Factors influencing success in endoscopic treatment of Grade 4-5 primary vesicoureteric reflux (VUR) in infancy and childhood

There is equipoise among pediatric urologists regarding endoscopic versus surgical intervention for symptomatic Grade 4-5 Vesicoureteric Reflux (VUR), particularly in infancy. Our aim was to assess outcomes of first-line endoscopic treatment in all cases of symptomatic Grade 4-5 VUR and we hypothesised that using endoscopic Dx/HA as first line management for primary VUR would obviate the need for ureteric reimplantation in the majority of cases. Retrospective single-surgeon analysis of consecutive patients with primary Grade 4-5 VUR over 15 years. Indication for intervention was breakthrough UTI on prophylaxis. Endoscopic dextranomer/ hyaluronic acid co-polymer (Dx/HA; Deflux®) injection was first-line procedure. Primary outcomes were both post-procedure febrile culture positive urinary tract infection (UTI) and VUR recurrence on post-operative VCUG requiring further surgical intervention. We postulated that risk factors influencing outcome are: age under 1 year, female gender, postnatal versus antenatal presentation, duplex anatomy, circumcision status and presence of congenital uptake defects on DMSA. Data analysed using Fisher’s Exact Test/ Multivariate Analysis. 77 patients with Grade 4-5 VUR were identified, of whom 49 (11 bilateral) underwent a Dx/HA injection at median 12 (3-84) months. Median follow-up post-injection was 32 (2–145) months. There were no reported complications or ureteral obstruction. Sixteen (33%) patients suffered a febrile UTI at follow-up; on further investigation, half (8/16) of these were found to have recurrent VUR. Therefore 67% were symptom free and 84% did not require further intervention after one injection (41/49), and 98% after further injections (48/49). Duplex systems had a similar outcome of 80% not requiring further intervention. On multivariate analysis, males were found to have a significantly better outcome than females (p