Teflon was the first bulking agent used for endoscopic correction of reflux. Although the results were encouraging, later studies showed that there was migration of the Teflon particles to the lung, lymph nodes, and brain as well as the finding of granuloma formation; this resulted in the search for more biocompatible bulking agents (14). These have included both autologous agents (fat, blood, human collagen, bladder muscle cells, and ChondroGEL) and nonautologous agents (silicone, BioGlass, polyvinyl alcohol, and dextranomer microspheres). Deflux (dextranomer microspheres) has emerged as the agent of choice for bulking agents and at present is the sole agent approved by the U.S. Food and Drug Administration. Endoscopic surgery technique for reflux will be discussed in another chapter.

Lich (15) and Gregoir (16) in the 1960s separately developed the extravesical approach to correct reflux. Further modifications of this approach have yielded success equal to that of the intravesical techniques (17). The benefits of this procedure are several: (a) The surgery is performed entirely outside of the bladder mucosa and as such avoids gross hematuria and irritable postoperative voiding problems such as urgency and bladder spasms, (b) catheter drainage of the bladder is brief, (c) wound drains are avoided, and (d) ureteral stents are eliminated. A further advantage of this technique is that hospital stay is brief, averaging 1.5 days in our hands, thus decreasing overall hospital costs.

The patient is placed in the supine position, and the bladder is catheterized on the field and filled to about one-third to onehalf of its estimated capacity with sterile saline. This facilitates dissection of the detrusor muscle from the mucosa. The bladder may be further filled or emptied throughout the procedure. The surgical procedure begins similarly to the intravesical approach with a Pfannenstiel incision. A Dennis-Browne retractor is then placed over moistened gauze pads, and the bladder is carefully mobilized and rotated anteromedially, exposing the perivesical space. Care should be taken to avoid entering the peritoneum during this maneuver. Placing an appropriate-sized Deaver retractor to help keep the rotated bladder in place will greatly facilitate locating the obliterated hypogastric vessel. This vessel is tied off with 3-0 polyglycolic acid suture, and the most lateral tie is tagged to help expose the ureter, which lies just beneath this vessel. In cases of bilateral detrusorrhaphy, the obliterated hypogastric vessel need not be tied off but simply recognized for ease of finding the underlying ureter. The detrusor innervation courses posteromedial to the ureter and care must be taken to limit dissection in this part of the bladder. This minimal dissection technique as described, as well as limiting the dissection of the extravesical submucosal tunnel, may help prevent significant denervation and avoid postoperative urinary retention. The ureter is carefully mobilized and encircled with a vessel loop (Fig. 92.2). The ureter is freed up to its entry point into the bladder. During this maneuver, the Deaver retractors may need to be reset to keep the ureter in the middle of the operative field. A tennis racket incision is made around the ureteral detrusor hiatus and deepened until the ureter is only attached to the mucosa. The detrusorotomy is then extended to create a 3- to 5-cm trough. It is helpful to place stay sutures of 3-0 polyglycolic acid on the detrusor edges to facilitate dissection of the detrusor muscle off the mucosa. All vessels encountered during this dissection are tied off with 4-0 or 3-0 polyglycolic acid suture, and great care is exercised to avoid making a rent in the bladder (Fig. 92.3). If this occurs, immediately close the defect with the 6-0 chromic catgut. The dissection should be generous enough to lay the ureter in the newly created trough and permit the detrusor muscle to be closed over the ureter without too much tension. To complete the detrusorotomy, dissection is extended toward the bladder neck beyond the distalmost detrusor incision to allow placement of the advancement sutures. The first limb of the two sutures is through the detrusor (outsidein), entering at the distal limit of the trigonal musculature and exiting in the plane between the mucosa and detrusor. The second limb of the suture is placed through the ureteral muscle, and the final limb of the suture is back through the detrusor (inside-out). Tying the pair of “vest- type” sutures advances the ureter on the trigone, creating a longer submucosal tunnel, and anchors the ureteral orifice distally, preventing proximal migration of the ureter (Fig. 92.4). The remaining detrusor defect is
closed over the ureter in two layers; the first is a running layer and the second is an interrupted Lembert suture, both using 4-0 polyglycolic acid suture. Care must be exercised to avoid making the ureteral hiatus too snug. The exit point for the ureter should be able to admit a hemostat between the detrusor and the ureter easily (Fig. 92.5). No perivesical drains or ureteral stents are used, and the Foley catheter is removed the following morning.