Factors Influencing Success in Endoscopic Treatment of Grade 4-5 Primary Vesicoureteric Reflux (VUR) in Infancy and Childhood

Introduction: There is equipoise among pediatric urologists regarding endoscopic versus surgical intervention for symptomatic Grade 4-5 Vesicoureteric Reflux (VUR), particularly in infancy. Our aim was to assess outcomes of first-line endoscopic treatment in all cases of symptomatic Grade 4-5 VUR and we hypothesised that using endoscopic Dx/HA as first line management for primary VUR would obviate the need for ureteric reimplantation in the majority of cases.

Methods: Retrospective single-surgeon analysis of consecutive patients with primary Grade 4-5 VUR over 15 years. Indication for intervention was breakthrough UTI on prophylaxis. Endoscopic dextranomer/hyaluronic acid co-polymer (Dx/HA; Deflux®) injection was first-line procedure. Primary outcomes were both post-procedure febrile culture positive urinary tract infection (UTI) and VUR recurrence on post-operative VCUG requiring further surgical intervention. We postulated that risk factors influencing outcome are: age under 1 year, female gender, postnatal versus antenatal presentation, duplex anatomy, circumcision status and presence of congenital uptake defects on DMSA. Data analysed using Fisher's Exact Test/Multivariate Analysis.

Results: 77 patients with Grade 4-5 VUR were identified, of whom 49 (11 bilateral) underwent a Dx/HA injection at median 12 (3-84) months. Median follow-up post-injection was 32 (2-145) months. There were no reported complications or ureteral obstruction. Sixteen (33 %) patients suffered a febrile UTI at follow-up; on further investigation, half (8/16) of these were found to have recurrent VUR. Therefore 67 % were symptom free and 84 % did not require further intervention after one injection (41/49), and 98 % after further injections (48/49). Duplex systems had a similar outcome of 80 % not requiring further intervention. On multivariate analysis, males were found to have a significantly better outcome than females (p < 0.015) irrespective of circumcision status. Forty-one percent of the children in our cohort had uptake defects on DMSA prior to intervention, but this did not have any difference on outcome.

Conclusion: Endoscopic Dx/HA injection is a safe first-line, day-case treatment for Grade 4-5 VUR in children of any age, with a low complication rate. Two-thirds of patients are asymptomatic after one injection; 84 % do not require further procedures after one injection, and 98 % after 2 injections.