# Current Status of Gil-Vernet Trigonoplasty Technique

Authors: Nasser Simforoosh; Mohammad H. Radfar
Journal: Advances in Urology
 (2008)

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## Abstract

Significant controversy exists regarding vesicoureteral reflux (VUR) management, due to lack of sufficient prospective studies. The rationale for surgical management is that VUR can cause recurrent episodes of pyelonephritis and long-term renal damage. Several surgical techniques have been introduced during the past decades. Open anti-reflux operations have high success rate, exceeding 95%, and long durability. The goal of this article is to review the Gil-Vernet trigonoplasty technique, which is a simple and highly successful technique but has not gained the attention it deserves. The mainstay of this technique is approximation of medial aspects of ureteral orifices to midline by one mattress suture. A unique advantage of Gil-Vernet trigonoplasty is its bilateral nature, which results in prevention from contralateral new reflux. Regarding not altering the normal course of the ureter in Gil-Vernet procedure, later catheterization of and retrograde access to the ureter can be performed normally. There is no report of ureterovesical junction obstruction following Gil-Vernet procedure. Gil-Vernet trigonoplasty can be performed without inserting a bladder catheter and drain on an outpatient setting. Several exclusive advantages of Gil-Vernet trigonoplasty make it necessary to reconsider the technique role in VUR management.


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## Body

## 1. Introduction

Vesicoureteral reflux (VUR) is the
most common urologic anomaly in children,  affecting almost 1% of normal
children [1, 2]. VUR is most commonly diagnosed during investigation of a child
with history of urinary tract   infection (UTI)
[3, 4].
The frequency of VUR in
children
with UTI is 20–40% [5].
Evidence
of renal involvement following UTI is more commonly found in children with VUR
than children without VUR [6]. The combination of VUR and UTI predisposes
children to acute pyelonephritis (APN) [7, 8]. Annual cost of hospitalization
for pyelonephritis  exceeds $180 000 000 in the U.S [9]. APN leads to subsequent
renal scarring in 15–52% of the
affected children [10, 11]. Renal scarring is an important risk factor for end
stage renal disease (ESRD) and hypertension [2, 12]. ESRD is associated with
reflux nephropathy in 3–25% of children
and 10–15%
of adults [5, 13].Cooper and Austin have considered
VUR as the “prostate cancer” of pediatric urology [14]. Significant controversy
exists regarding VUR management, due to lack of sufficient prospective studies.
The primary goal of VUR management is to prevent kidney damage. Management options include
conservative medical treatment (antibiotic prophylaxis), and surgery (open or
endoscopic). There are two important unanswered questions on who is a suitable
candidate for antireflux surgery, either open or endoscopic, and which
technique is the best for a patient. VUR resolves spontaneously with time in a
large proportion of patients. Spontaneous resolution rate of VUR depends on
reflux severity and patient’s age at diagnosis, with higher rates at lower
stages and younger ages. Reflux resolves in about 80%, 50%, and 30% of cases
with VUR grades I to II, III, and IV, respectively [15–17]. The rationale for
medical management is based on the potential of VUR for spontaneous resolution
or decrease in severity, and on the ability of antibiotics to prevent UTIs and
minimize renal damage until VUR ceases. Medical and surgical treatments of VUR have
been compared in a meta-analysis, the results indicate that there is no
significant difference in renal growth or scarring, and recurrence of UTI but
the incidence of pyelonephritis is significantly reduced in surgical group [18].
The need for long-term daily medication, potential side effects, incompliance
to the dosing regimen, and need for taking several voiding cystograms are
disadvantages of medical management of VUR [19, 20]. The rationale for surgical
management is that VUR can cause recurrent episodes of pyelonephritis and
long-term renal damage. Despite controversies regarding indications of surgical
treatment, expert opinion panels have described their recommendations on who is
a good candidate for surgery. The AUA Pediatric Vesicoureteral Reflux
Guidelines Panel recommended medical treatment as the initial management for
all children with VUR diagnosed following UTI, with the exception of children
over 1 year of age with grade V and older children with bilateral grade IV VUR.
Indications for antireflux surgery include failure of renal growth, febrile UTI
despite prophylaxis, noncompliance with medical management, the presence of new
scars or deterioration of renal function, and reflux associated with congenital
abnormalities of the ureterovesical junction [21]. Recommended indications are
mostly based on expert opinions rather than on prospective controlled trials. To
decide whether surgery is indicated for a particular child, the benefits and
risks of surgical and medical management must be carefully assessed and
individualized. In addition to the published indications for antireflux
surgery, some other factors such as renal function, bladder function, and
parental preference affect the final decision on selection of management
options [22–24].Antireflux surgical procedure may be performed
endoscopically or open. The first report on antireflux surgery was published by
Hutch in 1952 [25]. Several surgical techniques have been introduced during the
past decades. Open antireflux operations have high success rate, exceeding 95%,
and long durability. However, these techniques are invasive and impose a risk,
although small, of surgical complications to the patient. Open techniques are
categorized in two main groups; intravesical and extravesical. Politano and Leadbetter
described an intravesical antireflux operation using ureteroneocystostomy in
1958 [26]. Other intravesical operations include ureteral advancement
techniques; trigonal (Glenn-Anderson), (2) cross-trigonal (Cohen), and (3)
medial advancement (Gil-Vernet). Extravesical ureteral reimplant was introduced
by Lich and Gregoir in 1961 [27, 28].In the era of
minimally invasive surgery, particularly for procedures with high success rate,
capability of a technique to minimize surgery associated morbidities is significantly
focused by most surgeons. The purpose of this article is to review the
Gil-Vernet antireflux operation. Unfortunately, this simple and highly
successful technique [29–31] has not gained the attention it deserves in
urology field; it has not been evaluated by experts thoroughly. Since the
technique was introduced by Gil-Vernet, the author and his colleagues have used
this technique in more than one thousand pediatric and adult patients in their center,
and published the results in several reports [32–34] Figure 1. This article recalls the
advantages of Gil-Vernet technique such as high success rate, being simple and
rapid, and its potential to be performed on an outpatient setting.(a) Preoperative voiding cystoureterogram
of a patient with bilateral high-grade vesicoureteral reflux.
(b) Postoperative RNC of the patient reveals reflux resolution.
(a)(b)


## 2. Gil-Vernet Antireflux Technique

Gil-Vernet
introduced his technique for antireflux surgery in 1984. He reported his
experience in 38 patients with 94% success rate [35]. This technique is based
on the sphincteric action of intrinsic muscular fibers of the transmural
ureter, and additional muscular backing and intramural length provided by
medial advancement of the ureters. Bladder mucosa is incised between ureteral
orifices in a transverse fashion, and detrusor is taken down. Medial aspects of
ureters are freed carefully from their surrounding tissues to be prepared and
mobilized for advancement mattress sutures. Two 4-0 or 5-0 vycril mattress
sutures, incorporating ureteral musculature, are placed on the medial aspect of
the ureters. Mattress sutures bring ureters to the midline. It is highly
influential to include ureteral musculature in the mattress sutures for
prevention from late lateralization of ureters, technique failure, and VUR
recurrence. Mucosa is closed vertically with interrupted chromic sutures, and
the absorbable stitch is buried [35, 36] (Figure 2).(a) Ureteral orifices of a patient with
high-grade bilateral VUR located laterally (wide apart). (b) After
performing Gil-Vernet trigonoplasty, ureteral orifices are located in the
midline leading to effective detrusor support.
(a)(b)Ravasse et al. [37] reported their experience with
Gil-Vernet technique in 30 children with primary vesicoureteral reflux in 1989.
Patients were followed for 6–30 months. Reflux
was corrected in all cases. Later several reports were published on the
effectiveness of Gil-Vernet trigonoplasty. de Gennaro et al. [38] published
their report on 51 children with 69 refluxing units. Mean patient age was 74
months (range from 4 months to 13 years). Reflux was grade II, III, and IV in
25, 39, and 25 refluxing units, respectively. Follow-up was performed for one
year postoperatively. Surgery was successful in 97.7% of the patients. Reflux
persisted in only one patient one year after the operation, in whom bilateral
grade IV reflux was converted to unilateral grade III. In the study, patients were
divided into 2 age groups: less than and greater than 3 years old. Success rate
of surgery was 92.3% in children less than 3 years old and 100% in elder children. This
finding is clearly in contrast to the assumption that Gil-Vernet technique is
not appropriate for older children because of tenacious attachments of ureter
in older ages [36].Aghdas and Akhavizadegan [32] reported on applying Gil-Vernet
technique in adult women with primary vesicoureteral reflux. A total of 39
women (mean age 29 years; range 18–65 years) with 49
refluxing units were included in the study. The Gil-vernet technique was
successful in eliminating reflux in 48/49 renal units (97.95% success rate) and
38/39 patients (97.43% success rate). They concluded that Gil-Vernet antireflux
surgery is highly successful in adult patients.Zhao et al. [39] described Gil-Vernet's trigonoplasty in
treating vesicoureteral reflux (VUR) in neurogenic bladders. They introduced a
modification in technique as advancement of transmural ureters over the midline
and crossing each other in the trigone. 43 refluxing units in 26 patients with
neurogenic bladder underwent modified
Gil-Vernet trigonoplasty. Refluxing units had grade I, II, III, IV, and V in 5,
7, 5, 18, and 8 patients, respectively. Reflux was unilateral in 9 patients,
and bilateral in 17. Success rate of surgery was 95.3%, with a follow-up period
of more than 2 years in most patients. The group concluded that modified
Gil-Vernet's trigonoplasty might be a useful technique in the management of patients
with VUR secondary to neurogenic bladder dysfunction.The presence of a duplex ureter is one of the situations
which complicate reflux [40]. Various antireflux techniques have been applied
to correct reflux in duplex ureters.Kazemi-Rashed and Simforoosh [33] used
Gil-Vernet technique to correct reflux in 12 patients with unilateral duplicated
collecting system and 18 lower pole refluxing units. Reflux was bilateral in
50% of patients. Patient mean age was 5.6 years. Reflux was corrected or
improved in 94% of units.Garat et al. [41] reported an exclusive application of
Gil-Vernet technique in exstrophy- epispadias patients. Reflux is associated
with bladder exstrophy due to abnormal anatomic development of the distal
ureter and to a pathologic bladder disposition. Mitchell’s technique allows
performing bladder closure, reconstruction of epispadias and the bladder neck
in one single stage. However, pyelonephritis secondary to vesicouretral reflux
is the most common postoperative complication. They applied Gil-Vernet as a
first step of a bladder exstrophy repair followed by the Mitchell's technique.
They concluded that combination of Gil-Vernet technique with the primary
bladder closure could prevent the need for later surgical correction.Several reports have been published on undertaking various
antireflux techniques via a laparoscopic approach. Atala et al. [42] first
described laparoscopic antireflux surgery using Lich-Gregoir technique in 4 mini pigs. Later, Ehrlich and Jantschek published
the first reports on laparoscopic Lich-Gregoir surgery in human setting [43, 44]. Reports on laparoscopic
cross-trigonal Cohen procedure have been published by Gill and Yeung [45, 46]. Okamura
et al. reported their experience with endoscopic trigonoplasty but they could not
achieve good results, because they did not exactly duplicate the principles
used in open Gil-Vernet trigonoplasty [47]. Recently, we reported successful
results following extraperitoneal laparoscopic trigonoplasty by complete
duplication of Gil-Vernet open technique, achieving 93% success rate in all
grades of reflux (II–IV) [34]. Regarding the simplicity of Gil-Vernet
technique, it seems to be the most appropriate technique to be duplicated
laparoscopically.


## 3. Advantages

### 3.1. Contralateral De Novo Reflux

Despite the high success rate of antireflux procedures to
eliminate reflux in the operated ureter, secondary contralateral reflux is a
relatively common complication occurring in 10–32% of cases [48].
Although de novo contralateral reflux resolves with time in most cases, 1.9–20% of children
operated on for unilateral VUR have contralateral reflux after one year [49].
In one series, 13% of cases with contralateral reflux underwent surgical
correction eventually [50]. Considerable attempts have been made to describe
the possible mechanisms of developing contralateral reflux, but none of the
proposed mechanisms are proven [48]. The risk for
contralateral reflux is higher in patients with high
grades of reflux, previous history of bilateral reflux, and duplex system [51, 52]. Some authors have recommended bilateral reimplantation for patients with
the risk factors, but others have considered this as overtreatment [53]. One of the most important advantages of Gil-Vernet trigonoplasty is its bilateral nature. That is why in children with unilateral reflux; in contrast to other
techniques, either open or endoscopic, Gil-Vernet trigonoplasty is the only
technique that contralateral new reflux was not reported [54]. Furthermore,
combination of Gil-Vernet with unilateral antireflux procedures has been
recommended in several studies. Liard et al. [48] recommended contralateral
meatal advancement based on the Gil-Vernet technique in patients undergoing
Cohen antireflux procedure. Caione et al. [53] reported another series of
patients, in whom contralateral meatal advancement was undertaken in
combination with Cohen, Politano-Leadbetter, and Glenn-Anderson. Consequently,
contralateral reflux was seen in none of the patients.


### 3.2. Ureteroscopy

A main advantage of Gil-Vernet procedure is that later
catheterization of and retrograde access to the ureter can be performed
normally [53]. In Cohen procedure, a highly popular and successful antireflux
technique, the ureteral orifice is relocated. Alteration of the normal course
of the ureter makes retrograde access to the ureter difficult [55]. Regarding
almost all ureteral stones are currently treated endoscopically, the importance
of easy endoscopic access cannot be overemphasized.


### 3.3. Catheter-Free

Need for indwelling Foley catheter has been considered as
a disadvantage of intravesical antireflux operations [13]. Since in
extravesical Lich-Gregoir technique
a catheter does not need to be left in bladder, it is associated with reduced bladder spasm and discomfort, and
hematuria [13]. However, urinary retention occurs in 8%–35.6% of
children after extravesical reimplantation [56, 57]. Recently, a study has
described Gil-Vernet trigonoplasty without inserting a bladder catheter in 65
children with 103 refluxing units. VUR was corrected in 94.1% of patients, with
no considerable
complications. The authors concluded that Gil-Vernet surgery could be performed
on an outpatient setting [58].


### 3.4. Obstruction

The most serious
complication of antireflux procedure, which may require a reoperation, is
ureterovesical junction obstruction (UVJO) [22]. Totally UVJO is seen in 2.5%
of children underwent antireflux surgery, 2–4% after
Lich-Gregoir technique, and 1% after Politano-Leadbetter
[22, 59, 60]. In a report by Kliment et al. [61] on 60 children underwent Gil-Vernet
surgery, UVJO was seen in none of the cases. To our knowledge, there is no
report of UVJO following Gil-Vernet procedure. It is because the technique
preserves the integrity of ureterovesical junction.


## 3.1. Contralateral De Novo Reflux

Despite the high success rate of antireflux procedures to
eliminate reflux in the operated ureter, secondary contralateral reflux is a
relatively common complication occurring in 10–32% of cases [48].
Although de novo contralateral reflux resolves with time in most cases, 1.9–20% of children
operated on for unilateral VUR have contralateral reflux after one year [49].
In one series, 13% of cases with contralateral reflux underwent surgical
correction eventually [50]. Considerable attempts have been made to describe
the possible mechanisms of developing contralateral reflux, but none of the
proposed mechanisms are proven [48]. The risk for
contralateral reflux is higher in patients with high
grades of reflux, previous history of bilateral reflux, and duplex system [51, 52]. Some authors have recommended bilateral reimplantation for patients with
the risk factors, but others have considered this as overtreatment [53]. One of the most important advantages of Gil-Vernet trigonoplasty is its bilateral nature. That is why in children with unilateral reflux; in contrast to other
techniques, either open or endoscopic, Gil-Vernet trigonoplasty is the only
technique that contralateral new reflux was not reported [54]. Furthermore,
combination of Gil-Vernet with unilateral antireflux procedures has been
recommended in several studies. Liard et al. [48] recommended contralateral
meatal advancement based on the Gil-Vernet technique in patients undergoing
Cohen antireflux procedure. Caione et al. [53] reported another series of
patients, in whom contralateral meatal advancement was undertaken in
combination with Cohen, Politano-Leadbetter, and Glenn-Anderson. Consequently,
contralateral reflux was seen in none of the patients.


## 3.2. Ureteroscopy

A main advantage of Gil-Vernet procedure is that later
catheterization of and retrograde access to the ureter can be performed
normally [53]. In Cohen procedure, a highly popular and successful antireflux
technique, the ureteral orifice is relocated. Alteration of the normal course
of the ureter makes retrograde access to the ureter difficult [55]. Regarding
almost all ureteral stones are currently treated endoscopically, the importance
of easy endoscopic access cannot be overemphasized.


## 3.3. Catheter-Free

Need for indwelling Foley catheter has been considered as
a disadvantage of intravesical antireflux operations [13]. Since in
extravesical Lich-Gregoir technique
a catheter does not need to be left in bladder, it is associated with reduced bladder spasm and discomfort, and
hematuria [13]. However, urinary retention occurs in 8%–35.6% of
children after extravesical reimplantation [56, 57]. Recently, a study has
described Gil-Vernet trigonoplasty without inserting a bladder catheter in 65
children with 103 refluxing units. VUR was corrected in 94.1% of patients, with
no considerable
complications. The authors concluded that Gil-Vernet surgery could be performed
on an outpatient setting [58].


## 3.4. Obstruction

The most serious
complication of antireflux procedure, which may require a reoperation, is
ureterovesical junction obstruction (UVJO) [22]. Totally UVJO is seen in 2.5%
of children underwent antireflux surgery, 2–4% after
Lich-Gregoir technique, and 1% after Politano-Leadbetter
[22, 59, 60]. In a report by Kliment et al. [61] on 60 children underwent Gil-Vernet
surgery, UVJO was seen in none of the cases. To our knowledge, there is no
report of UVJO following Gil-Vernet procedure. It is because the technique
preserves the integrity of ureterovesical junction.


## 4. Conclusion

Among open surgical techniques commonly used, Gil-vernet
trigonoplasty seems to be one of the least invasive. It is simple, safe, highly
successful, with the advantage of possible ureteroscopy in the era of
Endourology. Contralateral reflux will not follow this technique in managing unilateral
reflux which is a unique advantage of this technique. The procedure could be
applied in various particular situations such as neurogenic bladder, adult
patients, duplex ureter, and exstrophy-epispadias. Simplicity of the technique
allows undertaking the surgery laparoscopically. Several exclusive advantages
of Gil-Vernet trigonoplasty make it necessary to reconsider the technique role
in VUR management.



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