Endoscopic treatment of complex vesicoureteral reflux in pediatric patients

Vesicoureteral reflux (VUR) is a common congenital anomaly affecting close to 1% of all children. It is often associated with other ureteral anomalies, including ureteral duplication, ectopia, ureteroceles, and paraureteral (Hutch) diverticula.

In contemporary series, success rates have been well over 85%, with rates of 90% and greater in grades II-IV VUR and rates approaching 100% in grade I VUR (J Urol 2004; 171[6 Pt. 1]:2413-6; Adv Urol 2008:513854). This renewed interest in endoscopic management of primary VUR using subureteral dextranomer/hyaluronic acid injection also has led to re-examination of the role of endoscopic approaches to correct complex VUR.

This article guides the clinician in surgical techniques, outcomes, and follow-up related to endoscopic treatment of complex cases of VUR, including reflux associated with other ureteral anomalies, reflux after failed open surgery, and reflux into the transplant kidney. While dextranomer/hyaluronic acid also has shown promise for the endoscopic treatment of urinary leakage via the bladder neck or catheterizable channel stoma, these uses are beyond the scope of this article.

Patient selection

As with cases of primary reflux, indications for open or endoscopic surgical intervention in the patient with associated anomalies or prior surgical treatment include recurrent febrile urinary tract infections while on antibiotic prophylaxis, persistent VUR after at least 2 years of observation, poor compliance with antibiotic therapy, and new evidence of renal scarring (J Urol 2004; 172[4 Pt 2]:1614-6). Relative indications for surgery include parental preference and the relative morbidity of serial voiding cystourethrography in the patient undergoing observation.

In the patient with reflux into the renal transplant, there is more consensus as to the benefit of treating VUR in patients who have a history of febrile urinary infection to prevent the documented risks of pyelonephritis and subsequent graft compromise or loss in this population (J Urol 1981; 125:277-83). Treatment of asymptomatic reflux in the transplant patient, however, is more controversial, and should be tailored to individual patient risk factors, such as grade of the reflux, associated lower urinary tract pathology, and the presence of renal scarring.