Intraoperative cystography pre- and post-endoscopic treatment for vesicoureteral reflux: guaranteed success?

This study was designed to investigate whether post-endoscopic treatment (ET) intraoperative cystography is predictive of treatment outcome.

Patients diagnosed with vesicoureteral reflux (VUR) and treated endoscopically with polyacrylate/polyalcohol copolymer or dextranomer hyaluronic acid were studied prospectively between August 2009 and April 2011. Slow infusion pre-ET cystography was performed under anesthesia. Post-ET cystography was performed only if the intraoperative pre-ET results demonstrated VUR.

Over a period of 20 months, 23 patients were studied (18 girls, five boys), with an average age of 41.9 months (range 13 months-11 years). Thirty-two renal units with reflux were treated: nine bilateral cases, seven right, and seven left. The distribution of reflux grades was as follows: two grade I, 10 grade II, 11 grade III, nine grade IV. All injected ureters demonstrated grade 0 hydrodistention after the procedure. Twelve of 23 of the pre-ET cystography results were negative for VUR, indicating that the sensitivity of this test is 47% compared with the preoperative voiding cystourethrography (VCUG) or nuclear cystogram. There were no procedure complications.

Of all patients (n = 23), nearly 60% did not demonstrate pre-ET VUR on intraoperative cystography. If a postoperative VCUG had been performed on all patients, more than half would have received unnecessary radiation. Therefore, this study demonstrates that post-ET cystography does not predict the success of ET of VUR intraoperative. Pre-ET cystography under general anesthesia before ureteral injection, has very low sensitivity, creating false-negatives that may complicate the interpretation of post-ET cystography. We suggest that intraoperative cystography before and after ET fails to show clinical utility and should not be used to predict the outcome of endoscopic VUR treatment.