Laparoscopic vs Open Extravesical Ureteral Reimplantation in Pediatric Population: A Single-Center Experience David Fernández-Alcaráz1 , José Iván Robles-Torres2*, Carlos García-Hernández1, Andres Heriberto Guillen-Lozoya3 , Sergio Landa-Juárez1 Purpose: To evaluate the safety and efficacy of conventional laparoscopic vs open Lich-Gregoir ureteral reimplan- tation in pediatric vesicoureteral reflux. Material and Methods: A retrospective study was conducted in a tertiary care hospital. Patients with vesicoure- teral reflux who underwent open or laparoscopic Lich-Gregoir ureteral reimplantation from 2013-2020 were in- cluded. The primary outcome was the resolution of reflux. Complications and perioperative characteristics were evaluated. The outcomes between open and laparoscopic surgery were analyzed. Results: A total of 110 patients and 150 ureters were included. The mean age was 4.5 years ± 3.4 and 73.6% were females. A total of 125 ureters (83.3%) underwent laparoscopic and 25 (16.6%) open Lich-Gregoir vesicoureteral reimplantation (5:1 Ratio). Resolution was reported in 112 (89.6%) for laparoscopy and 21 (84%) for open surgery (P = .42). Mean surgical time for laparoscopy and open surgery were 142.4 min ± 64.4 and 153 min ± 40, respec- tively (P =.29). Mean bleeding (9.5 mL ± 11.2 vs 29.6 mL ± 22.8) and length of hospital stay (2.4 days ± 2.3 vs 5.05 ± 3.1) were significantly higher with open surgery (P < .001). No significant difference in complications was reported between open surgery (32%) and laparoscopic approach (22.4%) (P = .305). Conclusion: Conventional laparoscopic vesicoureteral reimplantation with the Lich-Gregoir technique has an ac- ceptable success rate comparable with open surgery, with shorter hospital stay, less bleeding, and less need of transfusion. Keywords: laparoscopy; Lich-Gregoir; minimally invasive surgery; pediatrics; vesicoureteral reflux; vesicoure- teral reimplantation. INTRODUCTION Vesicoureteral reflux (VUR) is a frequent urologic anomaly that affects 1% of pediatric population.(1) This condition might be asymptomatic or being a cause of recurrent urinary tract infections (UTI), leading to renal scars and in long term, progression to chronic kid- ney disease.(2) The importance of early treatment among these patients is to avoid febrile UTIs, and in long term, preserve the renal function.(3,4) The current therapeutic options are pharmacological and surgical, the latter be- ing reserved for high-grade cases above the age of one year, with refractory febrile UTIs, and abnormal renal parenchyma caused by VUR.(5,6) Open vesicoureteral reimplantation is currently the reference surgical procedure for VUR among pediat- ric population. Success rates with this procedure have been reported up to 90% in some series, showing higher success rates compared to endoscopic procedures.(5,6) Differentiating by VUR grades I to V, success rates are 99.1%, 99.0%, 98.3%, 98.5%, and 80.7%, respectively. (7) Regarding intravesical approach, Ledbetter-Politano and the Cohen technique have been considered the most 1Servicio de Urología Pediátrica, Centro Médico Nacional Siglo XXI, Ciudad de México, México. 2Departamento de Urología, Universidad Autónoma de Nuevo León, Hospital Universitario “Dr. José Eleuterio González”; Monterrey, México. 3Clinical Research Fellow, Advantagene Inc. Massachusetts, United States. *Correspondence: Servicio de Urología, Hospital Universitario “Dr. José Eleuterio González”, Calle Francisco I. Madero S/N, CP 64460, Mitras Centro, Monterrey, Nuevo León, México. Phone: +526531191450. E-mail: ivan.robles25@live.com. Received February 2022 & Accepted July 2022 popular techniques of ureteral reimplantation with suc- cessful rate in the range of 97–99%.(8) In the last decade, several studies have shown compa- rable results with the conventional laparoscopic tech- nique, with additional benefits such as low rates of VUR recurrence, even in cases with complex anatomy. (9,10) Nevertheless, new techniques also come with new challenges, such as higher rates of complications com- pared to the reference procedure.(11) Minimally invasive techniques have acquired more popularity worldwide recently.(5) However, the debate between open and laparoscopic ureteral reimplantation continues and the literature among pediatric population is limited. The objective of this manuscript is to evalu- ate the safety and efficacy of conventional laparoscopic vs open Lich-Gregoir ureteral reimplantation in pediat- ric patients with VUR. MATERIALS AND METHODS A retrospective study was conducted in a tertiary care hospital in Mexico City. Patients with VUR who un- derwent open or laparoscopic Lich-Gregoir veiscoure- Urology Journal/Vol 19 No. 6/ November-December 2022/ pp. 427-432. [DOI: 10.22037/uj.v19i.7217] ROBOTIC AND LAPAROSCOPIC UROLGY teral reimplantation from 2013 to 2020 were included. Data was obtained from clinical records, including de- mographic parameters, total of ureters treated, indica- tions for surgery, previous therapy, and characteristics of VUR before and after surgery. Preoperative charac- teristics were laterality and grade of VUR, associated anatomical abnormalities such as duplex collecting system, megaureter, bladder diverticulum, ureterocele, vesicoureteral stenosis, anorectal malformations, and ectopic ureter. The peri- and postoperative characteris- tics evaluated were operation time, total bleeding, days of hospital stay, days of transurethral catheterization, days of percutaneous drainage, need of transfusion and use of opioids. The primary parameters measured were the frequency of complete resolution, decrease in the grade of reflux, and the persistence of reflux. Decrease in the grade of reflux was defined as an improvement to a low-grade reflux (grade 1 or 2). Persistence of reflux was defined as persistence of high-grade reflux after the procedure (grade 3, 4 or 5). Complications associ- ated with the procedure and reintervention rates were evaluated. Complications were classified using the Cla- vien-Dindo Classification of surgical complications.(12) VUR nephropathy progression after surgery was de- fined as new renal scars documented in renal scintigra- phy in patients with postoperative febrile UTI. Patients with a diagnosis of VUR secondary to infravesical obstruction, lower urinary tract dysfunction, and cases managed with conservative treatment were excluded. Indication for surgical management was a confirmed voiding cystourethrogram (VCUG) with VUR and re- current UTI or renal scars in renal scintigraphy. Family members or tutors of patients who were candidates for surgery were informed about the treatment options, in- cluding an open or laparoscopic technique for ureteral reimplantation. The surgical approach (open or laparo- Lap. and Open Extravesical Ureteral Reimplantation-Fernández-Alcaráz et al. Table 1. Study Population characteristics (n=150) Variables Total (n=150) Laparoscopy (n=125) Open Surgery (n=25) p-value Demophraphicsa Females, n (%) 81 (73.6) 70 (76.9) 11 (57.9) 0.095 Age Mean years ± SD 4.5 ± 3.4 4.8 ± 3.6 4.1 ± 2.4 0.329 Reimplant indication Recurrent Urinary Tract Infections 131 (87.3) 116 (92.8) 15 (60) < 0.001 Severe Hydronephrosis 21 (14) 17 (13.6) 4 (16) 0.752b Renal scars 24 (16) 19 (15.2) 5 (20) 0.555 Previous Treatment Antibiotic prophylaxis 96 (64) 79 (63.2) 17 (68) 0.82 Bulking agents 19 (12.7) 14 (11.2) 5 (20) 0.318 Additional procedures 16 (10.6) 12 (9.6) 4 (16) 0.527 Ureteroplasty 8 (5.3) 6 (4.8) 2 (8) Bladder diverticulum resection 8 (5.3) 6 (4.8) 2 (8) Reflux Characteristics Righta 24 (21.8) 21 (22.6) 8 (28.6) 0.852 Lefta 46 (41.8) 37 (40.7) 9 (47.4) Bilaterala 40 (36.4) 34 (37.4) 6 (31.6) Grade of reflux Grade 3 38 (25.3) 34 (27.2) 4 (16) 0.24b Grade 4 61 (40.7) 46 (36.8) 15 (60) 0.044 Grade 5 51 (34) 45 (36) 6 (24) 0.355 Anatomic abnormalities Duplex collecting system 17 (11.3) 9 (7.2) 8 (32) < 0.001 Megaureter 9 (6) 7 (5.6) 2 (8) 0.645b Diverticulum 8 (5.3) 6 (4.8) 2 (8) 0.166b Ureterocele 4 (2.7) 3 (2.4) 1 (4) 0.999b Vesicoureteral stenosis 5 (3.3) 1 (0.8) 4 (16) 0.003b Anorectal malformation 1 (0.7) 1 (0.8) 0 (0) 0.989b Ectopic ureter 1 (0.7) 0 (0) 1 (4) 0.167b a Considering 110 patients (100%); bFisher exact test; SD= Standard Deviation. Endourology and Stones diseases 269 Variables Laparoscopy Group Open Surgery Group p Value Characteristics Operation Time, mean min ± SD 142.4 ± 64.4 153 ± 40 0.29 Bleeding mean mL ± SD 9.5 ± 11.2 29.6 ± 22.8 < 0.001 Hospital stay mean days ± SD 2.4 ± 2.3 5.05 ± 3.1 < 0.001 Transurethral catheter, median (IQR) 1 (1-2) 4 (3-5) < 0.001a Percutaneous drainage, median (IQR) 0.01 (0.01-0.02) 3 (3-4) < 0.001a Transfusion 0 (0) 3 (12) 0.004b Opioid use 19 (15.2) 6 (24) 0.281 Outcomes VUR Resolution 112 (89.6) 21 (84) 0.42 Decrease in VUR grade 12 (9.6) 4 (16) 0.344 Persistence of VUR 1 (0.8) 0 (0) 0.999b Table 2. Comparison of perioperative findings and outcomes between laparoscopic and open surgery vesicoureteral reimplantation (n=150) VUR= Vesicoureteral reflux; a Mann-Whitnet U test. bFisher Exact Test; SD= standard deviation; IQR= interquartile range. Vol 19 No 6 November-December 2022 428 scopic) was selected based on surgeons' criteria, taking into consideration history of previous abdominal pro- cedures, and the availability of laparoscopic equipment at that time of the procedure. Informed consent was ob- tained in all recruited cases. In this study, no contrain- dication for laparoscopic surgery was found among the enrolled patients, such as multiple previous abdominal surgeries, marked obesity, large ventral hernia, or car- diorespiratory conditions. Surgical technique A laparoscopic extravesical transperitoneal approach was done following the Lich-Gregoir technique.(9,13) The procedure was performed under general anesthe- sia and endotracheal intubation. Three ports from 3 to 5 millimeters were used. The camera port was placed subxiphoid or at the level of the umbilical scar with the conventional open Hasson technique. Subsequently, two para-rectal working ports were placed either sub- costal or at the level of the umbilical scar under laparo- scopic vision. A bladder traction suture was placed per- cutaneously. The bladder was filled with saline solution to facilitate its dissection; the ureter was dissected from the lateral pelvic fascia for tension-free reimplantation. A detrusotomy was performed marking the cephalic end of the incision at the level where the full bladder rests without tension on the ureter, using a monopolar elec- trocautery hook together with blunt dissection, taking care not to perforate the bladder mucosa. Bladder dis- tention with an intravesical irrigation solution through the transurethral catheter allows better dissection down to the submucosal plane, thus the mucosa protrudes over the detrusotomy area. A tunnel was created using Paquins´ principle, with a length 4 to 5 times greater than the diameter of the ureter,(14-16) as seen in Figure 1. Detrusorrhaphy was performed over the ureter with an absorbable 3-0 to 4-0 monofilament stitch suture (Fig- ure 2). Bladder catheterization was performed, and the catheter was typically removed the next day. Open vesicoureteral reimplantation was performed us- ing the Lich-Gregoir extravesical ureteroneocystosto- my technique.(17) The technique was selected based on the experience and preference of the surgeon. Postoperative follow-up Postoperative follow-up was performed by renal and Robotic & Laparoscopic Urology 429 Variables Laparoscopic Group (n=125) Open Surgery Group (n=25) P value Total Complications 28 (22.4) 8 (32) 0.305 Clavien-Dindo Classification Grade ≤2 4 (3.2) 2 (8) 0.264 Urinary Retention 0 (0) 2 (8) 0.027a Urinary Tract Infection 22 (17.6) 5 (20) 0.776 Ileus 0 (0) 3 (12) 0.004a Hematuria 2 (1.6) 0 (0) 0.999a Surgical Wound infection 0 (0) 3 (12) 0.004a Progression of nephropathy 2 (1.6) 4 (16) 0.007a Grade >2a 4 (3.1) 4 (10.8) 0.078a Ureteral Stenosis 4 (3.2) 2 (8) 0.262a Need for reintervention 1 (0.8) 0 (0) 0.999a aNo Clavien-Dindo Grade 5 complications were reported; aFishers´Exact Test. Table 3. Complications of ureteral reimplantation surgery with a laparoscopic and open approach (n=150) Figure 1. Right extravesical ureteral reimplant. A detrusotomy is performed until the mucosa is exposed without violation (Arrow). The mucosa protrudes over the detrusotomy, this being the area of the submucosal tunnel that follows Paquins´ principle. The bladder is distended in order to facilitate dissection (arrowhead). A dilated ureter is observed in its distal section (asterisk). Figure 2. Detrusorrhaphy over the ureter with interrupted absorb- able sutures developing a submucosal tunnel following Paquin´s principle. Lap. and Open Extravesical Ureteral Reimplantation-Fernández-Alcaráz et al. bladder ultrasound 1-3 months postoperatively and a VCUG at 6 to 8 weeks after surgery. Approval of the internal ethics committee with registra- tion number R-2020-3603-065 was assigned. Statistical analysis Descriptive statistics were calculated for the variables included in the analysis. Categorical variables were represented by frequencies and percentages, and con- tinuous variables by mean and standard deviation. The results of open versus laparoscopic surgery were also compared. Kolmogorov-Smirnov statistic was used to assess distribution of continuous variables. For categor- ical variables, the Pearson Chi Square test was used for binary outcomes with large expected cell counts and Fisher´s exact test for small cell counts, and Student T test for independent continuous variables. For non-nor- mally distributed variables, the Mann-Whitney U test was used. Statistical analysis was performed in SPSS v26 software. RESULTS Study Population A total of 110 patients and 150 ureters were included in the study. The mean age was 4.5 years ± 3.4 months and 81 patients (73.6%) were females. Bilateral VUR was reported in 36.4% (n=40). The most common indication for ureteral reimplantation was the presence of recur- rent febrile UTIs (or pyelonephritis) in 87.3% (n=131) of ureters. In 64% (n=96) of treated ureters were re- fractory to a prophylactic antibiotic and 12.7% (n=19) to a bulking agent. The most frequent grade of reflux was grade 4 in 40.7% (n=61), followed by grade 5 in 34% (n=51). Anatomical abnormalities were reported in 30%, with a duplex collecting system being the most frequent abnormality in 11.3% (n=17). One hundred and twenty five ureters underwent a lap- aroscopic approach and 25 an open surgery (5:1 ratio). All procedures were done with the Lich-Gregoir tech- nique. An additional procedure was carried out during surgery in 12 cases (9.6%) in the laparoscopic group and 4 (16%) in open surgery (P = .527). The presence of recurrent febrile UTIs prior to surgery was more fre- quent in the laparoscopy group (92.8%) compared to the open surgery (60%) (P < .001). Grade 4 VUR was more frequent in the laparoscopic group (P =.044) and no significant difference was observed with grade 3 and grade 5 VUR between groups. Anatomical abnormali- ties were reported more frequently in the open surgery group (P < 0.001). The rest of population characteristics are described in Table 1. Effectiveness VUR was resolved in 112 of 125 ureters (89.6%) by laparoscopic approach and 21 of 25 patients (84%) by open surgery (P =.42). A decrease in the grade of reflux was reported in 12 cases (9.4%) with laparoscopy and 4 cases (16%) with open surgery (P = .344). The per- sistence of reflux was reported in only 1 case with lapa- roscopy and no cases with open surgery. The mean sur- gical time for laparoscopy and open surgery was 142.4 min ± 64.4 and 153 min ± 40, respectively (P = .29). The mean laparoscopic bleeding was 9.5 mL ± 11.2 and for open surgery 29.6 mL ± 22.8, showing a significant difference (P < .001). Hospital stay was lower in the laparoscopic approach (P < .001). The use of a transure- thral catheter, (P < .001), percutaneous drainage time (P < .001), and the need of transfusion (P = .004) were lower in the laparoscopic group. The use of opioids for pain relief was not significant different between groups. Table 2 describes the perioperative findings between groups. Complications Complications were reported in 36 cases (24%), 28 cas- es (22.4%) in the laparoscopic group and 8 (32%) in the open surgery group (P = .305). Urinary retention was reported in 2 cases (8%) only with open surgery. Ileus was significantly higher in the open surgery group (0% vs 12%, P = .004). Surgical wound infection (0% vs 12%) and progression of VUR nephropathy (1.6% vs 16%) were also higher between cases treated with open surgery (P = .002). All patients with progression of nephropathy had febrile UTI after surgery. According to Clavien-Dindo classification, 8 cases reported com- plications grade >2, requiring additional procedures. No statistical significant differences were reported be- tween groups for grade ≤2 and grade >2 (P = .194 and P = .078, respectively). However, there is a tendency to greater complications grade >2 in the open surgery group compared to laparoscopic approach (10.8 vs 3.1%, respectively) (See Table 3 for complete descrip- tion of complications). DISCUSSION Multiple studies published in recent years continue to consider open surgery as the reference surgical treat- ment for VUR with good long-term outcome and suc- cess rates up to 90%.(6) This procedure has long been touted as the “gold standard” due to its high radiograph- ic success rates reported.(18) Recently, the use of mini- mally invasive techniques such as the conventional or robot-assisted laparoscopic approach have gain popu- larity and have been used more frequently.(6,11) During the last decade, series of conventional laparoscopic ure- terovesical reimplantation have shown good results and few complications, even in cases of complex anatomy. (9,10) Bayne AP et al reported a retrospective study of 98 patients with VUR who underwent laparoscopic ure- teral reimplantation with the extravesical Lich Gregoir technique. The success rate was 93.5%, with complica- tions in 24% of the sample and requiring reoperation in 7% of cases.(9) They concluded that laparoscopic tech- nique is an effective and safe alternative for the surgical management of VUR. Despite a decrease in the use of open ureteral reimplan- tation in recent years, it continues to be a valid option in younger patients and in those with previous abdomi- nal surgeries.(18) Some cases are not suitable for laparo- scopic procedures, such as patients with severe cardiac diseases, pulmonary insufficiency, bleeding disorders, repeated abdominal procedures, patients with ileus, in- testinal obstruction, and abdominal sepsis.(19) In such patients, open surgery continue to be the most suitable option. Recently, Bustangi N et al compared open versus lap- aroscopic Lich-Gregoir technique in a multicenter ret- rospective study. A total of 96 patients with VUR were included of which 50 were operated by open approach and 46 by laparoscopic approach. A higher operative time was reported in the laparoscopic group (127.9 vs 63.2 min, p < 0.001), shorter length of stay in laparo- scopic approach (1.64 vs 5.4 days, P < .001), and short- er days of intravenous analgesia used (1.15 vs 3.9, P Endourology and Stones diseases 271 Lap. and Open Extravesical Ureteral Reimplantation-Fernández-Alcaráz et al. Vol 19 No 6 November-December 2022 430 < .001). There was no conversion in the laparoscopic group and only 1 case had to be reoperated for leakage. Success rate was 98% with open approach and 97.8% for laparoscopic approach with a mean follow-up of 3.6 and 1.5 years, respectively. The authors concluded that laparoscopic approach was as effective as the open ap- proach, with reduction in analgesia medication, hospital stay, and faster recovery, with the disadvantage of re- quiring twice the operative time.(20) In our study, the success rate with the laparoscopic approach was 89.6% with improvement in the grade of VUR in 9.6% and persistence of high-grade VUR in only 1 case (0.8%), similar to the reported in most series.(9,10) As compared with the results of Bustangi N et al(20), our success rate was lower (89.6 vs 97.8%) in the laparoscopic and open approach (84% vs 98%). One explanation for this discrepancy is the definition of therapeutic success. They defined success rate by the absence of documented febrile UTI or absence of recur- rence of VUR objectivized by VCUG in both groups. Only 5 cases in open approach and 3 in laparoscopic group had a VCUG due to recurrent postoperative fe- brile UTIs. This could have influenced in subclinical VUR cases to be underestimated. In our study, all pa- tients had a postoperative VCUG, and we differentiate between those patients with persistent VUR from those who had a decrease in the degree of VUR. Complications were reported in 24% of the cases, most of them minor and requiring reintervention in a single case (0.8%). In 2016, Farina et al conducted a systematic review evaluating ureteral reimplantation with laparoscopic technique. They concluded that this technique is safe and effective, comparable with open surgery.(21) They reported a success rate of up to 96%, shorter hospital stay, less bleeding and less pain compared to open sur- gery, similar to our study. Riquelme M et al in 2013, reported a success rate of 95.8% in 81 patients, with few complications, requiring reintervention in 2 cases (2.4%).(22) Other authors such as Perez et al in 2014, reported success rates of 96.5% for laparoscopic reim- plantation in 23 cases.(23) The laparoscopic technique has its drawbacks, for ex- ample, a greater learning curve and greater surgical dex- terity to achieve success rates compared to the standard open surgery, but a remarkable set of benefits as well as shorter hospital stay. The authors consider that this technique should be the new reference procedure and the experience required for better outcomes must spread to as many centers around the globe as possible, with enough case volume and appropriate training. This study has several limitations, starting with its ret- rospective nature and wide distribution of the study groups. This is because in the center were the study was carried out, the laparoscopic procedure has been consid- ered the treatment of choice when there is no contrain- dication. Selection of surgical approach was decided by surgeons´ criteria, and not randomly assigned. Further randomized prospective studies comparing open versus laparoscopic surgery using a specific reimplantation technique are needed to reinforce these findings. CONCLUSIONS Laparoscopic vesicoureteral reimplantation with the Lich-Gregoir technique is a procedure that has an ac- ceptable success rate and a safe profile comparable to open surgery. Shorter hospital stay, less bleeding, and less blood transfusion were reported using laparoscopic vesicoureteral reimplantation. SUMMARY Open and laparoscopic vesicoureteral reimplantation seem to have similar success rate and comparable complication rates. However, laparoscopic approach demonstrated shorter hospital stay and less bleeding compared to the open approach. CONFLICTS OF INTEREST The authors do not declare conflicts of interest. REFERENCES 1. Sargent MA. What is the normal prevalence of vesicoureteral reflux? Pediatr radiol. 2000;30:587-93. 2. Peters CA, Skoog SJ, Arant BS, et al. Summary of the AUA guideline on management of primary vesicoureteral reflux in children. J Urol 2010;184:1134-44 3. Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management. Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics. 2011;128:595-610. 4. Tokhmafshan F, Brophy PD, Gbadegesin RA, Gupta IR. Vesicoureteral reflux and the extracellular matrix connection. Pediatr nephrol. 2017;32 565–76. 5. Baek M, Kim KD. Current surgical management of vesicoureteral reflux. Korean J Urol. 2013;54:732-37. 6. Radmayr C, Bogaert G, Dogan HS, et al. Guidelines on paediatric urology. European Association of Urology. 2020:67-9. 7. Elder JS, Peters CA, Arant BS, et al. Pediatric Vesicoureteral Reflux Guidelines Panel summary report on the management of primary vesicoureteral reflux in children. J Urol. 1997;157:1846–51. 8. Sung J, Skoog S. Surgical management of vesicoureteral reflux in children. Pediatr Nephrol. 2012;27:551-61. 9. Bayne AP, Shoss JM, Starke NR, Cisek LJ. Single-center experience with pediatric laparoscopic extravesical reimplantation: safe and effective in simple and complex anatomy. J Laparoendosc Adv Surg Tech 2012;22:102- 6. 10. Kurtz MP, Leow JJ, Varda BK, et al. The decline of the open ureteral reimplant in the United States: national data from 2003 to 2013. Urology. 2017; 100:193-7. 11. Casale P, Patel RP, Kolon TF. Nerve sparing robotic extravesical ureteral reimplantation. J Urol 2008;179:1987. 12. Clavien PA, Barkun J, De Oliveira ML, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg. 2009;250:1987-90. 13. Lopez M, Varlet F. Laparoscopic extravesical transperitoneal approach following the Lap. and Open Extravesical Ureteral Reimplantation-Fernández-Alcaráz et al. Robotic & Laparoscopic Urology 431 Urological Oncology 200 Lich-Gregoir technique in the treatment of vesicoureteral reflux in children. J Pediatr Urol. 2010;45:806-10. 14. Roshani H, Dabhoiwala NF, Verbeek FJ, Kurth KH, Lamers WH. Anatomy of ureterovesical junction and distal ureter studied by endoluminal ultrasonography in vitro. J Urol. 1999;161:1614-19. 15. Tanagho EA, Pugh RC. The anatomy of the ureterovesical junction. Br J Urol. 1963;35:151-65. 16. Paquin AJ. Ureterovesical anastomosis: the description and evaluation of a technique. J Urol. 1959;82:573-83. 17. Riedmiller H, Gerharz EW. Antireflux surgery: Lich‐Gregoir extravesical ureteric tunnelling. BJUI. 2008;101:1467-82. 18. Kirsch AJ, Arlen AM. Evolving surgical management of pediatric vesicoureteral reflux: is open ureteral reimplantation still the ‘Gold Standard’?. International braz J Urol. 2020;46:314-21. 19. Tam PK. Laparoscopic surgery in children. Arch Dis Child. 2000;82(3):240-3. 20. Bustangi N, Kallas Chemaly A, Scalabre A, et al. Extravesical Ureteral Reimplantation Following Lich-Gregoir Technique for the Correction of Vesico-Ureteral Reflux Retrospective Comparative Study Open vs. Laparoscopy. Front Pediatr. 2018;6:388. 21. Farina A, Esposito C, Escolino M, Lopez M, Settimi A, Varlet F. Laparoscopic extravesical ureteral reimplantation (LEVUR): a systematic review. Transl Pediatr. 2016;5:291-4. 22. Riquelme M, Lopez M, Landa S, et al. Laparoscopic extravesical ureteral reimplantation (LEVUR): a multicenter experience with 95 cases. Eur J Pediatr Surg. 2013;23:143-7. 23. Pérez-Etchepare E, Varlet F, López M. Laparoscopic extravesical ureteral reimplantation following Lich-Gregoire technique. Medium-term prospective study. Cir Pediatr. 2014;2:74-7. Lap. and Open Extravesical Ureteral Reimplantation-Fernández-Alcaráz et al. Vol 19 No 6 November-December 2022 432