Lich-Gregoir Anastomosis is Non-Refluxing
The Lich-Gregoir technique is a non-refluxing (anti-reflux) ureteral reimplantation procedure designed specifically to prevent vesicoureteral reflux. This extravesical approach creates a submucosal tunnel that functions as an anti-reflux mechanism with excellent success rates of 92-98% 1.
Mechanism of Anti-Reflux Protection
The Lich-Gregoir procedure achieves its anti-reflux properties through:
- Submucosal tunnel creation: The ureter is embedded beneath the bladder mucosa via an extravesical approach, lengthening the intramural portion of the ureter 1
- Detrusor muscle closure: The detrusor muscle is closed over the ureter, creating a flap-valve mechanism that prevents retrograde urine flow 2
- Preservation of ureterotrigonal integrity: The technique maintains the natural anatomy while creating the anti-reflux barrier 2
Clinical Evidence Supporting Non-Refluxing Nature
Multiple studies confirm the anti-reflux efficacy:
- Success rates: 98% reflux resolution rate in pediatric series with mean 58-month follow-up 2
- Comparative effectiveness: In kidney transplantation, Lich-Gregoir demonstrates significantly lower urinary leakage (RR: 0.47) and hematuria (RR: 0.28) compared to other techniques, with no difference in vesicoureteral reflux rates—confirming its anti-reflux design 3
- Long-term durability: The technique shows sustained anti-reflux protection when proper tunnel integrity is maintained 2
Technical Considerations for Success
To ensure optimal anti-reflux function:
- Adequate tunnel length: Create a 3-5 cm detrusorotomy extending from the ureterovesical junction toward the umbilicus 2
- Tunnel integrity preservation: Consider fixation of the ureter during detrusorraphy with sutures that pass through detrusor, take 1-2 mm "bites" of ureteral adventitia, then through contralateral detrusor 2
- Avoid excessive tension: Use loosely running sutures to prevent obstruction while maintaining anti-reflux properties 2
Common Pitfall
The primary risk is not reflux recurrence but rather obstruction if the tunnel is created too tightly. De novo hydronephrosis occurs in up to 30% of cases after extravesical procedures but is typically self-resolving 1. This represents transient functional obstruction rather than true anatomic stenosis in most cases.
The Lich-Gregoir technique remains one of the two most frequently used anti-reflux procedures worldwide, with the 2024 EAU/ESPU guidelines confirming that all surgical anti-reflux procedures (including Lich-Gregoir) share the basic principle of lengthening the intramural ureter via submucosal embedding to prevent reflux 1.