Editorial comment

Abstract

As surgeons, we have been instilled with the responsibility to assess the outcome of our operative interventions to prove efficacy and optimize patient care. The authors have added to the published data, advancing the argument that cystography is unnecessary for most patients after ureteroneocystostomy. This thesis is predicated on the fact that ureteroneocystostomy is highly successful, and those at risk of failing may be identified by clinical or noninvasive radiographic criteria. Patients who do not fall into such high-risk groups may thus be spared the discomfort and radiation exposure associated with VCUG. This approach appears to contravene traditional practice. When one examines published reports, the criteria whereby patients are considered at risk of failure and require VCUG after reimplantation vary. In the report by Bomalaski et al.1 Bomalaski M.D. Ritchey M.L. Bloom D.A. What imaging studies are necessary to determine outcome after ureteroneocystostomy. J Urol. 1997; 158: 1226-1228 Abstract Full Text Full Text PDF Scopus (37) Google Scholar patients identified as requiring postoperative VCUG included those with voiding dysfunction, preoperative hydronephrosis or renal scarring, and postoperative urinary tract infection. Bisignani and Decter, 2 Bisignani G. Decter R.M. Voiding cystourethrography after uncomplicated ureteral reimplantation in children is it necessary?. J Urol. 1997; 158: 1229-1231 Abstract Full Text Full Text PDF Scopus (57) Google Scholar and El-Ghoneimi et al.3 El-Ghoneimi A. Odet E. Lamer S. et al. Cystography after the Cohen ureterovesical reimplantation is it necessary at a training center?. J Urol. 1999; 162: 1201-1202 Abstract Full Text Full Text PDF Scopus (27) Google Scholar did not analyze the risk factors as such, but mentioned that VCUGs were likely to be obtained in the setting of voiding dysfunction, parental anxiety, and/or a thickened bladder wall noted at surgery. Barrieras et al.4 Barrieras D. Lapointe S. Reddy P.P. et al. Are postoperative studies justified after extravesical ureteric reimplantation?. J Urol. 2000; 164: 1064-1066 Abstract Full Text Full Text PDF Google Scholar showed that high-grade reflux, more commonly seen in males, was a risk factor for reimplantation failure. Lavine et al.5 Lavine M.A. Siddiq F.M. Cahn D.J. et al. Vesicoureteral reflux after ureteroneocystostomy indications for postoperative voiding cystography. Tech Urol. 2001; 7: 50-54 Google Scholar documented that patients with preoperative and postoperative hydronephrosis, renal scarring, and tapered ureteral reimplantations were at higher risk of reimplant failure. In the current study, the authors could not find a correlation with dysfunctional voiding, postoperative hydronephrosis or febrile urinary tract infection and reimplant failure. Thus, given the findings of the retrospective studies previously quoted, it is difficult to reach a consensus on which criteria place a patient at risk of reimplantation failure and merit the performance of a cystogram. One could argue that patients identified as having persistent reflux in the current series were asymptomatic, thus what does the persistence of reflux matter? If this is the case, the indications for operative intervention should be examined, as in this series 39% of patients underwent reimplantation for high-grade or worsening reflux in the absence of infection. If any of these patients went on to fail surgery and remained asymptomatic, the authors have argued it is irrelevant to the patient’s well-being.