UROLOGICAL SURVEY
Lee EK, Gatti JM, Demarco RT, Murphy JP
Kansas University Medical Center, Kansas City, Kansas and Children's Mercy Hospital, Kansas City, Missouri, USA
J Urol. 2009; 181: 1869-74; discussion 1874-5
PURPOSE: Dextranomer/hyaluronic acid injection of ureteral orifices is a popular option in the treatment of vesicoureteral reflux, with success rates ranging from 69% to 89%. We found only 1 study that followed patients beyond the initial postoperative voiding cystourethrogram, which describes a 96% success rate at 2 to 5 years but defines success as "nondilating" reflux. We examined our dextranomer/hyaluronic acid series to evaluate the long-term (1-year) outcome in children who had resolution of reflux on initial postoperative voiding cystourethrography.
MATERIAL AND METHODS: We retrospectively reviewed our dextranomer/hyaluronic acid experience from February of 2002 to December of 2005. We determined initial success on early (6 to 12-week) postoperative voiding cystourethrogram. We then evaluated long-term success by obtaining a voiding cystourethrogram at 1 year postoperatively in patients who were initially cured of reflux. In addition, success rates between the first and second halves of our experience were evaluated to account for surgeon experience and modification of technique.
RESULTS: Our total success rate at initial voiding cystourethrogram was 73% (246 of 337 total ureters). The success rate in the first half of our experience was 65.9% (112 of 170 ureters) and in the second half was 80.2% (134 of 167). A total of 150 ureteral units with initial successful dextranomer/hyaluronic acid treatment were evaluated at 1 year by voiding cystourethrogram. Of these ureters 111 had continued resolution of vesicoureteral reflux, for a long-term success rate of 74%. Including initial postoperative failures, the complete 1-year total success rate was 46.1% (111 of 241 ureters).
CONCLUSIONS: Although the reflux resolution rates at initial postoperative voiding cystourethrogram approach those of open surgery, there is a significant failure rate at 1 year, which warrants long-term followup.
Editorial Comment
This manuscript shows an almost 4-year experience with 219 patients and 337 ureters. The 6-12 week postoperative VCUGs showed a success rate of 73% and a one year VCUG on the same patients who had initial resolution showed a lower 74% success rate. Considering the overall patients altogether, the total success rate at one year was 46.1%. 74 of their 219 patients dropped out of the study and did not complete the VCUG at one year after surgery. The authors did note that switching to the HIT technique improved their early success from 65.9 to 80.2%. However, at one year after surgery their success rate was essentially identical at 74.2 and 73.8%. There was no statistical difference in STING versus HIT techniques in their study. If the data was broken down by grade of reflux, 100% of Grade I reflux was gone one year later, and 79.8% of Grade II reflux was gone one year later. Grade III reflux was 37.2%. The authors suggest that Deflux may be considered in low-grade refluxes but the long-term outlook for higher grades of reflux is particularly disappointing.
This manuscript brings into question the long-term success of injection therapy for reflux and in particular, the need for long-term radiographic follow up for these patients. If the criterion for success is absence of reflux, Deflux treatment will need to be reconsidered by those who take care of this disease in children.
Dr. Brent W. Snow
Division of Urology
University of Utah Health Sci Ctr
Salt Lake City, Utah, USA
E-mail: brent.snow@hsc.utah.edu
Pediatric Urology
Publication Dates
-
Publication in this collection
24 Aug 2009 -
Date of issue
June 2009
