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2 0 0 4 B J U I N T E R N A T I O N A L | 9 4 , 6 7 9 – 6 9 8 | doi:10.1111/j.1464-410X.2004.05083.x
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Surgical Atlas
The Cohen procedure
PIERRE-YVES MURE and PIERRE D.E. MOURIQUAND
Claude Bernard University – Lyon I, Debrousse Hospital, Lyon, France
ILLUSTRATIONS by STEPHAN SPITZER, www.spitzer-illustration.com
HISTORY
Pozzi first described the concept of VUR at the
end of the 19th century. The antireflux
mechanism of the vesico-ureteric junction
(VUJ) was reported by Sampson in 1903 and
in 1923 Graves and Davidoff stated that reflux
does not normally exist [1].
VUR and associated renal lesions remained
poorly understood until recently. Hodson and
Edwards [2] in 1960 established a correlation
between VUR and renal damage, and stressed
the importance of pyelotubular back-flow of
urine into certain papillae. In 1973 Bailey
introduced the term ‘reflux nephropathy’ [3].
The concept of early damage of renal
parenchyma (‘big-bang’) at the first UTI in
infants with VUR and the potential danger of
intrarenal reflux of infected urine into
‘compound’ papillae was proposed by Ransley
and Risdon [4], and Smellie
et al.
[5] in 1975.
The surgical correction of VUR was
widespread until it was documented that in
many cases the reflux resolved spontaneously
with the growth of the child, and the only
treatment required was prophylaxis against
UTIs. Although antibiotic prophylaxis remains
a questionable treatment, the antenatal
detection of urinary dilatation and reflux now
provides an opportunity to commence
prophylaxis soon after birth.
PRINCIPLES AND JUSTIFICATION
VUR may be defined as a permanent or
intermittent intrusion of bladder urine into
the upper urinary tract caused by a defective
VUJ. The defect in the junction may be a
primary disorder or may arise secondary to a
lower urinary tract dysfunction (neuropathic
or unstable bladder) or BOO (PUV).
The refluxing urine can fill the upper excretory
system (ureters and renal pelvis) between
and/or durin