Endoscopic Treatment Articles

Articles

  • Beyond the Abstract - Selective endoscopic treatment of the non-refluxing contralateral ureter prevents new contralateral vesicoureteral reflux, by Wolfgang H. Cerwinka and Andrew J. Kirsch

    BERKELEY, CA (UroToday.com) -

    Management of New Contralateral Vesicoureteral Reflux in the Era of Endoscopic Treatment

    New contralateral vesicoureteral reflux (NCVUR) is a potential complication of unilateral anti-reflux surgery. It was found to occur in 7 to 18% after ureteral reimplantation1-2 and 8 to 14% after endoscopic injection.3-6 By definition NCVUR does not denote treatment failure, however, renders a procedure incomplete that was primarily intended to eliminate vesicoureteral reflux (VUR). Several studies have attempted to detect risk factors for NCVUR in order to establish guidelines for the selective and prophylactic treatment of the non-refluxing contralateral ureter (NRCU).

    The dilemma of contralateral management in unilateral VUR is shared with unilateral inguinal hernias:

    1. No risk factors for contralateral occurrence have been clearly established to date.
    2. No standardized test exists that identifies patients at risk for developing contralateral disease.
    3. The clinical significance of a positive test result is unknown.
    4. There is great variability among surgeons as to when to test and when to intervene.
    5. The indication for contralateral evaluation depends generally on surgeon’s and parents’ preference.

    During ureteral reimplantation the contralateral ureteral orifice is cystoscopically evaluated to determine the need for bilateral repair. Since the cystoscopic appearance of the ureteral orifice was found to be an unreliable predictor for NCVUR, and intravesical reimplantation is a far more morbid procedure, reimplantation of the NRCU is rarely performed.7If NCVUR occurs after ureteral reimplantation, the patient is most commonly observed to avoid another invasive procedure.

    Injection of the NRCU does not add to the morbidity of the procedure and complications such as ureteral obstruction are very uncommon. Consequently, in the era of endoscopic VUR treatment, NCVUR may be efficaciously prevented by prophylactic injection. However, to date, studies have failed to elucidate risk factors for NCVUR.5 We hypothesized that incompetence of the ureterovesical junction, which can be determined by the degree of hydrodistention (irrigation stream directed toward ureteral orifice), may place the ureter at risk for NCVUR. Our results demonstrated that prophylactic injection of high-grade hydrodistending ureters (H2 and H3) prevented the occurrence of NCVUR.6

    Arguments for prophylactic injection include avoidance of continued radiographic surveillance, antibiotic prophylaxis, and further interventions for VUR. Prophylactic injection does not substantially increase morbidity and anesthesia time and reduces surgeon and parent anxiety of a “failed” procedure. Others would argue that NCVUR is clinically insignificant (i.e., low risk for pyelonephritis) with a high chance of spontaneous resolution and consequently little need for surgical intervention. The rate of endoscopic treatment of new contralateral refluxing ureters is estimated to lie between 50 and 70%.5,6

    The cost of one milliliter Deflux® in the United States is $1900 with an institutional surcharge of up to 100%. Our unpublished data demonstrate that the cost of primary endoscopic injection (initial cost) was significantly higher with contralateral injection (prophylaxis group) than if the NRCU was only observed (observation group). Although 10% of patients whose NRCU was observed developed NCVUR and consequently required radiographic surveillance, antibiotic prophylaxis, and sometimes surgery; the total cost was still significantly higher in patients who did undergo prophylactic injection of the NRCU. The following table summarizes the cost analysis expressed in US Dollars. If the NRCU was only observed, more additional surgeries were required.  

     

    Observation Group

    Prophylaxis Group

    P-Value

    Patients

    267

    72

     

    Initial Cost

     

     

    <0.0001

              Mean

    13982.10

    19324.30

     

              SD

    1856

    3769

     

              Range

    (12813-20158)

    (12813-29103)

     

    Total Cost

     

     

    <0.0051

              Mean

    18002.20

    20159.20

     

              SD

    8697.5

    4632.9

     

              Range

    (12813-64912)

    (12813-34497.50)

     

    Surgeries

     

     

    <0.0001

              Initial

    200

    68

     

              1

    60

    4

     

              2

    6

     

     

              3

    1

     

     

    † denotes statistically significant difference.

     

    In conclusion, injection of the non-refluxing contralateral ureter is controversial. Parents should be counseled regarding the possibility of NCVUR with continued surveillance and further surgical treatment. Prophylactic injection of the non-refluxing contralateral ureter may be offered if high-grade hydrodistention is demonstrated. However, prophylactic injection increases overall healthcare cost.

    References:

    1. Diamond DA, Rabinowitz R, Hoenig D, Caldamone AA. The mechanism of new onset contralateral reflux following unilateral ureteroneocystostomy. J Urol 1996;156:665-7.
    2. Noe HN. The risk and risk factors of contralateral reflux following repair of simple unilateral primary reflux. J Urol 1998;160:849-50.
    3. Lavelle MT, Conlin MJ, Skoog SJ. Subureteral injection of Deflux for correction of reflux: analysis of factors predicting success. Urology 2005;65:564-7.
    4. Yu RN, Roth DR. Treatment of vesicoureteral reflux using endoscopic injection of nonanimal stabilized hyaluronic acid/dextranomer gel: initial experience in pediatric patients by a single surgeon. Pediatrics 2006;118:698-703.
    5. Menezes M, Mohanan N, Haroun J, Colhoun E, Puri P. New contralateral vesicoureteral reflux after endoscopic correction of unilateral reflux - is routine contralateral injection indicated at initial treatment? J Urol 2007;178:1711-3.
    6. Cerwinka WH, Kaye JD, Leong TL, Elmore JM, Scherz HC, Kirsch AJ. Selective endoscopic treatment of the non-refluxing contralateral ureter prevents new contralateral vesicoureteral reflux. J Pediatr Urol 2011.
    7. Parrott T, Woodard J. Reflux in opposite ureter after successful correction of unilateral vesicoureteral reflux. Urology 1976;7:276-8.

     


     Written by:

    Wolfgang H. Cerwinka and Andrew J. Kirsch as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.

    Children’s Healthcare of Atlanta, Emory University School of Medicine 


     

    Selective endoscopic treatment of the non-refluxing contralateral ureter prevents new contralateral vesicoureteral reflux - Abstract

    More Information about Beyond the Abstract

    Published August 1, 2012
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