Cohen versus Lich-Gregoir ureteral reimplantation for pediatric primary vesicoureteral reflux: a systematic review and meta-analysis of comparative studies.

BACKGROUND: Cohen and Lich-Gregoir ureteral reimplantation are the two most widely used open reconstructive options for children with primary vesicoureteral reflux (VUR), yet their relative advantages remain debated. We aimed to compare anti-reflux efficacy, perioperative outcomes, and complication profiles between these procedures using direct comparative evidence only. METHODS: PubMed, Embase, and the Cochrane Library were searched from inception to March 2026 for comparative studies evaluating Cohen versus Lich-Gregoir reimplantation in children with primary VUR. Outcomes included persistent postoperative reflux, overall complications, reoperation, operative time, length of stay (LOS), postoperative acute retention of urine (ARU), obstruction/hydronephrosis, hematuria, and febrile urinary tract infection (UTI). A bilateral VUR subgroup analysis was prespecified. Risk of bias was assessed with ROBINS-I, and certainty of evidence was judged using a GRADE-informed approach. Because fewer than 10 studies contributed to each synthesis, formal publication-bias testing was not performed. RESULTS: Nine retrospective comparative studies involving 655 children (370 Cohen, 285 Lich-Gregoir) were included. Baseline age and preoperative reflux grade were comparable between groups. There were no significant differences in persistent postoperative VUR [odds ratio (OR) 0.72, 95% confidence interval (CI): 0.34-1.54], overall complications (OR 0.97, 95% CI: 0.30-3.09), reoperation (OR 0.54, 95% CI: 0.15-1.94), obstruction/hydronephrosis (OR 1.15, 95% CI: 0.34-3.83), or febrile UTI (OR 0.45, 95% CI: 0.18-1.12). Lich-Gregoir was associated with shorter operative time [mean difference (MD) 28.59 minutes, 95% CI: 3.37-53.81] and shorter LOS (MD 3.41 days, 95% CI: 2.15-4.61). ARU occurred more often after Lich-Gregoir (6.4% vs. 1.7%; OR 0.32, 95% CI: 0.12-0.91), whereas hematuria was markedly more common after Cohen. In bilateral VUR, Lich-Gregoir retained advantages in operative time and LOS, but differences in overall complications, persistent reflux, and ARU were not statistically significant. Evidence certainty was low to very low across outcomes and was limited by retrospective study design, serious risk of bias, inconsistent complication definitions, and heterogeneity in surgical platform and perioperative care. CONCLUSIONS: Cohen and Lich-Gregoir reimplantation provide comparable anti-reflux efficacy and similar major postoperative outcomes in children with primary VUR. Lich‑Gregoir was associated with shorter operative time with very high heterogeneity, but procedure selection should also consider its higher risk of postoperative urinary retention and the still-limited evidence in bilateral disease.