Outcomes of a minimally invasive surgical approach to manage persistent high-grade vesicoureteric reflux post successful augmentation cystoplasty of patients with non-compliant bladder.
INTRODUCTION
Secondary vesicoureteric reflux (VUR) is a common problem associated with non-compliant bladders. Management of this disorder is debatable in literature. Many authors reported high resolution rate of VUR with augmentation cystoplasty (ACP) alone. Others showed significant residual VUR after ACP and recommend ureteric re-implantation (UR) at time of augmentation.


OBJECTIVE
Studying efficacy of endoscopic correction of persistent high-grade VUR (ECVUR) post successful ACP.


DESIGN
Patients with non-compliant bladders and high-grade VUR are enrolled in the program of our institute, where they are initially managed conservatively. Those not responding are managed endoscopically using intravesical botulinum toxin A and ECVUR. Patients who are not candidates or failed this approach undergo ACP without UR. A total of 82 patients with non-compliant bladder underwent ACP between 2001 and 2011. Of those, 24 patients had high-grade VUR with 44 refluxing units (RU), 20 bilateral and 4 unilateral. The mean age at intervention was 7.62 years with a mean follow-up of 5.6 years. Patients with persistent high-grade VUR and recurrent breakthrough febrile UTI despite antibiotic prophylaxis following ACP were identified and enrolled in our prospective trial of interval ECVUR. Statistical analyses was performed to identify predictors of high-grade VUR resolution after ACP and ECVUR. A p value <0.05 was considered statistically significant (Table 1).


RESULTS
Of the 24 patients, 17 underwent ileocystoplasty and 7 underwent ureterocystoplasty. One of the patients that underwent ileocystoplasty found to have a blind ending RU that was excised. Of the 36 remaining RU, 21/36 (58.3%) showed complete resolution in the first follow-up cystogram, and 1 showed complete resolution after 1 year. Two patients, each with single RU, received repeat ACP because of poor compliance and/or inadequate bladder capacity post ureterocystoplasty and showed complete resolution of reflux post-operatively, which increased the resolution rate post ACP to 66.6% (24/36) (Table 2). Of the remaining 12 RU in 7 patients, 10 underwent trial of ECVUR. VUR resolved in 8 RU after the first trial and in another 2 after the second trial (Table 3). Parents of 1 patient with the remaining 2 RU preferred to continue with conservative management (Table 2).


DISCUSSION
VUR in patients with non-compliant bladder is usually secondary to high detrusor pressure, low compliance and small capacity. Whereas some investigators showed high resolution rate of VUR post augmentation without UR, claiming that by successfully augmenting the bladder, compliance will increase, detrusor pressure will decrease, and as a result, VUR will spontaneously resolve. Others showed high incidence of persistent VUR (47-57%) and recommend UR at time of ACP. In our study, the incidence of spontaneous resolution was 66.6% (24/36). In cases where VUR persists, ECVUR was performed. With this approach, VUR resolution increased to 94% (34/36). This study is limited by the small number of patients, lack of randomization and lack of comparison group in which patients undergo ACP with UR.


CONCLUSION
ACP without UR with interval endoscopic management seems to be an effective and adequate treatment for high pressure, non-compliant bladder as well as high-grade VUR when conservative management fails.
['Alsowayan|Ossamah|O|', 'Barham|Alaa|A|', 'Alqarni|Naif|N|', 'Alnazari|Mansour|M|', 'Alsakharni|Mahmoud|M|', 'Ewida|Tamer|T|', 'Trbay|Mahmoud|M|', 'Elderwy|Ahmad A|AA|', 'Alhazmi|Hamdan|H|', 'Neel|Khalid Fouda|KF|']
D000704:Analysis of Variance D016009:Chi-Square Distribution D002648:Child D002675:Child, Preschool D002908:Chronic Disease D015331:Cohort Studies D003558:Cystoscopy D005260:Female D006801:Humans D008297:Male D019060:Minimally Invasive Surgical Procedures D020127:Recovery of Function D012086:Reoperation D012189:Retrospective Studies D012720:Severity of Illness Index D016896:Treatment Outcome D001743:Urinary Bladder D001750:Urinary Bladder, Neurogenic D014563:Urodynamics D013520:Urologic Surgical Procedures D014718:Vesico-Ureteral Reflux
Vesicoureteral reflux Augmentation cystoplasty Intravesical botulinum toxin A Dextranomer/hyaluronic acid copolymer Neuropathic bladder