The need for ureteric re-implantation during augmentation cystoplasty: video-urodynamic evaluation
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Published on: August 9, 2012
Tarkan Soygur1, Berk Burgu, Ali Zümrütbas
1Department of Urology, Division of Paediatric Urology, Faculty of Medicine, University of Ankara, Ankara, Turkey.
Insights
In children with bladder augmentation and vesico-ureteric reflux (VUR), preoperative video-urodynamics (VUD) can predict if VUR will persist. If VUR begins at low pressures, simultaneous antireflux surgery is recommended to prevent febrile urinary tract infections and potential kidney scarring.
Area of Science:
- Pediatric Urology
- Urodynamics
- Reconstructive Urology
Background:
- Children with high-pressure, low-compliance bladders often have vesico-ureteric reflux (VUR).
- Augmentation cystoplasty aims to improve bladder capacity and compliance, but VUR may persist post-surgery.
- The role of preoperative bladder dynamics in predicting VUR persistence after augmentation is not fully understood.
Purpose of the Study:
- To evaluate video-urodynamic (VUD) results before and after augmentation cystoplasty in children with VUR.
- To determine if preoperative VUD can predict the persistence of VUR after augmentation without antireflux surgery.
- To assess the clinical consequences of persistent VUR.
Main Methods:
- Retrospective evaluation of 19 children who underwent augmentation ileocystoplasty for VUR and hypocompliant bladders.
- Video-urodynamic (VUD) assessments were performed before and at 3 and 6 months after surgery.
- Clinical outcomes, including febrile urinary tract infections (UTIs) and renal scarring, were retrospectively analyzed.
Main Results:
- Vesico-ureteric reflux (VUR) persisted in nine patients despite achieving a low-pressure bladder post-augmentation.
- In patients with persistent VUR, reflux initiated at significantly lower bladder volumes and pressures both pre- and post-operatively compared to those without persistent VUR.
- Persistent VUR was associated with a higher frequency of febrile UTIs and one case of progressive renal scarring.
Conclusions:
- Preoperative video-urodynamic (VUD) findings are crucial predictors of spontaneous VUR resolution after augmentation cystoplasty.
- Concomitant antireflux surgery during bladder augmentation is recommended if VUR initiates at low pressures on preoperative VUD.
- Failure to address low-pressure VUR can lead to recurrent febrile UTIs and subsequent renal damage.
Objective:
To evaluate video-urodynamic (VUD) results before and after surgery in children with high-pressure, low-compliance bladders and vesico-ureteric reflux (VUR), who had augmentation cystoplasty with no antireflux surgery, hypothesising that in these patients, poor preoperative bladder dynamics is not always the cause of the associated VUR, as VUR persists in some patients.
Patients And Methods:
We assessed objective VUD criteria where antireflux surgery might potentially be necessary to avoid reflux after augmentation, and retrospectively evaluated the clinical consequences of persistent VUR and compared it to those whom VUR resolved. In all, 19 patients with VUR and hypocompliant bladders (mean age 11.4 years, range 5-21) had augmentation ileocystoplasty. Lower urinary tract function was assessed before surgery and at 3 and 6 months afterward with VUD. Symptomatic febrile urinary tract infections (UTIs) and progressive renal scarring on scintigraphy were retrospectively evaluated in all patients.
Results:
VUR persisted in nine patients despite a low-pressure bladder. In all patients with persistent VUR, VUD at 6 months after surgery showed that VUR started at low bladder volumes (mean 29.6 mL, range 19-52) and low pressures (mean 14.6 cmH(2)O, range 9.6-25) when compared to the group with no persistent VUR. Before surgery VUD showed that reflux started at the beginning of the filling phase (mean 14.8 mL, range 8-33) with very low intravesical pressures (mean 7.8 cmH(2)O, range 4-17) in these nine patients. During the follow-up febrile UTIs were significantly more frequent in the group with persistent VUR. One patient had progressive renal scarring on scintigraphy after cystoplasty.
Conclusion:
Preoperative VUD findings might be a very important predictor of the spontaneous resolution of VUR. In these patients concomitant VUR should be corrected simultaneously during bladder augmentation if it starts at low pressures on preoperative VUD, as persistence of VUR can induce scarring from febrile UTIs.
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