INTRODUCTION AND OBJECTIVES: Vesicoureteral reflux (VUR) is a common disorder in the pediatric population. Surgical treatment includes both open and endoscopic dextranomer-hyaluronic acid (DHA) injection techniques with success rates near 95% and 65 to 90%, respectively. Prior studies have correlated the general appearance of the subureteric mound with post-operative outcomes. We intend to evaluate the appearance of the ureteral orifices (UO) after DHA injection with objective visible findings and correlate these findings with post-operative outcomes. In doing so, we hope to use the visible assessable cues during surgery to predict success or failure of DHA injections.

METHODS: A prospective, observational, single center study was performed. Patients were under 18 years, met criteria for surgical intervention for VUR, and elected to proceed with DHA injection. Data collected included patient age, sex, confounding urologic diagnoses, voiding dysfunction, previous urologic surgery, and grade of reflux as determined by most recent voiding cystourethrogram (VCUG). Outcome variables included pre-injection and post-injection hydrodistention grade (H-grade) of each UO, appearance of UO after injection including mound position and coaptation, volume of DHA used, number of “sticks,” and results at follow-up VCUG. We also introduce the term “effacement” to indicate an inconspicuous, “crescent-like” slit appearance of the UO after injection.

RESULTS: 42 patients agreed to participate in the study beginning January 2006. Of those, 63 ureters were treated at initial presentation. VCUG obtained 8-12 weeks postoperatively showed 48 ureters without reflux (76.1% success rate). Patients with post-operative H-grade greater than 0 had continued reflux after treatment, but this was observed in only 3 ureters. Of the successful 48 ureters, 29 underwent repeat VCUG at or beyond 1 year with 3 failures noted. Effacement was absent in 2 failures, but present in 1. Effacement of the orifice was predictive of long-term success (present in 27/29 ureters without reflux, p<0.001). Other pre-operative variables had no statistically significant bearing on success.

CONCLUSIONS: Effacement of the orifice is an excellent predictor of success which may be very useful in postoperative patient counseling. Although post-operative H-grade of 0 was present in all successful injections, it did not discriminate success from failure as nearly all ureters were H-grade of 0 after injection.

Source of Funding: None