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PEDIATRIC UROLOGY
Long-term
followup of dextranomer/hyaluronic acid injection for vesicoureteral
reflux: late failure warrants continued followup
Lee EK, Gatti JM, Demarco RT, Murphy JP
Kansas University Medical Center, Kansas City, Kansas and Children’s Mercy
Hospital, Kansas City, Missouri, USA
J Urol. 2009; 181: 1869-74; discussion 1874-5
- Purpose: Dextranomer/hyaluronic acid injection of ureteral orifices is a popular
option in the treatment of vesicoureteral reflux,
with success
rates ranging from 69% to 89%. We found only 1 study that followed patients
beyond the initial postoperative voiding cystourethrogram, which describes
a 96% success rate at 2 to 5 years but defines success as “nondilating” reflux.
We examined our dextranomer/hyaluronic acid series to evaluate the long-term
(1-year) outcome in children who had resolution of reflux on initial
postoperative voiding cystourethrography.
- Materials
and Methods: We retrospectively reviewed our dextranomer/hyaluronic
acid experience from February of 2002 to December of 2005. We determined
initial success on early (6 to 12-week) postoperative voiding
cystourethrogram. We
then evaluated long-term success by obtaining a voiding cystourethrogram
at 1 year postoperatively in patients who were initially cured
of reflux. In addition,
success rates between the first and second halves of our experience were
evaluated to account for surgeon experience and modification
of technique.
- Results: Our total success rate at initial voiding cystourethrogram
was 73% (246 of 337 total ureters). The success rate in the
first half of
our experience
was 65.9% (112 of 170 ureters) and in the second half was 80.2% (134
of 167). A total of 150 ureteral units with initial successful dextranomer/hyaluronic
acid treatment were evaluated at 1 year by voiding cystourethrogram.
Of these
ureters 111 had continued resolution of vesicoureteral reflux, for
a long-term success rate of 74%. Including initial postoperative
failures,
the complete
1-year total success rate was 46.1% (111 of 241 ureters).
- Conclusions: Although the reflux resolution rates at initial postoperative
voiding cystourethrogram approach those of open surgery, there is
a significant failure rate at 1 year, which warrants long-term
followup.
- Editorial Comment
This manuscript shows an almost 4-year experience with 219 patients and 337
ureters. The 6-12 week postoperative VCUGs showed a success rate of 73% and
a one year VCUG on the same patients who had initial resolution showed a
lower 74% success rate. Considering the overall patients altogether, the
total success rate at one year was 46.1%. 74 of their 219 patients dropped
out of the study and did not complete the VCUG at one year after surgery.
The authors did note that switching to the HIT technique improved their early
success from 65.9 to 80.2%. However, at one year after surgery their success
rate was essentially identical at 74.2 and 73.8%. There was no statistical
difference in STING versus HIT techniques in their study. If the data was
broken down by grade of reflux, 100% of Grade I reflux was gone one year
later, and 79.8% of Grade II reflux was gone one year later. Grade III reflux
was 37.2%. The authors suggest that Deflux may be considered in low-grade
refluxes but the long-term outlook for higher grades of reflux is particularly
disappointing.
This manuscript brings into question the long-term success of injection therapy
for reflux and in particular, the need for long-term radiographic follow up
for these patients. If the criterion for success is absence of reflux, Deflux
treatment will need to be reconsidered by those who take care of this disease
in children.
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
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