vesicoureteral reflux ( vur ) occurs commonly in children , resulting in potentially serious complications .
this could result in renal scarring , hypertension , and even end - stage renal failure .
treatment options for children with vur include continuous antibiotic prophylaxis , endoscopic injections , and laparoscopic or open ureteroneocystostomy . since hutch   introduced open ureteral reimplantation to correct vur in 1952 , many such techniques have been developed . in 1984 ,
endoscopic injections of tissueaugmenting material for the correction of vur were introduced ; since then , many urologists prefer this procedure .
endoscopic injection is frequently used now as a firstline treatment because it involves less pain and a shorter hospitalization period and leaves no scar , in contrast to open reimplantation .
however , when an injection treatment fails , open ureteral reimplantation should be considered for treating persistent vur .
we aimed to test the usefulness of open reimplantations , which were performed primarily and after failed endoscopic injection procedures .
we analyzed the records of 81 children who underwent open reimplantation surgery over about 10 years . among them , 64 underwent open reimplantation as a primary procedure ( group a ) , and 17 underwent it after failed endoscopic injection ( group b ) .
we retrospectively analyzed the clinical data of both groups , including age , sex , preoperative reflux grade , operation time , laterality of surgery , postoperative complications , and hospitalization period .
all patients were classed in terms of preoperative reflux grade using voiding cystourethrography ( vcug ) .
reflux grade was classed as grades i - v according to the international classification system of the international reflux study committee .
we classified patients with reflux grades i - iii as a low - grade reflux group , and patients with grades iv and v as a high - grade reflux group .
success of surgery was defined as resolution of the vur as determined by vcug 6 months after surgery .
in addition , we conducted a telephone - based survey of the parents of group b about their preference for endoscopic injection or open reimplantation , and the reasons for their preference ; we asked the parents " which surgery do you choose primarily between endoscopic injection again and ureteral reimplantation if your child have to undergo surgery for vesicoureteral reflux again ? and what is the reason ? " .
statistical analysis was performed using ibm spss statistics ver . 20.0 ( ibm co. , armonk
student t - tests and chi - square tests were applied to compare the parameters of each group ; p - values < 0.05 were considered statistically significant .
the mean ages of groups a and b were 49.637.1 months and 56.522.5 months , respectively .
the male - to - female ratios of groups a and b were 43:21 and 12:5 , respectively .
there were no statistically significant differences in age or sex distribution between the 2 groups ( p=0.236 and p=0.312 , respectively ) .
the low - grade reflux rates in groups a and b were 12 ( 18.8% , grade ii were 2 [ 3.2% ] and grade iii were 10 [ 15.6% ] ) and 8 ( 47.1% , grade ii were 3 [ 17.7% ] and grade iii were 5 [ 29.4% ] ) , respectively , and the high - grade reflux rates were 52 ( 81.2% , grade iv were 34 [ 53.1% ] and grade v were 18 [ 28.1% ] ) and 9 ( 52.9% , grade iv were 7 [ 41.3% ] and grade v were 2 [ 22.2% ] ) , respectively .
patients with high - grade reflux were significantly more common in group a than b ( p=0.022 ) . at 6 months after endoscopic surgery in group b ,
the numbers of patients with low- and high - grade reflux were 10 ( 58.8% , grade ii were 5 [ 29.4% ] and grade iii were 5 [ 29.4% ] ) and seven ( 41.2% , grade iv were 6 [ 35.3% ] and grade v were 1 [ 5.9% ] ) , respectively .
there was no significant change in the numbers before and after primary endoscopic surgery in group b ( p=0.738 ) .
however , group a still had more patients with high - grade reflux after endoscopic surgery than did group b ( p=0.020 ) .
the operation times for unilateral cases in groups a and b were 16736 minutes and 15518 minutes , respectively .
those for bilateral cases in groups a and b were 21533 minutes and 21623 minutes , respectively .
the mean hospitalization periods for groups a and b were 10.45 days and 8.82 days , respectively .
there were no serious postoperative complications except that bleeding occurred in both groups . in groups
a and b , 7 ( 11.0% ) and 2 patients ( 11.9% ) , respectively , needed postoperative blood transfusions because of anemia .
however , this difference was not statistically significant ( p=0.107 ) . at 6 months after surgery ,
resolution of vur was found in all patients who underwent vcug . in the survey of the parents of children in group b ,
eleven parents ( 64.7% ) answered that they would choose endoscopic injection first in the same situation .
the reasons included the convenience of endoscopic treatment , that there was no need for hospitalization , that it involved less pain than open surgery , and that it avoided the discomfort from urethral catheterization after open surgery .
the main reason was that they did not want their children to have multiple procedures and anesthesia . among the eleven parents who chose primary endoscopic surgery , 7 of their children had low - grade reflux , and 4 had high - grade reflux . among the 6 parents who chose primary open surgery , one of them had a child with low - grade reflux , and 5 had a child with high - grade reflux .
parents of children with low - grade reflux preferred endoscopic surgery ; however , there was no statistically significant difference ( p=0.064 ) ( table 2 ) .
selecting the treatment option for different grades of vur reflux depends on the clinical presentation and renal function .
however , minimally invasive treatments such as endoscopic injection have advantages over open surgery , including less postoperative pain and fewer bladder spasms and infections , and the absence of surgical scarring .
furthermore , this procedure can be performed in a short operation time , in an outpatient setting , and with minimal use of postoperative analgesics .
therefore , endoscopic treatments have been preferred as the first - line treatment for children with vur . in a meta - analysis , elder et al
.   showed that after one injection the reflux resolution rate was 78.5% for grades i and ii reflux , 73% for grade iii , 63% for grade iv , and 51% for grade v .
the american urological association ( aua ) vesicoureteral reflux guideline update committee analyzed data from 17,972 patients , and reported that the overall success rate of a single endoscopic treatment was 83.0% . as seen above , endoscopic treatment of children with vur had many advantages and a high success rate , but there were also many failures , especially in the children with more severe reflux . when the first endoscopic treatment fails , endoscopic treatment needs to be repeated or reimplantation surgery is indicated . in this study , we analyzed the characteristics of our patients who underwent open reimplantation surgery .
patients who underwent reimplantation as a primary treatment did not differ from those who underwent it after endoscopic injection in terms of age , sex , operation time , hospitalization period , or postoperative complications .
it is generally assumed that a secondary operation after failed a primary procedure is more difficult and has more complications . in open reimplantation for vur
after failed endoscopic surgery , we also supposed that it may show less success rate , more operation time , more complications , and more hospitalization periods because of ureteral adhesion or inflammation due to primary injection or because each patient had more severe vur .
however , as in our findings , several studies have reported that previous endoscopic treatment does not have an adverse effect on the success of subsequent open reimplantation . in many studies ,
open reimplantation for vur showed much higher success rates than endoscopic treatment for all grades of reflux . in the aua guidelines , the success rate for open surgical procedures was 98.1% .
chertin et al .   reported the success rate of open reimplantation following failed deflux injections to be 100% . a similar study by moreira - pinto et al
sencan et al .   showed that previous endoscopic injections could cause difficulties in dissection of the ureter because of fibrosis ; however , they did not alter the success rate or complications following open surgery .
parental preference has a major role in the selection of endoscopic treatment compared with long - term antibiotic treatment . in a survey ,
80% of parents preferred endoscopic treatment rather than antibiotic prophylaxis or open surgery when given the option of any of the three treatment modalities .
this is due to the failed cases of endoscopic injection is very small , because of high success rate of endoscopic injection .
these patients were received endoscopic injection again or ureteral reimplantation to treat vur after failed endoscopic injection according to patients conditions and parents demand .
therefore , the number of patients underwent ureteral reimplantation was very little , and this study was not analyzed by patient matched - anlaysis .
in addition , the follow - up duration after surgery was not long , and several patients did not undergo a follow - up vcug .
accordingly , further studies with more patients and a longer follow - up duration are needed .
however , it is meaningful that this study showed open reimplantation can be applied effectively for failed endoscopic surgery .
in addition , even a parent whose child experienced failed endoscopic injection prefer endoscopic injection as primary treatment for vur .
patients with high - grade vur tended to have open ureteral reimplantation as their primary surgery rather than endoscopic injections .
however , there were no significant differences in operation time , postoperative complications , hospitalization period , or surgical success rates between open ureteral reimplantation surgery after failed endoscopic injection for vur and primary open reimplantation .
we conclude that open reimplantation can be conducted safely and effectively after failed endoscopic treatment .
in addition , parents prefer endoscopic injection as the first - line treatment option for their children with vur because of its convenience and reduced postoperative discomfort .
 purposeas endoscopic treatment for vesicoureteral reflux ( vur ) has increased , secondary ureteral reimplantation ( ur ) after failure of endoscopic treatment has increased . 
 we studied the clinical feature and efficacy of secondary ur after failure of endoscopic treatment compared with primary ur.materials and methodseighty - one children who had ur for vur were enrolled . 
 charts were reviewed retrospectively for age , sex , grade of vur before surgery , operative time , hospitalization period , postoperative complication , and success rate . 
 primary ur ( group a , n=64 ) was compared with secondary ur after failed endoscopic treatment ( group b , n=17 ) . in group 
 b , telephone survey for the satisfaction of endoscopic treatment and surgery was done.resultsmean age of each group was 49.637.1 and 56.622.5 months ( p=0.236 ) . 
 there was no significant difference between each group in sex , mean operative time , postoperative transfusion , complication rate , and success rate . 
 as telephone survey in group b , eleven responders preferred endoscopic treatment as primary treatment of vur because it was a simple method and no hospitalization.conclusionssecondary ur after failure of endoscopic treatment was similar to primary ur . 
 parents preferred endoscopic treatment as first line treatment for vur in spite of the need for secondary ur after failure of endoscopic treatment . 
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
CONCLUSIONS