Long-term Outcomes of Endoscopic Anti-reflux Surgery in Pediatric Patients with Vesicoureteral Reflux: Urinary Tract Infection, Renal Scarring, and Predictive Factors for Success

Factors affecting endoscopic treatment’s failure for primary vesicoureteral reflux in the paediatric population

Objective:

The purpose of this study is to identify which factors could determine endoscopic therapy’s failure in the paediatric patients with primary vesicoureteral reflux (VUR).

Methods:

We reviewed data from patients who underwent endoscopic surgery for primary reflux. We performed a multivariate logistic regression analysis considering factors conditioning therapeutic failure. All the tests were performed considering significant values of p < 0.05. Statistical analysis was performed with the SPSS 19.0 program. Study sample was homogenised by just including patients with primary reflux and excluding both patients with secondary reflux and patients with functional lower urinary conditions.

Results:

A total of 96 patients were included for review. Median age at surgery was 28 months. The overall success rate of endoscopic surgery for vesicoureteral reflux was 57%. Female sex, age under 24 months at the time of surgical intervention and having suffered a urinary tract infection (UTI) despite antibiotic prophylaxis are statistically significant risk factors for therapy failure.

Conclusions:

Nonetheless, differences between series could explain these differences in success rates. The lack of standardisation of the definition of ‘success’, the heterogeneity of patients included, and variables such as the degree of reflux, the presence of dysfunctional voiding, age or follow-up make it difficult to compare the success rate between series. Therefore, homogenisation of study samples assessing the evolution of primary reflux and response to endoscopic therapy is warranted.

Level of evidence:

Not applicable

Safety assessment and diagnostic evaluation of patients undergoing contrast-enhanced urosonography in the setting of vesicoureteral reflux confirmation

BACKGROUND

Vesicoureteral reflux (VUR) represents a common pediatric anomaly in children with an upper urinary tract infection (UTI) and is defined as a retrograde flow of urine from the bladder into the upper urinary tract. There are many diagnostic options available, including voiding cystourethrography (VCUG) and contrasted-enhanced urosonography (ceVUS). ceVUS combines a diagnostic tool with a high sensitivity and specificity which, according to previous study results, was even shown to be superior to VCUG. Nevertheless, despite the recommendation of the EFSUMB, the ceVUS has not found a widespread use in clinical diagnostics in Europe yet.

MATERIALS AND METHODS

Between 2016 and 2020, 49 patients with a marked female dominance (n = 37) were included. The youngest patient had an age of 5 months, the oldest patient 60 years. The contrast agent used in ceVUS was SonoVue®, a second-generation blood-pool agent. All examinations were performed and interpreted by a single experienced radiologist (EFSUMB Level 3).

RESULTS

The 49 patients included in the study showed no adverse effects. 51% of patients (n = 26) were referred with the initial diagnosis of suspected VUR, while 49% of patients (n = 23) came for follow-up examination or to rule out recurrence of VUR. The vast majority had at least one febrile urinary tract infection in their recent medical history (n = 45; 91,8%).

CONCLUSION

ceVUS is an examination method with a low risk profile which represents with its high sensitivity and specificity an excellent diagnostic tool in the evaluation of vesicoureteral reflux, especially in consideration of a generally very young patient cohort.

Evaluation of the Diagnostic Value of Contrast-Enhanced Voiding Urosonography with Regard to the Further Therapy Regime and Patient Outcome-A Single-Center Experience in an Interdisciplinary Uroradiological Setting

Background and Objectives: Vesicoureteral reflux (VUR) describes a common pediatric anomaly in pediatric urology with a prevalence of 1-2%. In diagnostics, in addition to the gold standard of voiding cystourethrography (VCUG), contrast-enhanced urosonography (ceVUS) offers a radiation-free procedure, which, despite its advantages, is not yet widely used. In the present single-center study, subsequent therapeutic procedures and outcomes after ceVUS of 49 patients were investigated. The aim of the study is to investigate the efficacy of ceVUS with the intention of broader clinical implementation. Materials and Methods: Between 2016 and 2020, 49 patients were retrospectively included and received a ceVUS to evaluate VUR. With a distribution of 47:2 (95.9%), a clear female predominance was present. The age of the patients varied between 5 months and 60 years at the time of ceVUS. All examinations were all performed and subsequently interpreted by a single experienced radiologist (EFSUMB level 3). Results: Compared to intraoperative findings, ceVUS shows a sensitivity of 95.7% with a specificity of 100%. Allergic reactions to the contrast medium could not be observed. Conclusion: With its high sensitivity and intraoperative validation, ceVUS offers an excellent alternative to VCUG, the gold standard in the diagnosis of VUR. In addition, ceVUS is a radiation-free examination method with a low risk profile that offers an exceptional diagnostic tool in the diagnostic clarification of recurrent urinary tract infections with the suspected diagnosis of VUR and should also be included in the consideration of a diagnosis next to the established VCUG, especially in younger children.

Endoscopic Injection Treatment of Vesicoureteral Reflux in Children: Meeting with the Factors Involved in the Success Rate

The challenges and controversies in vesicoureteral reflux intervention guidelines resulted in a more individualized treatment planning. Endoscopic injection therapy is now widely used and is considered preferable, but still remains less successful than ureteral reimplantation. Τhe endoscopic vesicoureteral reflux approach should be risk-adapted to current knowledge, so more experience and longer-term follow-up are needed. The precise of preoperative, intraoperative, and postoperative factors that affecting endoscopic injection therapy success rates and outcome have not yet been clearly determined. The aim of this study was to investigate these associated factors. Although the reflux grade is the most well-known factor that can affect the success of the procedure, there is no agreement on which factors are the most influential for the efficacy of endoscopic reflux treatment. So, we carried out a broad review of published papers on this topic, and we presented all the potential predictive variables of endoscopic reflux resolution in children.