Abstract
Purpose: Endoscopic dextranomer/hyaluronic acid (Dx/HA) injection is a common treatment for vesicoureteral reflux (VUR) with excellent reported short-term clinical success rates. Long-term outcomes are less well-defined. We assessed long-term outcomes and parental satisfaction after Dx/HA injection for primary VUR with >5-year follow-up.Materials and Methods: Families of all patients who underwent Dx/HA injection for primary VUR at our institution between 2008 and 2012 were contacted for telephone interview. Data collected by phone included parental satisfaction and presence and severity of UTIs pre-operatively and post-operatively. Patient demographics, radiographic VUR data, need for secondary surgery, and surgical indications were obtained through chart review.Results: Five hundred and seventy-five patients underwent Dx/HA injection for primary VUR between 2008 and 2012. Ninety-nine (17.2%) of these patients' parents were successfully contacted and interviewed. Median follow-up time from surgery to survey was 8.4 (IQR 6.8–9.6) years. Secondary surgery was performed in 13/99 (13.1%), most commonly repeat Dx/HA injection. Seven patients (7.1%) underwent secondary Dx/HA injection for persistent VUR without UTIs at a median of 0.35 (IQR 0.33–0.77) years post-operatively. Five patients (5.1%) underwent Dx/HA injection (n = 3) or ureteral reimplantation (n = 2) for VUR with febrile UTIs (fUTIs) at a median of 2.2 (IQR 1.3–5.1) years. One patient had ureteral reimplantation for symptomatic obstruction 2.8 years after initial surgery. Only 3/99 (3.0%) required open or laparoscopic surgery after Dx/HA injection. Eighty-three families (84.7%) reported ≥1 fUTIs pre-operatively. Of these, only 9/83 (10.8%) reported fUTIs post-operatively, for an overall clinical success rate of 89.2%. Clinical success was 93.1% in patients whose pre-operative fUTIs were treated outpatient and 80.0% in those hospitalized at least once for fUTI treatment pre-operatively. Ninety-four percent of parents were highly satisfied, 2.4% partially satisfied, and 3.5% dissatisfied.Conclusions: Endoscopic injection with Dx/HA for primary VUR appears to have good long-term clinical success rates and high parental satisfaction, mirroring our previously reported short-term results. Post-operative ureteral obstruction is rare but may occur years post-operatively, justifying initial sonographic surveillance, and repeat imaging in symptomatic patients.
Highlights
In order to characterize the outcomes of children with primary vesicoureteral reflux (VUR), patients with secondary VUR or inadequately treated bladder/bowel dysfunction (BBD) were excluded
From 2002 to 2004, the number of subureteral injections performed in the United States increased 288% while open ureteral reimplantation rates remained stable [23]
Its minimally invasive nature and low incidence of post-operative bladder spasms, hematuria, emergency room visits, and readmissions favor dextranomer/hyaluronic acid (Dx/HA), open ureteral reimplantation is associated with higher initial success and fewer reoperations [24]
Summary
While open ureteral reimplantation has a reported success of 96–98% in older studies [1, 2], the most recent larger series reported a 93.5% radiographic success rate defined as no post-operative VUR and a 95.9% clinical success rate defined as absence of post-operative fUTI [3]. Lower cure rates are associated with high-grade reflux, duplicated systems, and neurogenic bladder dysfunction; higher resolution rates are seen in the absence of anatomic abnormalities or bladder/bowel dysfunction (BBD) [5]. The hydrodistention implantation technique (HIT) injection method is associated with better outcomes than the older subureteric transurethral injection (STING) procedure, with several authors reporting radiographic success rates ≥80% [9,10,11]. The Double HIT affords the highest success rates [8, 12], and has emerged as the most common injection technique in the United States [13]
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