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Surgical versus endoscopic correction of vesicoureteral reflux in children with neurogenic bladder dysfunction
J D Engel1, L S Palmer, E Y Cheng
1Division of Urology, Children's Memorial Medical Center, Northwestern University Medical School, Chicago, Illinois, USA.
Insights
Open ureteral reimplantation is more effective than subureteral polytetrafluoroethylene injection for treating vesicoureteral reflux in children with neurogenic bladder. Injection may still have a role due to its simplicity and potential for secondary reimplantation.
Area of Science:
- Pediatric Urology
- Nephrology
- Surgical Innovation
Background:
- Vesicoureteral reflux (VUR) in children with neurogenic bladder dysfunction presents a complex management challenge.
- Current treatment options include open ureteral reimplantation and minimally invasive endoscopic injection therapies.
Purpose of the Study:
- To compare the efficacy of subureteral polytetrafluoroethylene (PTFE) injection versus open ureteral reimplantation for VUR in pediatric neurogenic bladder.
- To evaluate success rates and influencing factors for each treatment modality.
Main Methods:
- Retrospective study of children with neurogenic bladder and VUR treated with ureteroneocystostomy or subureteral PTFE injection.
- Success defined as complete reflux eradication; follow-up via cystography and ultrasound.
- Data stratified by procedure, patient demographics, and reflux characteristics; analyzed using chi-square tests.
Main Results:
- Ureteroneocystostomy achieved a higher success rate (84.3%) compared to single PTFE injection (56.7%).
- Cumulative success for PTFE injection reached 61% after a second injection; ureteroneocystostomy success was independent of reflux grade or laterality.
- PTFE injection failure was associated with higher reflux grades; secondary reimplantation was successful in cases where injection failed.
Conclusions:
- Primary open ureteral reimplantation demonstrates superior efficacy for correcting VUR in pediatric neurogenic bladder.
- Subureteral PTFE injection, despite lower success rates, offers benefits like technical simplicity and outpatient management, supporting its role in select cases.
Purpose:
We attempted to compare the efficacy of subureteral polytetrafluoroethylene injection and ureteral reimplantation for treating vesicoureteral reflux in children with neurogenic bladder dysfunction.
Materials And Methods:
We retrospectively studied the records of all children with neurogenic bladder dysfunction and reflux into single collecting systems treated with cross-trigonal ureteroneocystostomy or subureteral polytetrafluoroethylene injection. Followup cystography was performed 2 months postoperatively and ultrasound was done twice yearly thereafter. Urodynamic data were evaluated when available. Success was defined as complete eradication of reflux. Data were stratified by procedure, patient sex, grade and laterality of reflux, and the presence of unilateral or bilateral reflux, and then compared using chi-square analysis.
Results:
Of 85 patients (118 ureters) identified followup data were available in 95%. Subureteral polytetrafluoroethylene injection and ureteroneocystostomy were done on 60 and 47 ureters, respectively. Both groups were similar in mean patient age, followup and preoperative degree of reflux. Success rates after ureteroneocystostomy and a single injection were 84.3 versus 56.7%. The cumulative success rate of subureteral polytetrafluoroethylene injection was 61% after a second injection. The success rate of ureteroneocystostomy was significantly greater than that of injection (p = 0.02). Reflux resolved in all patients in whom injection failed and who underwent secondary reimplantation. Successful ureteroneocystostomy was unrelated to patient sex, reflux grade or laterality, or bilateral versus unilateral reflux. Subureteral polytetrafluoroethylene injection was more likely to fail in higher grades of reflux (p = 0.03) but success was otherwise unrelated to other parameters. Failure to correct reflux was unrelated to urodynamic findings.
Conclusions:
Primary open ureteral reimplantation is more effective than subureteral polytetrafluoroethylene injection for correcting reflux in children with neurogenic bladder dysfunction. Despite controversy related to the appropriate injectable substance, the relative technical simplicity, outpatient nature, rapid recovery and potential for successful secondary reimplantation support a role for subureteral polytetrafluoroethylene injection in managing reflux in these difficult cases.