|
PEDIATRIC
UROLOGY
doi: 10.1590/S1677-553820100001000033
Risk
factors for urinary tract infection after dextranomer/hyaluronic acid
endoscopic injection
Traxel E, DeFoor W, Reddy P, Sheldon C, Minevich E
Division of Pediatric Urology, Cincinnati Children’s Hospital Medical
Center, Cincinnati, Ohio, USA
J Urol. 2009; 182 (4 Suppl): 1708-12
- Purpose:
Endoscopic injection of dextranomer/hyaluronic acid is an option for
primary vesicoureteral reflux. Few groups have assessed the rate of
urinary tract infection after dextranomer/hyaluronic acid injection.
We reviewed our experience with dextranomer/hyaluronic acid injection,
and determined the incidence of and risk factors for postoperative urinary
tract infection.
Materials and Methods: A retrospective cohort study was performed of
all children with primary vesicoureteral reflux treated with dextranomer/hyaluronic
acid from 2002 to 2007 at a single institution. Patient demographics
and clinical outcomes were abstracted from the medical record. Risk
factors for postoperative urinary tract infection, including female
gender, preoperative vesicoureteral reflux grade, recurrent urinary
tract infection, bladder dysfunction, nephropathy and persistent vesicoureteral
reflux after surgery, were analyzed in a multivariate logistic regression
model.
Results: We treated 311 children, of whom 87% were female and 13% were
male (464 renal units), during the study period. Mode of presentation
was urinary tract infection in 85% of cases. Mean followup was 2.6 years.
Postoperatively urinary tract infection developed in 40 patients (13%)
and febrile urinary tract infection developed in 11 (3.5%). Of patients
with urinary tract infection 26 had initially negative postoperative
voiding cystourethrogram, of whom 16 underwent repeat voiding cystourethrogram
and 9 showed recurrent vesicoureteral reflux. Five of these 9 patients
had clinical pyelonephritis. Of assessed risk factors only preoperative
recurrent urinary tract infection (OR 2.2, p = 0.03) and bladder dysfunction
(OR 3.3, p = 0.001) were independent predictors of post-injection urinary
tract infection.
Conclusions: In our series urinary tract infection after dextranomer/hyaluronic
acid injection was rare. Patients with recurrent urinary tract infections
and bladder dysfunction preoperatively are at increased risk for urinary
tract infection after treatment. Patients with febrile urinary tract
infection after dextranomer/hyaluronic acid injection are at high risk
for recurrent vesicoureteral reflux.
- Editorial
Comment
This manuscript studies 311 children over a five-year period that had
Dx/HA. Secondary causes of reflux and poor follow-up patients were excluded.
Bladder dysfunction included patients with enuresis, frequency/urgency,
or urge incontinence and when discovered, standard treatment was instituted
prior to surgery. This behavior and dietary modifications were continued
after surgery if the bladder dysfunction persisted. Antibiotic prophylaxis
was continued until a follow-up VCUG at 2-3 months showed no further
reflux. The results showed 87% of their patients were female and 85%
presented with a UTI and 60.5% were febrile. 90% of their patients had
Grade III reflux or less. Preoperative nephropathy was present in 62
patients (20%) and bladder dysfunction was present in 64 patients (21%).
The mean patient age was 5.7 years with mean follow-up of 2.6 years.
The first time success rate for the sting procedure was 70%. With follow-up
injections, the overall success rate by patient was 81% and renal unit
88% and these results correlated with preoperative grade of reflux.
Postoperatively 40 patients (13%) developed UTI and 11 (3.5%) had febrile
UTI’s. Independent risk factors for postoperative UTI’s
by multivariate analysis were preoperative recurrent UTI’s and
bladder dysfunction. 4 of the 11 febrile UTI patients had a follow-up
VCUG showing vesicoureteral reflux and subsequently 5 more of these
patients had a VCUG positive for VUR. 10 patients of the afebrile UTI
group were positive for VUR. Upon repeat, 11 more showed VUR later.
Vesicoureteral reflux and urinary tract infection are known risk factors
for kidney scarring and modifications of both of these risk factors
have been sought over the years to prevent permanent kidney damage.
As noted in the discussion, the international reflux study group, a
28% incidence of afebrile UTI and 18% instance of febrile UTI in that
population over 10 years. It is interesting to note that subureteric
injection of Dx/HA seems to add some protective benefit for recurrent
UTI’s. In my mind, this may be the most important benefit. Recurrent
UTI’s correlate quite well with failed Deflux, although it is
interesting to note that in a recent study by Lee et al. (1), it was
showed the sting patients only had 46% of a durable reflux resolution
after one year. During this 2.6 years of follow-up, that should mean
that half of these patients had their reflux return, and yet the sting
procedure seems to offer a UTI prevention benefit even in patients that
did not have a long-term success. Readers should watch this data carefully
and I think that these issues will become more clear over the next several
years.
References
- Lee EK,
Gatti JM, Demarco RT, Murphy JP. Long-term followup of dextranomer/hyaluronic
acid injection for vesicoureteral reflux: late failure warrants continued
followup. J Urol. 2009; 181: 1869-74; discussion 1874-5.
Dr.
Brent W. Snow
Division of Urology
University of Utah Health Sci Ctr
Salt Lake City, Utah, USA
E-mail: brent.snow@hsc.utah.edu
|