation surgery generally requires a hospital stay. During this time, a urinary catheter helps expel urine without strain on your bladder. Your pain is watched closely, too.

You may go home with a urinary catheter in place or with a drainage tube near the incision to be removed at a later date.

Strenuous activity isn’t recommended for at least 3 weeks after surgery.

With an endoscopic injection, you can usually go home the same day. A urinary catheter isn’t necessary, and normal activity can be resumed as early as the next day.

Alternative treatments for urinary reflux surgery

Long-term antibiotic use is the most common alternative to urinary reflux surgery.

The benefits of long-term antibiotics for VUR are controversial. Long-term use may result in antibiotic resistance and treatment not being as effective.

A Cochrane review in 2019 found long-term antibiotic use had little effect on managing the risk of urinary tract infections in VUR. It wasn’t superior as a stand-alone treatment when compared with surgery.