New contralateral vesicoureteral reflux after unilateral ureteral reimplantation: predictive factors and clinical outcomes

Unilateral open extravesical ureteral reimplanation with contralateral dextronomer/hyaluronic acid injection performed as an outpatient therapy

INTRODUCTION

Historically, patients with unilateral high-grade vesicoureteral reflux (VUR) and contralateral low-grade or resolved VUR have been treated with bilateral intravesical ureteral reimplantation, which requires postoperative admission. If the high-grade VUR side is treated alone, then the contralateral side is at risk of developing recurrent or worsening VUR. Bilateral subureteric injection of dextronomer/hyaluronic acid (DHA) is another option that can be performed as an outpatient therapy, but a single injection is less effective for high-grade VUR.

OBJECTIVE

The safety and efficacy of an outpatient combination of open extravesical ureteral reimplantation (EVUR) and contralateral DHA injection were investigated.

STUDY DESIGN

A retrospective review of children who had concomitant EVUR and subureteric injection of DHA between January 2005 and December 2015 was performed. Exclusion criteria were diagnosis other than VUR, repeat procedures, and patients with no follow-up. Patient characteristics, postsurgical complications, and follow-up imaging were evaluated. Febrile urinary tract infection (fUTI) was defined as ≥50,000 Colony Forming Units (CFU) of an organism from clean-catch or catheterized urine and temperature ≥ 101.5 F. Clinical success is defined as no fUTI for 1 year after the initial operation. Univariate analyses were used to identify risk factors for treatment failure.

RESULTS

A total of 117 patients met inclusion criteria. Mean age at surgery was 6.0 years, and 85% were female. The mean pre-operative grade of VUR was 3.3 on the EVUR side and 0.6 on the contralateral side (42% resolved before treatment). Median follow-up was 12.2 months (interquartile range, 3.1-25.4). Sixteen patients (14%) had documented fUTI within 1 year, with a clinical success rate of 86%. Of these, five had a postoperative imaging showing resolution of VUR, increasing overall success to 91%. Postoperative fUTI was more common in patients with pre-operative bowel and bladder dysfunction (BBD) (P = 0.003), but this was not associated with a higher reoperation rate (P = 0.168). There were 11 total complications, with three grade 3 complications.

DISCUSSION

This study is the first to report safety and outcomes of EVUR and contralateral DHA injection for patients with high-grade VUR with contralateral low-grade or resolved VUR. It was shown that it is an effective and safe treatment that can be performed as an outpatient therapy. Limitations to this study include the retrospective design and the clinical definition of success that is used in a cohort of patients from across the mountain west region without routine postoperative voiding cystourethrogram.

CONCLUSION

Extravesical ureteral reimplantation and contralateral DHA injection can safely be performed as an outpatient therapy and are effective in the treatment of higher grade VUR with contralateral low-grade or resolved VUR. Treatment failure is more likely in patients with BBD.

Diagnostic value of hydrodistention of the ureteral orifice

INTRODUCTION/OBJECTIVE

The dynamic hydrodistention (HD) classification is a basic and objective way of rating the ureteral orifice opening. This study evaluated the value of hydrodistention of the ureteral orifice in the diagnosis of vesicoureteral reflux (VUR).

MATERIAL AND METHODS

Between January 2012 and March 2013 the HD grade in 106 ureters was prospectively assigned. A 9.5-Fr rigid cystoscope with a 0-degree lens was used in all procedures. Warm saline was used and the irrigation bag was placed approximately 1 m above the bladder level on full flow. The grading is as follows: H0 denotes absence of ureteral dilation; H1 indicates dilation of the ureteral orifice only; H2 allows visualization of the intramural ureter; and H3 allows visualization of the extramural ureter. Indications for cystoscopy were endoscopic and open surgical treatment of VUR, stent removal, and any other diagnostic reasons. Exclusion criteria were patients with: infravesical obstruction, neuropathic bladder, severe detrusor over activity/dysfunctional voiding, duplex system, paraureteral diverticulum, bladder exstrophy and grade-1 VUR. The 51 refluxing ureters (RUs) were compared with 55 non-refluxing ureters (NRUs). Finally, sensitivity, specificity, positive and negative predictive values, and accuracy rate of HD were evaluated.

RESULTS

A total of 106 ureters in 61 patients with a mean age of 5.3 ± 3.9 years (range 2 months-15 years, median 5 years) were prospectively assigned. The mean HD grade in the RUs was 2.17 ± 0.55. The mean HD grades were 2.0 ± 0.63, 2.07 ± 0.53, 2.38 ± 0.5 and 2.5 ± 0.57 for VUR grades 2-5, respectively. The mean HD grade in the NRUs was 1.60 ± 0.70. The HD grades were H0 to H3 in 7.3%, 30.9%, 56.4% and 5.4% of the NRUs, respectively. The RUs group (2.17 ± 0.55) showed a statistically higher HD grade than the NRUs group (1.60 ± 0.70) (P < 0.005). Sensitivity, specificity, positive and negative predictive values, and accuracy rate of HD grading in the diagnosis of VUR were 92%, 38%, 58%, 84%, and 64%, respectively. The mean HD grade in contralateral ureters of unilateral VUR was 1.55 ± 0.72 and HD grades were H0-H3 in 0%, 55.6%, 33.3% and 11.1% of these nine ureters, respectively. In these nine non-refluxing contralateral ureters, after endoscopic correction of ipsilateral VUR, new contralateral VUR did not occur.

CONCLUSION

Even though HD grade was high in the VUR group and popularity of the HD grading is on the increase, HD grading by itself still has a low diagnostic value.