There are several invasive strategies for the management of high-grade vesicoureteral reﬂux (VUR, see Plate 2-21), and the cross-trigonal ureteral reimplantation is one of the most popular and effective techniques. In this procedure, the reﬂuxing ureter is dissected free of its attachments to the bladder wall, then advanced through a new submucosal tunnel that extends toward the opposite side of the trigone. The signiﬁcantly lengthened intramural segment prevents further reﬂux. The surgery begins with a transverse incision approximately one ﬁngerbreadth above the pubis to the lateral edges of both rectus muscles. The rectus fascia is incised transversely, and fascial ﬂaps are raised. The rectus muscle bellies are longitudinally divided in the midline until the pubis is reached, then a self-retaining ring retractor is inserted to expose the bladder.
The peritoneum is identiﬁed and avoided, and the bladder is opened from the dome to just above the bladder neck. Traction sutures can be used to secure the inferior aspects of the cystotomy to the rectus fascia. The self-retaining ring retractor is repositioned to achieve a clear view of the trigone and ureteric oriﬁces. Rolled moist gauzes are counted and placed into the dome of the bladder.
A 5-Fr feeding tube is placed into the oriﬁce of the reﬂuxing ureter and then secured using traction sutures at the 6- and 12-o’clock positions. The bladder mucosa is scored around the oriﬁce in an oval shape using needletip electrocautery with a low cutting current. The plane of dissection is then established by incising the bladder wall perpendicular to the ureter at the 6-o’clock position of the oriﬁce until the ureteral adventitia is reached. The intramural ureter is then circumferentially dissected free of its attachments using ﬁne tenotomy scissors and a ﬁne right angle clamp. In males, it is important to be cognizant of the nearby vas deferens.
The traction sutures and dissection sequentially release the intramural portion of the ureter until an adequate length for reimplantation is obtained, usually deﬁned as four times the ureteral diameter. The dissection process often leaves a gap in the detrusor ﬂoor, which should be reapproximated to prevent formation of a diverticulum.
A new submucosal tunnel is then established between the mucosa and detrusor. Tenotomy scissors are introduced into the original hiatus (i.e., the site where the ureter ﬁrst enters the bladder wall) and advanced under the mucosa toward the contralateral side of the trigone. Once a tunnel of adequate length has been created, a new ureteric oriﬁce is created by incising the mucosa. Using the traction sutures to ﬂatten the bladder ﬂoor facilitates this process.
The ureter is passed through the new tunnel, with care taken to avoid twisting, and then secured to the new oriﬁce with a single stitch through the cuff of the distal end of the ureter, the bladder mucosa, and the detrusor muscle. A feeding tube is passed to conﬁrm no twisting has occurred. The remainder of the cuff is sutured to the bladder mucosa with interrupted absorbable sutures. The gap in the bladder mucosa from the prior dissection is now closed with a running absorbable suture. The feeding tube is passed a ﬁnal time to ensure patency. Stenting is not performed unless the ureter has been tapered (i.e., redundant ureteral wall has been removed because the ureter was severely dilated).
The gauzes are removed and counted, then the bladder is closed in two layers. The ﬁrst is an absorbable running suture of the bladder mucosa, followed by a running absorbable suture of the seromuscular layer. The bladder is distended with saline through a Foley catheter to conﬁrm a watertight closure. The rectus muscles are then reapproximated and the rectus fascia closed. The remaining fascial planes and skin are then closed.
Postoperatively, the patient should receive double the maintenance intravenous ﬂuid rate for the ﬁrst 12 to 24 hours, which will irrigate the bladder and ureteral anastomosis. The Foley catheter should remain in place for the ﬁrst several days to facilitate healing of the cystotomy. After the catheter is removed, the patient should void frequently to maintain low bladder pressure. The routine use of postoperative VCUG to check for resolution of reﬂux has been abandoned. An ultra-sound, however, should be obtained several weeks after the surgery to assess for possible hydronephrosis secondary to ongoing ureteral obstruction.