DOES EVERY PATIENT WITH URETEROPELVIC JUNCTION OBSTRUCTION NEED VOIDING CYSTOURETHROGRAPHY?

Abstract

Voiding cystourethrography is routinely recommended to detect vesicoureteral reflux in children with ureteropelvic junction obstruction. Vesicouretral reflux coexisting with primary ureteropelvic junction obstruction is usually of low grade and resolves spontaneously after pyeloplasty, whereas pseudo ureteropelvic junction obstruction and obstruction secondary to high grade reflux usually present with a dilated ureter that is easily detected on real-time ultrasonography. We assessed the role of voiding cystourethrography in children with ureteropelvic junction obstruction by retrospectively evaluating the incidence and natural history of coexisting vesicourethral reflux. We reviewed the records of 106 children younger than 15 years who underwent pyeloplasty for ureteropelvic junction obstruction at our hospital between January 1990 and December 1998. A patient who had initially undergone antireflux surgery later underwent pyeloplasty for newly developed secondary obstruction was not included in the analysis. The diagnosis of ureteropelvic junction obstruction was based on ultrasonography and diuretic renography. Preoperative voiding cystourethrography was performed in all patients to detect vesicourethral reflux. We categorized reflux as low grade if the ureters were not dilated and as high grade if the ureters were dilated and tortuous. There were 89 boys and 17 girls who underwent 115 pyeloplasties, including 9 who underwent bilateral pyeloplasty. Mean patient age at surgery was 27.4 months (63 infants, 6 between 1 and 2 years old, and 37 older than 2 years). Of these 106 patients 85 had unilateral (left side 64, right side 21) and 21 had bilateral ureteropelvic junction obstruction. Vesicourethral reflux was documented in 19 ureters of 12 children. Of the 85 cases of unilateral ureteropelvic junction obstructions 10 had vesicourethral reflux, which was bilateral 6, ipsilateral in 2 and contralateral in 2. Of the 21 cases of bilateral obstructions 2 had reflux, which was bilateral in 1 and was unilateral in 1. Reflux was low grade reflux in 6 and high grade in 6 cases. All low grade reflux disappeared spontaneously at an average period of 4.2 months (range 2 to 10) after pyeloplasty. All 6 patients with high grade reflux subsequently underwent antireflux surgery because of breakthrough urinary tract infection in 2 and persistent in 4 at an average of 36 months (range 3 to 112) after pyeloplasty. All high grade reflux coexisting with ureteropelvic junction obstruction was easily detected on real-time ultrasonography. Low grade reflux coexisting with ureteropelvic junction obstruction spontaneously disappeared after pyeloplasty, and all high grade reflux coexisting with obstruction was easily detected on ultrasonography using real-time mode. Therefore, we believe that indication for voiding cystourethrography in children with ureteropelvic junction obstruction should be limited to those with dilated ureters on ultrasonography.