30th ESPU Congress - Lyon, France - 2019

S4: VESICOURETERAL REFLUX

Moderators: Josef Oswald (Austria), Raimondo Maximilian Cervellione (UK)

ESPU Meeting on Thursday 25, April 2019, 08:20 - 08:52


08:20 - 08:25
S4-1 (LO)

RESULTS OF OPEN, LAPAROSCOPIC AND ENDOSCOPIC SURGERY FOR INTERMEDIATE GRADE VESICOURETERAL REFLUX (VUR) IN CHILDREN: A COMPARATIVE MULTICENTRIC STUDY

Benoit TESSIER 1, Sophie VERMERSCH 2, Luke HARPER 3, Sarah GARNIER 4, Leslie REMONT 4, Christophe LOPEZ 4, François VARLET 2 and Nicolas KALFA 4
1) CHU Lapeyronie, Chirurgie pediatrique viscéral et urologique, Montpellier, FRANCE - 2) CHU Saint Etienne, Chirurgie pédiatrique viscéral et urologique, Saint-Priest-En-Jarez, FRANCE - 3) Groupe Hospitalier Pellegrin - CHU, Chirurgie pédiatrique viscéral et urologique, Bordeaux, FRANCE - 4) CHU Lapeyronie, Chirurgie pédiatrique viscéral et urologique, Montpellier, FRANCE

PURPOSE

VUR is commonly associated with febrile urinary-tract-infection (UTI). Endoscopic management is preferred for low-grade reflux whereas open or laparoscopic procedures are rather performed for high-grade reflux. Management of intermediate grade is still controversial. This study aims to compare the results of open, laparoscopic and endoscopic approaches in children with grade III VUR. 

MATERIAL AND METHODS

This multicentric comparative retrospective study included children with a grade III VUR operated on for febrile UTIs (2007-2016). VUR was either unilateral or bilateral with grade III as the highest grade. Neurological bladders, renal duplex systems, posterior urethral valves and bladder exstrophies were excluded. Success was defined as no recurrence of febrile UTI. 

RESULTS

171 children were included including 77 open Cohen procedures, 35 laparoscopic Lich-Gregoire and 59 submucosal endoscopic injections. Groups were comparable for age and sex. The length of follow-up was 64 months (mean,12-132). Recurrence of febrile UTI was significantly different in the 3 groups (6/77 Cohen vs 13/35 laparoscopy vs 16/59 endoscopic injection, p=0,0005). Febrile UTI more frequently recur after laparoscopic(p=0,0001) or endoscopic treatment(p=0,002) than open Cohen surgery. The success rate was similar between laparoscopic and endoscopic treatments (p=0,31). Redosurgery was more frequent after laparoscopic Lich-Gregoire (n=4,p=0.008) and endoscopic injection (n=15,p<0.0001) than in open Cohen surgery(n=0).

CONCLUSIONS

The success rate of endoscopic and laparoscopic procedures in grade III VUR is lower than open Cohen surgery and redosurgery is more frequently needed. If the lower morbidity of laparoscopic and endoscopic approaches worth the higher risk of recurrent febrile UTI remains to be determined for intermediate grade reflux.


08:25 - 08:28
S4-2 (PP)

LONG-TERM OUTCOME OF SURGERY IN PATIENTS OF PRIMARY VUR WITH FEBRILE UTI-A RETROSPECTIVE STUDY OF 16 YEARS

Anil TAKVANI and Virender SEKHON
Takvani Kidney Hospital, Urology, Junagadh, INDIA

PURPOSE

The aim of this study was to determine long-term outcome in terms of UTI, febrile UTI or pyelonephritis (PN) and renal scarring after reimplantation surgery in patients of high grade VUR who had recurrent or febrile UTI.

MATERIAL AND METHODS

It is a retrospective review of 156 consecutive cases that underwent reimplantation for primary VUR in last 16 years. Included patients were having dilating reflux with a history of recurrent or febrile UTI. All were subjected to DMSA scan prior to surgery. Lesions on scans were classified into congenital and acquired reflux nephropathy. Patients of VUR without history of UTI and scan suggestive of congenital reflux nephropathy were not included. Indications for surgery were: breakthrough PN and and/or post PN scarring (acquired lesions). Patients with antenatal diagnosis of hydroureteronephrosis and detection of VUR during postnatal work-up without any history of documented UTI were excluded. Post surgery regular USG done to look at the renal conditions. New MCU and DMSA scan were done in patients who developed UTI post reimplantation.

RESULTS

Sixteen patients could not be followed. Median age at surgery was 25 months. Follow up was ranging from 1 to 16 years. Out of 140, 21 patients had post reimplant UTI (15.0%). Febrile UTI rate was 5%. Of this, except 1 all were females. 7/21 had urge incontinence and dysfunctional voiding, and 12/21 had constipation (BBD). In MCU 7/21 had persistent reflux. Only 3/156 showed new scarring or worsening scars. 1 male and 2 female patients required redo reimplantation for recurrent PN because of persistent high grade reflux.

CONCLUSIONS

Reimplantation surgery is giving excellent results in patient of primary VUR with febrile UTI with least surgical morbidity. Over all post reimplant UTI, febrile UTI or PN resulting in new renal scars is rare(p<0.001). Female sex and BBD are most prominent risk factors for post reimplant UTI.


08:28 - 08:31
S4-3 (PP)

TIME PERIOD FOR DETECTION OF OBSTRUCTIVE COMPLICATIONS FOLLOWING ENDOSCOPIC TREATMENT OF VESICOURETERAL REFLUX WITH POLYACRYLATE-POLYALCOHOL COPOLYMER

Vladimir SIZONOV 1, Ilia KAGANTSOV 2, Nail AKRAMOV 3, Aleksandr PIROGOV 4 and Dzhalil GASANOV 5
1) Regional Children's Hospital, Paediatric Urology, Rostov On Don, RUSSIAN FEDERATION - 2) Children's Republican Clinical Hospital, Paediatric Urology, Syktyvkar, RUSSIAN FEDERATION - 3) Kazan state medical university, Paediatric Urology, Kazan, RUSSIAN FEDERATION - 4) Children's Clinical Hospital of the Astrakhan Province, Paediatric Urology, Astrakhan, RUSSIAN FEDERATION - 5) Samara Regional Clinical Hospital, Paediatric Urology, Samara, RUSSIAN FEDERATION

PURPOSE

The development timeline of obstructive complications represents an essential aspect defining the duration of mandatory postoperative supervision for children who have undergone endoscopic treatment of vesicoureteral reflux. Polyacrylate-polyalcohol copolymer has unique properties manifesting themselves in the interaction with the ureterovesical junction tissues, which determine the importance of researching the timeline of obstruction development typical for the substance.

MATERIAL AND METHODS

We performed retrospective analysis of treatment experience for 774 patients comprising 1133 renal units (RU) in five clinics where polyacrylate-polyalcohol copolymer was used for implantation throughout 2012-2017. 449 (58.0%) of the patients were girls and 325 (42.0%) - boys. Right-sided VUR was found in 180 (23.3%) patients, left-sided - in 235 (30.4%) children, and bilateral process - in 359 (46.4%) cases. Median age (months) [Q1; Q3] of all the patients was 39 [17; 78]. Renosonography was carried out in a day, after 3 days, and then every 6 months following endoscopic treatment. Control micturating cystography was performed in 4-6 months after endoscopic treatment. Whenever renosonography data revealed signs of obstruction, radioisotope diuretic renography was carried out.

RESULTS

Obstructive complications were found in 41 (5%) patients, median age - 21.5 months [12.0; 43.0], 27 boys (65.9%), and 14 girls (34.1%). Late obstructive complications were diagnosed in the interval from 1 to 41 month following the last injection of the implant substance. More than a half of the cases (29 (70.7%)) were revealed during the first year of observation, 6 (14%) during the second year, 2 (4.9%) - in the third year, and 3 (7%) - during the fourth year following the operation.

CONCLUSIONS

Collected data demonstrated that patients who have undergone endoscopic treatment using polyacrylate-polyalcohol copolymer must be monitored for at least 4 years in order to detect delayed development of late obstructive complications.


08:31 - 08:34
S4-4 (PP)

EFFECTS OF BIOFEEDBACK THERAPY FOR CHILDREN WITH VESICOURETERAL REFLUX: A 18-YEAR EXPERIENCE.

Yoonhye JI 1, Young Seung LEE 2, Sang Woon KIM 3, Eun Kyoung CHIO 4 and Sang Won HAN 5
1) Severance Children's Hospital, Yonsei University, Pediatric Bladder-Urethral Rehabilitation Clinic(Pediatric Urology), Seoul, REPUBLIC OF KOREA - 2) Severance Children's Hospital, Yonsei Univ, Pediatric Urology, Seoul, REPUBLIC OF KOREA - 3) Severance Children's Hospital, Pediatric Urology, Seoul, REPUBLIC OF KOREA - 4) Yonsei University, College of Nursing, Seoul, REPUBLIC OF KOREA - 5) Severance Children's Hospital, Yonsei University, Pediatric Urology, Seoul, REPUBLIC OF KOREA

PURPOSE

It has been widely known that biofeedback therapy is effective for vesicoureteral reflux(VUR) with dysfunctional voiding. We evaluated the results of biofeedback on children with VUR.

MATERIAL AND METHODS

A total of 475 patients received biofeedback therapy from February 2000 through June 2018. Among them, patients who had VUR(non-neurogenic) at the time of biofeedback were analyzed retrospectively.

RESULTS

There were 51 patients and girls were 94.1%(48/51). The mean age at which patients first visited the center was 5.5±2.98(0.3-12) years old and at the time of biofeedback was 6.7±2.64(4.0-14.8) years old. There were 66.7%(34) cases where biofeedback treatments were prescribed for the primary purpose of VUR and 33.3%(17) cases for the lower urinary tract symptoms(LUTS) with VUR. The average number of treatment was 7.2±3.90 and average period was 1.6±1.40 months.

Among them, 26 cases were monitored with VCUG and 40% of right(4/10) and 40% of left(2/5) dilating VUR(grade 3-5) were lost or decreased to non-dilating VUR(grade 1-2). 10 cases were monitored with DMSA and 90% showed normal or no difference from before when 1 case showed new defect.  

Among 36 patients identified without interruption at this point, 10 patients experienced febrile UTI and 6 of them got anti-reflux surgery. 1 patient who didn’t get surgery but showed additional defect are under close observation(average tracking period: 75.7±34.1, min-max 27-144 months). Meanwhile, the number of patients who’s never had a febrile UTI after biofeedback therapy were 26 and 7 of them got anti-reflux surgery(21.6%). All 26 patients were either on a follow-up or discontinue the observation without any problems(average tracking period: 59.6±39.5, min-max 7-161months).

CONCLUSIONS

After biofeedback therapy, 40% of dilating VUR became non-dilating VUR and 61% of patients with VUR healthily discontinued or under observation without febrile UTI, additional renal damage and anti-reflux surgery.    


08:34 - 08:37
S4-5 (PP)

CURRENT TRENDS IN MANAGEMENT OF VESICOURETERIC REFLUX (VUR) WITH RESPECT TO EAU GUIDELINES: A MULTICENTER STUDY

Serhat GÜROCAK 1, Eda TOKAT 1, Seçil ÖZKAN 2, Hasan Serkan DOĞAN 3, Burak ÇITAMAK 4, Nihat SATAR 5, Volkan İZOL 5, Mutlu DEĞER 5, Şaban SARIKAYA 6, Yakup BOSTANCI 6, Murat GÜLŞEN 6, Bülent ÖNAL 7, Elif ALTINAY KIRLI 7, Berk BURGU 8, Tarkan SOYGÜR 8, Perviz HACIYEV 8, Koray AĞRAS 9, Bilge KARABULUT 10, Cem AKBAL 11, Çağrı Akın ŞEKERCİ 11, Deniz DEMİRCİ 12, Numan BAYDİLLİ 12, Serdar TEKGÜL 4 and Mustafa Özgür TAN 13
1) Gazi University School of Medicine, Urology, Ankara, TURKEY - 2) Gazi University School of Medicine, Public Health, Ankara, TURKEY - 3) Hacettepe University School of Medicine, Urology, Ankara, TURKEY - 4) Hacettepe University School of Medicine, Ankara, TURKEY - 5) Cukurova University School of Medicine, Urology, Adana, TURKEY - 6) Samsun Ondokuz Mayıs University School of Medicine, Urology, Samsun, TURKEY - 7) Istanbul University Cerrahpasa School of Medicine, Urology, Istanbul, TURKEY - 8) Ankara University School of Medicine, Urology, Ankara, TURKEY - 9) Atatürk Training and Research Hospital, Urology, Ankara, TURKEY - 10) Atatürk Training and Research Hospital, Pediatric Urology, Ankara, TURKEY - 11) Marmara University School of Medicine, Urology, Istanbul, TURKEY - 12) Erciyes University School of Medicine, Urology, Kayseri, TURKEY - 13) Gazi University School of Medicine, Ankara, TURKEY

PURPOSE

To investigate the current trends in management of reflux with respect to EAU risk groups and effect on results of treatments in our country.

MATERIAL AND METHODS

The study group consisted of 1988 renal units of 1345 (%70 female, %30 male) patients treated surgically due to VUR between years 2003-2016 in 9 different institutions. Patients were divided into 2 groups according to time of initial treatment and also grouped according to risk factors by “EAU guidelines on VUR”. The data were analyzed due to risk groups, time of diagnosis (before-after 2013) and initial treatments and subsequently for success according to risk groups and diagnosis time.

RESULTS

The mean age and follow up were 5.18 ±3.6 years and 32 (1-184) months respectively.Among the preoperative parameters, only the presence of renal scar on DMSA and treating lower urinary tract symptoms were found to determine the postoperative success rates (p:0.002, p:0.000). Surgery as the initial treatment approach increased significantly in both moderate and high risk groups (p=0.000,p=0.0001 respectively) after 2013 (Table). In the low and moderate risk groups, clinical success rates of medical treatment increased (p=0.0001, p=0.0001) while success rates of surgery decreased (p=0.046, p=0.0001) after 2013. However, in the high risk group, medical treatment’s success rate was higher (p=0.018), while there was no significant change in success of surgery (p=0.46) after 2013.

EAU/ESPU VUR Grouping

Medical Treatment(%)

Surgical Treatment(%)

p value

Low risk

Before 2013

135(73.4)

49(26.6)

0.096

After 2013

125(65.4)

66(34.6)

Moderate risk

Before 2013

469(77)

140(23)

0.000

After 2013

287(65.7)

150(34.3)

High risk

Before 2013

264(77.2)

78(22.8)

0.001

After 2013

146 (64.9)

79(35.1)

Total

1426(71.7)

562(28,3)

 

CONCLUSIONS

Current trends in management of reflux in our country do not yet follow the EAU guidelines on VUR in low and moderate risk groups. 


08:37 - 08:52
Discussion