If the severity and clinical signs of vesicoureteral reflux are determined to require surgical treatment, several common procedures may be considered. The principle of surgery is mostly the same, i.e., to create a submucosal ureteral channel to restore the anatomy of the ureteral-vesical interface to normal anatomy. When the bladder fills, urine squeezes this submucosal ureter, temporarily closing the lumen of the ureter and acting as a reflux. The results and success rates of each procedure are similar, ranging from 95-99%. The choice of procedure depends on the experience of the surgeon. If the surgeon has more personal experience with the procedure, there is less chance of morbidity. Intravesical ureteral reimplantation. After opening the bladder, the ureter is transected and a section of the ureter is freed, a submucosal channel is created, the ureter is placed under the mucosa, and the ureteral outlet is reanastomosed at the exit of the channel. The ureteral outlet is performed by the Politano-Leadbetter procedure with the original outlet, the Cohen procedure with the new outlet (cross-trigonal), or the Glen-Anderson procedure (new outlet near the internal urethra). The procedure requires an incision of the bladder and there is a new anastomosis. These methods, especially the Cohen’s procedure, are popular in China, Hong Kong, the United Kingdom and Australia (formerly Commonwealth countries). The most feared complications of this type of surgery are ureteral anastomotic stricture and torsion or tortuosity of the ureter after freeing. Due to the incision of the bladder, a urinary catheter is required postoperatively and there will be hematuria for a few days. You can be discharged from the hospital 2-3 days after surgery. Extravesical surgery, also known as Lich-Gregoir’s surgery. The procedure involves cutting through a segment of the detrusor muscle and using it to encase a segment of the ureter, also creating a submucosal ureter with an anti-reflux mechanism. The advantage is that the bladder does not have to be incised and the ureter does not have to be reanastomosed. It is less disruptive. This procedure is more popular in the United States and some European countries. Since the bladder is not incised and the ureter is not cut, this avoids twisting and stricture of the ureter. The child can usually be discharged after 1-2 days. Because the forceps is cut, a small percentage of children (especially those who have had bilateral surgery) are slower to recover bladder function after surgery and need a urinary catheter for 2-3 days. Minimally invasive surgery: The above two methods are traditionally done as open surgery accessed through a transverse incision in the lower abdomen. Professor Chong-Kuang Yang of the Chinese University of Hong Kong has developed a minimally invasive Cohen’s surgical approach using laparoscopy, known as the pneumovesicum technique. I learned a lot from him when I worked at CUHK from 2006-08. Lich-Gregoir’s surgery can now be done laparoscopically as well. In some western countries, especially in the United States, robotic (da Vinci) assisted laparoscopy is becoming popular for these surgeries, and the most performed are Lich-Gregoir’s surgeries. I personally feel that robots have the advantage of precision in suturing in the pelvic cavity. The minimally invasive wound is smaller and the recovery should be faster. Of course it is natural that everyone, due to different personal experiences, will have a different opinion about a new technology. Only with the test of time can we make a final judgment. For low grade reflux, a submucosal injection of a filling substance through the cystoscopic ureteral outlet can also be considered abroad with a slightly lower success rate of 53%-87%. The most popular is a filler called Deflux, which is not currently available in China. The advantage of this treatment is that there is no wound and the child can be discharged the same day. the recurrence rate after 2-5 years is 13% (Lackgren 2001).