Vesicoureteral Reflux After Transurethral Resection of Bladder
Mircea Teodorescu Brюnzeu
Department of Urology
Victor Babes University of Medicine and Pharmacy Timisoara
The development of endoscopic surgery in the treatment of
superficial bladder tumors allowed the control of these tumors in a
great number of patients with a high tendency of recurrence due to
repeated transurethral endoscopic resections.
The advantages of transurethral resection are emphasized: reduced
operational stress, early mobilization, quick removal of the
catheter, low cost of nursing. Therefore the operation is given
preference mainly in the treatment of elderly patients with bladder
This treatment is not devoid of minor or major secondary effects
such as hematuria, infection, enuresis2, the perforation of the
bladder wall, intraperitoneal and extraperitoneal perforations,
strictures of urethra and/or bladder neck, ureteric stenosis 3 and
Radical, full-thickness resection of the bladder wall and overlying
bladder tumor is a management option in highly selected patients
with muscle invasive bladder cancer. The resection of tumors
localized in the trigone of bladder and close to the ureteric
orifice may cause the damage of BellТs muscle and may alter the
antireflux valvular mechanism.4
Reflux can be associated with ureterotrigonal abnormalities such as
paraureteric diverticulum, complete duplication of the ureter and
gaping ureteric orifice, and it can be diagnosed before the bladder
Patients treated with transurethral slitting of the ureteral orifice
for a stone at the distal end of the ureter or a ureterocele can
show vesicoureteral reflux previous to bladder tumor resection. 6
Morita and Tokue reported a case of vesicoureteral reflux 3 years
after intravesical instillation of bacillus Calmette-Guerin against
carcinoma in situ of the bladder. 7
Vesicoureteral reflux after transurethral resection of bladder
tumors is a significant complication. Some of the patients with such
reflux suffer no apparent ill effects. Others can develop urinary
infection, hydronephrosis, nephrotic syndrome, chronic renal
failure. A higher risk of upper urinary tract cancer must be
expected in cases of multiple primary superficial bladder tumors and
vesicoureteral reflux after transurethral resection of bladder
We have the obligation to recognize the reflux when it exists and
treat it proper with antirefluxing ureteric reimplantation
(ureterocystoneostomies) or by polytetrafluoroethylene (Teflon)
MATERIAL AND METHOD
The aim of this study was to highlight the vesicoureteral reflux in
patients who had removed one or more bladder tumors situated in the
neighbourhood of the ureteric orifice and the trigone of bladder.10
The object of study were patients with bladder tumors who had no
other kind of vesicoureteral reflux diagnosed before endoscopic
The evaluation of the patients included intravenous pyelography,
voiding cystography, abdominal radiography, cystoscopy and serum
In the 11 patients surveyed, the periodical cystoscopic control
highlighted an abnormal localization of one or both ureteric
orifices, situated sideways, most frequently with a large orifice
and a damaged antireflux mechanism. The length of the submucosal
ureter, the orifice configuration and its location as well as the
trigonal muscular development are parameters evaluated
Ultrasonography was performed to all patient because it is safe,
easily available, cost effective and provides images of both upper
and lower renal tract. It helped us to diagnose recurrence of
bladder tumors and changes in the bladder wall. Data about sizes of
the kidney and renal parenchyma, as well as about the status of
upper-collecting system were gathered. It is recommended to use
ultrasonography as the initial radiological investigation for
detection of bladder carcinomas in patients presenting hematuria. 12
Ultrasonography was more sensitive in clarifying the pathology in
upper renal tracts when urography failed due to none or poor
excretion of contrast substance.
A standard voiding cystourethrography was obtained by instilling
radiopaque contrast medium into the bladder and imaging the bladder
and renal fossae during filling and voiding. The voiding cystography
highlighted both the vesicoureteral reflux and the degree of reflux.
Reflux occurs in varying degrees of severity ranging from Grade I to
Grade V, with Grade I being the least severe and Grade V being the
Grade I reflux does not reach the renal pelvis. Grade II reflux
reaches the renal pelvis, without the dilatation of the collectiong
system. Grade III reflux produces moderate dilatation of the ureter,
mild dilatation of the collecting system, minimally deformed
fornices. Grade IV reflux causes moderate dilatation of the ureter,
moderate dilatation of the collecting system, blunt fornices and
impressions of the papillae. Grade V reflux produces gross
dilatation and kinking of the ureter, market dilatation of the
collecting system, papillary impressions no longer visibile and
The magnetic resonance voiding cystography compared with voiding
cystourethrography for detecting and grading vesicoureteral reflux
(VUR) is less sensitivit for bladder reflux13. Our patients didnot
undergo resonance voiding cystography.
An intravenous pyelogram was performed to detect possible problems
of the kidneys, ureters, and bladder. An non-iodine containing
contrast medium is given by intravenous injection. A series of
abdominal radiographs are taken at the time of injection, at
measured times afterwards, and after the patient has voided.
The urography helped determine the renal function and the morphology
of the entire upper urinary system. Intravenous pyelography showed
the size, shape, and position of the urinary tract, and it evaluated
the collecting system inside the kidneys. We followed the
implantation of the ureter in the urinary bladder wall.
64% of the patients investigated were men and 36% women. The mean
age of the patients was 74.8 years, including an age range 53 to 80.
Only one tumor was observed in 63%, of which 57% had a large tumor.
In 36% several bladder tumors were revealed after cystoscopy. 27.2%
underwent no surgical intervention prior to the endoscopic resection
which altered the antireflux mechanism. 45.4% had several
transbladder resections for bladder tumors, 18.2% had a
transurethral resection of the bladder tumour, and 9.2% had partial
Unilateral urethral reflux was diagnosed in 72.7% of patients and
bilateral in 9.2%. In 2 patients (19.1%) no vesicoureteral reflux
was noticed after cystography although cystoscopic investigation
highlighted a large urethral orifice, in a lateral position.
An equal number of patients with reflux on the right and on left
side was noticed.
Grade I reflux was present in 27.2% of the patients under study,
grade II reflux in 45.4%, and a massive reflux with reduction of
renal parenchyma (grade IV) in 9.1% of patients.
Fig.1.Grade I Vesicoureteral Reflux: urine
refluxes part-way up the ureter
Fig.2 Grade IV Vesicoureteral Reflux: urine
refluxes all the way up the ureter with marked dilatation of the
ureter and calyces.
The renal and urethral modifications caused by bladder-urethral
reflux were highlighted with the help of imagistic investigation (
ecography and urography) which showed pyelonephritic modifications
in 36.3% of the investigated patients.14
Analysing the degree of tumoral invasion in the bladder, one can
reach the following conclusions: in 45.5% of patients the tumor
invaded the internal elastic subepithelial connective tissue (T1),
in 27.3% an invasion of the superficial muscle was noticed, while in
27.2% the external half of the bladder wall was invaded (T3).
DISCUSSION AND CONCLUSION
Endoscopic surgery of bladder tumors requires a radical attitude
which implies the resection of the deep muscular layer, giving the
anatomo-pathologist the possibility of differentiating the
superficial tumors from the infiltrative ones. The adequate
treatment can be followed according to the nature of the tumor.
Bladder-urethral reflux may appear during the multimodal therapy of
the bladder tumor.
Mukamel et al. 15 mention a low incidence of bladder-urethral reflux
in the case of tumors with trigonal localization (17.3%), while
tumors within the immediate neighbourhood of urethral orifices have
an incidence of 24%. The authors consider this situation to be the
result of fibrosis and inflammatory phenomena after instillations
with Thiotepa over a longer period of time in the patients under
The study undertaken by Ricos Torrent et al. 16 shows the existence
of bladder-urethral reflux after Tur-TV in 20% of patients, when the
tumour was localized in the trigonal area close to the urethral
orifice. In 9 out of 96 patients bladder-ureteral reflux increased,
in 4 patients bilateral reflux was noticed and in 5 patients reflux
was due to the enlargement of the ureteral orifice. The patients
followed a treatment with 9 endovesical instillations and only 2
patients underwent new resections because of local recurrence of the
tumor. It is considered that chemical cystitis produced by repeated
chemotherapeutic agents is the cause for the apparition of the
bladder-ureteral reflux and its maintainance. The main cause for
bladder-urethral reflux remains the alteration of the antireflux
mechanism through the morphological and topographic alteration of
the urethral orifice. The alteration of the antireflux mechanism was
noticed in 43.3% of the patients with reflux and was not noticed in
the patients without reflux.
In Gottfries and NilssonТs study no severe stenosis was found at the
follow-up investigation after the resection of the bladder tumor
near the ureteric orifice. In all cases at least a 5 French catheter
could be inserted.14
Amar and Das showed in most patients with reflux benign clinical
findings, but it caused recurrent pyelonephritis in 9 cases and
secondary struvite calculi in 2.10
The experience of See suggests that iatrogenic injury to the distal
ureter during radical transurethral resection of tumor involving the
hemi-trigone does not result in long-term distal ureteral damage.17
Some authors recommend catheterization of the ureteral orifice while
resecting the bladder tumors close to the ureteral orifice.
In some cases the resection of the ureteral orifice should not be
Considering the low incidence of renal parenchimatose lesions due to
reflux in only 6.7% of patients, we belief that a radical attitude
is justified irrespective of the options some authors go for.18
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