5th Joint Meeting of ESPU-SPU - Virtual

S5: VESICOURETERAL REFLUX

Moderators: Pedro-Jose Lopez (Chile)

ESPU-SPU Meeting on Thursday 23, September 2021, 16:35 - 17:11


16:35 - 16:38
S5-1 (PP)

★ VOIDING UROSSONOGRAPHY, A COMPARISON WITH VOIDING CYSTOURETHROGRAM IN THE DIAGNOSIS OF VESICOURETERAL REFLUX

Marcelo TAKAHASHI 1, Mauricio Gustavo Ieiri YAMANARI 1, Lisa SUZUKI 1, Taisa Davaus GASPARETTO 2, Roberto Iglesias LOPES 3 and Maria Cristina CHAMMAS 1
1) Universidade de Sao Paulo, Radiology, Sao Paulo, BRAZIL - 2) DASA, Radiology, Sao Paulo, BRAZIL - 3) Universidade de Sao Paulo, Urology, Sao Paulo, BRAZIL

PURPOSE

Compare the feasibility and effectives of voiding urossonography for the diagnosis of vesicoureteral reflux in a tertiary pediatric hospital in Brazil, when compared with voiding cystourethrography.

MATERIAL AND METHODS

This is an ongoing study that begun January 2016 with ethical review board approval.

Pediatric patients (<18 years) referred for voiding cystourethrogram were included in our study. Any patient with contraindication for the realization of voiding cystography or who did not consent with the study was excluded

All patients underwent first regular B mode ultrasound of the kidneys and bladder.  Afterwards bladder catheterization and emptying were performed. The bladder was slowly filled with the contrast solution (Sonovue 1,0 mL diluted in 500 mL of saline). Veiscoureteral reflux was diagnosed whenever microbubbles were visualized in the ureter or renal pelvis. When able patients underwent up to two voiding-filling cycles as to diagnose active reflux.

Afterwards patients were referred to voiding cystourethrography (wiith same bladder catheter still in place) and underwent regular exam.

One radiologist reviewed every urossongoraphy exams and another reviewed all cystourethrography exams, with both being blind to the others results and images.

RESULTS

A total of 41 patients underwent voiding urossonography for a total of 85 kidney-ureter units (2 patients with transplant kidneys and 1 patient with ureteral duplication), with age ranging from 6 months to 16 years)

Results:

VCUG POSITIVE VCUG NEGATIVE
US POSITIVE 24 1
US NEGATIVE 2 58

Sensitivy: 92%

Specificity: 98%

Acuracy: 96%

Approximate cost of exams:

- Voiding cystouretrhgoram: aprox 66 dollars

- Voidiing urossonography: between 46 and 99 dollars (one vial of contrast could be used for up to five patients).

CONCLUSIONS

Voiding urossonography a reliable and cost-efficient alternative for voiding cystouretrography in Brazil, specially when considering the relatively low availability of fluoroscopy equipment in the country when compared to ultrasound equipements.


16:38 - 16:41
S5-2 (PP)

VOIDING CYSTOURETHROGRAPHY; IS IT NECESSARY FOR ALL PATIENTS WHO UNDERWENT ENDOSCOPIC TREATMENT OF VUR

Ahsen KARAGÖZLÜ AKGÜL 1, Arzu CANMEMIŞ 2, Mert Berke GÜR 3 and Halil TUĞTEPE 4
1) Marmara University, Pendik Education and Research Hospital, Paediatric Urology, Istanbul, TURKEY - 2) Marmara University,, Paediatric Surgery, Division of Paediatric Urology, İstanbul, TURKEY - 3) Marmara University,, Faculty of Medicine, İstanbul, TURKEY - 4) Istanbul Bilim University, Paediatric Surgery, İstanbul, TURKEY

PURPOSE

During the period of treatment and follow up of vesicouretheral reflux (VUR), the morbidity of the imaging modalities should be considered. Many paediatric urologist prefer to perform voiding cysto-urethrogram (VCUG), for all patients to assess the success of the endoscopic treatment (ET). We designed a retrospective study, to determine if it is necessary, for all patients or for selected the cases.

MATERIAL AND METHODS

From the data of patient who underwent ET because of primary reflux , we select randomly 50 patients with persistent VUR (Group 1), and 50 without VUR (Group 2) on VCUG postoperatively. Demographic features, use of prophylactics, grade of VUR, presence of lower urinary tract dysfunction (LUTD), recurrent urinary tract infection (UTI), and new renal scar postoperatively were documented.

RESULTS

The mean age of patients were 73 months. In terms of sex, age and side of VUR, there were no statistically significant difference between groups. 24 patients in Group 1, and 4 in Group 2 had UTI postoperatively (p<0,001). Among 72 patients who didn’t have UTI postoperatively, 26 had VUR, and 46 didn't have VUR on VCUG. New renal scar formation after operation was observed in 9 (18%) and 4 (8%) patients in group 1 and 2 respectively (p>0,05). New scar formation was observed in one of 72 patients without UTI. Mean follow up time were 45 and 37 months in group 1 and 2 respectively.
If patients would be selected due to UTI, only 28 patients will have been experienced VCUG, however, VCUG would not be performed for 72 of 100 patient without UTI.

CONCLUSIONS

VCUG is an imaging test that may not be suitable for all patients. The patients should be selected due to risk factors such as UTI. Selecting only patients with UTI for VCUG will bring 1/72 risk for new renal scar to asymptomatic patient but protect 71/72 cases from VCUG.


16:41 - 16:44
S5-3 (PP)

ADDITIONAL PARAMETERS IN VCUG TO PREDICT THE SUCCESS OF ENDOSCOPIC SUBURETERAL INJECTION IN CHILDREN

Numan BAYDILLI 1, İsmail SELVI 2, Ayşe Seda PINARBAŞI 3, Emre Can AKINSAL 1 and Deniz DEMIRCI 4
1) Erciyes University School of Medicine, Urology, Kayseri, TURKEY - 2) Karabük University Training and Research Hospital, Urology, Karabük, TURKEY - 3) Erciyes University School of Medicine, Pediatric nephrology, Kayseri, TURKEY - 4) Erciyes University School of Medicine, Pediatric urology, Kayseri, TURKEY

PURPOSE

Although the grade of vesicoureteral reflux is accepted as one of the reliable tools to predict the success of endoscopic injection, new parameters have been investigated. The aim of this study is to investigate the effect of ureter diameter ratio (UDR), timing of reflux and delayed upper tract drainage in voiding phase of voiding cystourethrography (VCUG) to predict treatment success.

MATERIAL AND METHODS

We retrospectively reviewed VCUG data of 135 children with primary VUR, undergoing endoscopic injection  between 2011 and 2018. Age, history of febrile urinary tract infection, voiding dysfunction, presence of scar in DMSA, grade of reflux, UDR, timing of reflux and presence of delay in upper tract drainage were recorded. UDR was calculated by dividing the largest ureteral diameter within the false pelvis by the distance between L1–L3 vertebral bodies. The patients were evaluated into two groups according to success of endoscopic injection.

RESULTS

A total of 176 renal units (44 boys and 91 girls) with a median age of 5.5(3-8) years were included. Presence of grade IV-V reflux (p<0.001), the rate of scar in DMSA (p=0.007), UDR value (p<0.001) and the rate of delayed upper tract drainage (p=0.018) were statistically lower in success group. In univariate analysis, grade of reflux (OR:0.498, 95% CI 0.371-0.669;p<0.001), scar in DMSA (OR:0.36, 95% CI 0.170-0.765; p=0.008) and UDR (OR:0.66, 95% CI 0.001-0.053; p<0.001) were found to be predictive factors for treatment success. The cut-off value of UDR to predict success of endoscopic injection was calculated to be 0.22 [AUR: 0.740, 95% CI (0.667-0.813), (p<0.001)].

CONCLUSIONS

While UDR appeared as a reliable predictor of success after endoscopic injection, timing of reflux and delayed
upper tract drainage were not found as independent risk factors.


16:44 - 16:53
Discussion
 

16:53 - 16:56
S5-4 (PP)

URETERONEOCYSTOSTOMY (URETERIC REIMPLANTATION) FOR GRADE III-IV VESICOURETERAL REFLUX: HIGH RESOLUTION RATES WITHOUT URETERAL TAPERING OR TAILORING

Tiffany TONI 1, Ciro ANDOLFI 2, Alyssa LOMBARDO 1 and Mohan GUNDETI 2
1) University of Chicago, Medical School, Chicago, USA - 2) University of Chicago, Department of Urology, Chicago, USA

PURPOSE

Ureteroneocystostomy (ureteric reimplantation) for high-grade vesicoureteral reflux (VUR) is often associated with traditional tapering or tailoring of the dilated ureter despite limited data demonstrating its efficacy in promoting reflux resolution.

MATERIAL AND METHODS

A retrospective analysis identified pediatric patients who underwent open or robotic ureteroneocystostomy (OUN and RAUN, respectively) without ureteral remodeling at a single tertiary care center. The primary endpoint of reflux resolution was defined as no VUR on postoperative voiding cystourethrogram (VCUG). Ureteral dilation was analyzed using the ureteral diameter ratio (UDR), which normalized for image characteristics. Inclusion criteria was as follows: grade III-V reflux, accessible VCUG scans, and RAUN after June 2013 following robotic technique optimization.

RESULTS

A total of 75 ureters were analyzed (OUN=33, RAUN=42). Complete reflux resolution was achieved in 100% (33/33) of OUN cases and 95.2% (40/42) of RAUN cases. The resolution rates did not differ by operative type (Chi-Squared=1.61, p=0.20). The preoperative VUR grade distribution for OUN procedures was 8/33 grade III (UDR=0.26 plus/minus 0.13), 11/33 grade IV (UDR=0.45 plus/minus 0.19), and 14/33 grade V (UDR=0.66 plus/minus 0.24). For RAUN procedures, the grade distribution was 15/42 grade III (UDR=0.24 plus/minus 0.08), 21/42 grade IV (UDR=0.38 plus/minus 0.15), and 6/42 grade V (UDR=0.43 plus/minus 0.13). Of the two RAUN cases that had persistent, though diminished, reflux the pre-operative UDRs were 0.28 and 0.34.

CONCLUSIONS

In this study, traditional ureteral tapering was unnecessary for high rates of reflux resolution for both OUN and RAUN procedures. Additionally, the UDRs of unsuccessful cases were in the second quartile of all ureters operated on, suggesting that ureteral dilatation was not the primary driver of reflux persistence.


16:56 - 16:59
S5-5 (PP)

LATE-ONSET URETERAL OBSTRUCTION AFTER USE OF POLYACRYLATE-POLYALCOHOL COPOLYMER (PPC) FOR ENDOSCOPIC TREATMENT OF VESICOURETERAL REFLUX IN CHILDREN

Andrzej GOLEBIEWSKI, Stefan ANZELEWICZ, Leszek KOMASARA and Piotr CZAUDERNA
Medical University of Gdansk, Surgery and Urology for Children and Adolescents, Gdansk, POLAND

PURPOSE

Various balking agents are used for endoscopic correction of all grades of vesicoureteral reflux (VUR) in children. The aim of the study was to evaluate the clinical outcomes after VUR treatment using two bulking agents: PPC and dextranomer/hyaluronic acid copolymer (Dx/HA).

MATERIAL AND METHODS

A total 457 patients (312 girls and 145 boys) aged 1-12 years (mean age 4,6 years) underwent endoscopic correction of VUR (539 refluxing ureters –RU). Patients were divided into two groups; 283 (54,4 %) RUs were treated with Dx/HA and 246 (45,6%) RUs with PPC. VUR grade was II in 191 ureters, III in 307, IV in 28 and V in 13. Success was defined as the complete resolution of reflux in VCUG three months after injection. Ultrasonography was performed after 3, 6 and 12 months.

RESULTS

The success rate was comparable. Mean injection volume was significantly lower in PPC group (p < 0.05). Ureteral obstruction was seen in 3 of 283 injected ureters (0,7%) in Dx/HA Group. Obstructions were observed at 1 month after injection. In PPC Group were no early obstruction, but late obstruction (after 1 year) was present in 9 high grade RUs, which is 3,7% of PPC Group, but 64,3% of high grade RUs in that group. All patients required surgery. 

CONCLUSIONS

PPC and Dx/HA have equal level of reflux resolution. However, a significantly higher rate of late vesicoureteric obstruction was in PPC Group. Due to the risk of late stenosis, PPC should be avoided in high grade reflux. Long-term follow-up randomized prospective studies are needed to clarify the safety of PPC.


16:59 - 17:02
S5-6 (PP)

A SCORING SYSTEM FOR PREDICTIVE ASSESSMENT OF VESICOURETERAL REFLUX RESOLUTION AFTER PEDIATRIC ROBOT-ASSISTED LAPAROSCOPIC EXTRAVESICAL URETERAL REIMPLANTATION

Sang Hoon SONG 1, Il-Hwan KIM 1, Jae Hyun HAN 2, Kun Suk KIM 2, Vinaya BHATIA 1, Jonathan GERBER 1, Minki BAEK 3 and Chester J. KOH 1
1) Texas Children's Hospital, and Scott Department of Urology, Baylor College of Medicine, Division of Pediatric Urology, Department of Surgery, Houston, USA - 2) Asan Medical Center, University of Ulsan College of Medicine, Department of Urology, Seoul, REPUBLIC OF KOREA - 3) Samsung Medical Center, Sungkyunkwan University College of Medicine, Department of Urology, Seoul, REPUBLIC OF KOREA

PURPOSE

We aimed to develop and validate a scoring system to predict vesicoureteral reflux (VUR) resolution after robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR-EV)

MATERIAL AND METHODS

We retrospectively reviewed data from two tertiary referral hospitals. We included patients who underwent RALUR-EV for primary VUR. Using potential predictive factors for VUR resolution such as age, BBD status, and VUR grade, we developed a prediction model as a regression equation from the larger cohort and a scoring system for easier use in practice. Patients were classified according to their risk score into three categories as listed here with cutoffs of 52 and 71 point. External validation of the scoring system was performed in the smaller cohort.

RESULTS

115 renal units in the development cohort and 46 renal units in the validation cohort were utilized for this study. The success rate of VUR resolution after RALUR-EV was 93.0% and 87.0% in the development and validation cohort, respectively. Perioperative values were assigned to weighted points proportional to their beta-coefficients from a regression analysis in the development cohort. Risk score was calculated as ‘age (yr) + BMI + BBD times 10 + VUR grade times 7 + console time (hr) + hospital stay times 6’. The area under the Receiver Operating Characteristic (ROC) curve of our scoring system was 0.859 (p=0.001) and 0.770 (p=0.040) in the development and validation cohorts, respectively. VUR resolution was significantly different among risk groups: 100% (low-risk), 96.7% (intermediate-risk), and 77.8% (high-risk) (p=0.004) in the development cohort and 100% (low-risk), 90.0% (intermediate-risk), and 63.3% (high-risk) in the validation cohort (p=0.205). 

CONCLUSIONS

A novel VUR resolution scoring system including patient’s age, BMI, BBD, VUR grade, console time, and hospital stay provides a prediction of children at risk for failure of VUR resolution after RALUR-EV.


17:02 - 17:11
Discussion