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concomittant PUV and VUR

Pediatric Urology
The Management of Vesicoureteral Reflux in
the Setting of Posterior Urethral Valve With
Emphasis on Bladder Function and Renal
Outcome: A Single Center Cohort Study
Ali Tourchi, Abdol-Mohammad Kajbafzadeh, Zahra Aryan, and Maryam Ebadi
To represent our experience in the management of posterior urethral valves and concomitant
vesicoureteral reflux (VUR).
A total of 326 children with posterior urethral valve who had underwent valve ablation/bladder
neck incision were studied, and those who had persistent VUR and were categorized under 3
main groups were followed up. Group 1 (n ¼ 71) received prophylactic antibiotic, group 2 (n ¼
50) underwent Deflux injection (2a) (n ¼ 28): Deflux injection alone, group 2b (n ¼ 22) Deflux
with concomitant autologous blood injection (HABIT), and group 3 (n ¼ 19) underwent ureteroneocystostomy before referral and was followed up conservatively. VUR resolution, incidence
of urinary tract infections (UTI), and bladder function were assessed.
Mean duration of follow-up was 3.8 years; VUR resolution occurred in 66.1%, 86.0%, and
94.0% of groups 1-3, respectively (P ¼ .013). Resolution rate in group 2b was significantly
higher than group 2a (90.9% vs 78.5%). Patients in group 2 experienced a longer UTI-free
period compared with others (P <.05). Urodynamic studies demonstrated significant decrease
in maximum voiding detrusor pressure and detrusor overactivity in all groups (P <.001).
Children in group 3 ended up with lower compliance compared with others (P <.001). After
toilet training, only 2.8%, 21.4%, 13.6%, and 27% children were diagnosed with lower urinary
tract dysfunction in groups 1-3, respectively (P ¼ .027). Myogenic failure developed only in 3
boys in group 3.
Ablation/bladder neck incision leads to significant improvement in VUR status in part because of
improvement in bladder function. After successful valve removal, conservative therapy can be
regarded as the mainstay of reflux treatment, whereas HABIT is recommended for high grade
VUR associated with febrile UTI or deterioration in renal function. UROLOGY 83: 199e205,
2014. 2014 Elsevier Inc.
osterior urethral valves (PUV) are recognized as
the most common cause of congenital urethral
obstruction.1,2 Vesicoureteral reflux (VUR) secondary to PUV is known to affect the ultimate outcome of
treatment and renal function status after correction of
PUV1 and is present in up to 72% of cases. Therefore,
management of VUR in these patients, where there is no
standard approach, is of utmost importance. However,
Financial Disclosure: The authors declare that they have no relevant financial interests.
From the Division of Pediatric Urology, Brady Urological Institute, The Johns
Hopkins Medical Institutions, Baltimore, MD; and the Pediatric Urology Research
Center, Section of Tissue Engineering and Stem Cell Therapy, Department of Pediatric
Urology, Children’s Pediatric Center of Excellence, Children’s Hospital Medical Center,
Tehran University of Medical Sciences, Tehran, Iran
Reprint requests: Abdol-Mohammad Kajbafzadeh, M.D., Pediatric Urology Research
Center, Section of Tissue Engineering and Stem Cell Therapy, Department of Pediatric
Urology, Children’s Pediatric Center of Excellence, Children’s Hospital Medical Center,
Tehran University of Medical Sciences, No. 62, Dr. Gharib’s Street, Keshavarz
Boulevard, 1419433151 Tehran, Iran. E-mail: [email protected]
Submitted: June 12, 2013, accepted (with revisions): July 24, 2013
ª 2014 Elsevier Inc.
All Rights Reserved
after successful correction of the obstruction, performing
antireflux procedures for persistent high-grade VUR is
Currently, various treatment strategies are available for
correction of VUR consisting of the following: (1)
conservative antibiotic prophylaxis; (2) open surgical
treatment; (3) minimally invasive endoscopic treatment;
and (4) observation or intermittent therapy with
management of bladder/bowel dysfunction (BBD), in
addition to treatment of urinary tract infections (UTI), as
they occur.3 The management of concomitant VUR and
PUV represents a unique challenge.
This study aimed to present the follow-up of patients with
PUV and concomitant VUR. VUR status was evaluated
after ablation and bladder neck incision (ablation/BNI).
Persistent VUR was managed with conservative antibiotic
prophylaxis, injection of Deflux alone, or concomitant
with autologous blood and ureteral reimplantation.
Study Population
We retrospectively reviewed the medical records of children
with PUV who underwent ablation/BNI as the initial management from April 1999 to November 2009. Those with evidence
of VUR on preoperative voiding cystourethrogram (VCUG)
and postoperative VUR within 3-6 months after successful
ablation/BNI were included. All patients had been receiving
Oxybutynin (0.2 mg/kg) and Baclofen for overactive bladder
symptoms since ablation/BNI and yet presented with VUR.
Exclusion criteria were the presence of complex urologic
anomalies such as prune belly syndrome or duplex systems,
age 15 years, or those who had not been monitored for at least
a year (Sup 1). Children were managed conservatively
(nonsurgical, group 1), underwent endoscopic Deflux injection
(group 2), or ureteroneocystostomy (UNC; group 3). Our
institutional review board approved this study. Adherence was
defined on the basis of the patient’s compliance with physician’s
recommendations and was expressed as the proportion of
patients who proceeded in exact accordance with the
Data Acquisition
Ultrasound evaluation of the urinary tract was performed for all
children before obstruction relief, at first and sixth months
postoperatively, then annually. Postoperative VCUG was obtained to ensure the absence of residual valve obstruction and to
evaluate the status of VUR annually in those with persistent
VUR. In patients who underwent surgical VUR correction,
VCUG was obtained 3-6 months postoperatively. VUR was
graded in accordance with the international system of radiographic grading of VUR in children.4 99Technetium dimercaptosuccinic acid scan was performed preoperatively and 6 months
postoperatively. It was performed 6 months after documented
UTI and a year thereafter. Relative kidney uptake of 45%-55%
was considered normal, whereas mild, moderate, and severe
renal function deterioration were defined as relative uptake
between 40%-45%, 20%-40%, and less than 20%, respectively.
Serum creatinine >1-2 mg/dL was considered as chronic renal
failure (CRF), and the need for renal transplantation was
regarded as end stage renal disease.5 Urodynamic studies (UDS)
were performed before and 6 months after ablation/BNI and
annually thereafter and was continued till normal urination.
Maximum voiding detrusor pressure (Pdetmax), detrusor overactivity (DO), myogenic failure, dysfunctional voiding (DV),
and bladder compliance were determined.6,7 Postvoid residual
was considered significant if it exceeded 15% of the expected
bladder capacity (EBC) (age >2:EBC ¼ [age (years) þ 2] 30,
age <2:EBC ¼ weight (kg) 7)8 (Sup 2).
Surgical Techniques and Interventions for VUR
During postoperative follow-up, all patients received antibiotic
prophylaxis (Cephalexin 15 mg/kg/night) till the disappearance
of VUR. For those children who experienced febrile UTIs or
deterioration in renal function during the first year after ablation/BNI, Deflux was injected. Conservative management with
antibiotic prophylaxis (Cephalexin 15 mg/kg/night) was performed on patients in group 1 until spontaneous resolution of
VUR. Endoscopic Deflux injection with autologous blood was
performed in the presence of breakthrough UTIs in this
subgroup. To determine the exact resolution rate under
conservative approach, last VUR state of these children before
injection therapy was considered in our estimations.
In group 2, endoscopic injection of Deflux was performed.
One subgroup received solitary Deflux (group 2a) injection,
whereas the other received Deflux and concomitant autologous
blood injection (group 2b). The surgical technique has been
previously described in detail.9,10,12,13 UNC was performed in
a subset of patients (group 3) who were referred to our center
from other primary and secondary centers; complete medical
records were present at referral, and follow-up visits were performed at our center. Antibiotic treatment/prophylaxis, anticholinergic medication (Baclofen or Oxybutynin), a1-adrenergic
antagonists (Terazosin or Prazosin), and biofeedback therapy
were prescribed as indicated,14 which were the same in all 3
Statistical Analysis
Data analysis was performed using SPSS (version 16.0). Normally distributed variables were expressed as mean SD. Chi
square test and analysis of variance were used to compare
categorical and continues normally distributed variables among
study groups, respectively. Fischer exact and Kruskal Wallis tests
were performed when applicable. Kaplan-Meier method was
used to compare the time to first occurrence of UTIs and CRF
among study groups. Survival plots were drawn and log rank
(Mantel-Cox) test was performed. All tests were 2-sided and a P
value <.05 was considered statistically significant. Lost to
follow-up after 1 year were not excluded, but the last data
regarding VUR status and occurrence of UTI was included.
UDS and dimercaptosuccinic acid scan were performed only as
aforementioned; therefore, no estimation was used.
A total of 140 children with persistent VUR in 224 renal
refluxing units after obstruction relief were included in
the study (Sup 1). Mean age of patients was 2.7 3.1 years (range, 2 months-14 years). Mean duration of
follow-up was 3.8 years (range, 2-6). Characteristics of
the patients and mode of diagnosis are outlined in
Table 1. In this historical cohort, 16 patients had
concomitant ureteropelvic junction obstruction, and 7
had megaureter (4 with concomitant ureteropelvic junction obstruction and megaureter) in whom UNC was
performed. Least adherence (54%) was seen in group 1,
mostly because of refusal of repeat VCUGs and no
compliance with antibiotic prophylaxis, whereas in
groups 2 and 3, it was approximately 90% (Sup 1).
Radiologic Evidence of VUR Correction
No complications such as urethral stricture or valve
residual were observed in immediate or repeat VCUGs
after ablation/BNI. In addition to 75 patients (34%) with
no sign of VUR on VCUG obtained within 6 months
after ablation/BNI, 57 of 140 of the patients (40%) with
persistent VUR experienced improvement from high
grade (IV-V) to low grade (I-III) VUR. During follow-up,
VUR resolution in group 1 was 66.1% and differed with
UROLOGY 83 (1), 2014
Table 1. Demographics
Group 2
Group 1 No. (%)
2a No. (%)
2b No. (%)
Group 3 No. (%)
Total No. (%)
Age ,*
33 (46.5)
18 (25.3)
10 (14.1)
7 (9.9)
3 (4.2)
Mode of
47 (66.1)
22 (30.9)
Urine retention
7 (9.8)
15 (21.2)
2 (2.8)
flank mass
VUR gradey
Grade I
1 (1.4)/30 (42.3)
Grade II
5 (7.0)/23 (32.4)
Grade III
13 (18.3)/5 (7.0)
Grade IV
21 (29.6)/9 (12.7)
Grade V
31 (43.7)/4 (5.6)
23 (32.4)/31 (43.6)
48 (67.6)/40 (56.4)
17 (60.7)
15 (68.1)
7 (25)
3 (10.7)
7 (25)
5 (22.7)
5 (22.7)
8 (36.3)
0/2 (7.1)
1 (3.6)/10 (35.7)
6 (21.4)/5 (17.9)
14 (50.0)/9 (32.1)
7 (25.0)/2 (7.1)
0/6 (27.3)
3 (13.6)/4 (18.2)
9 (40.9)/6 (27.3)
3 (13.6)/4 (18.2)
7 (31.8)/2 (9.1)
13 (68.4)
92 (65.7)
1 (5.3)/7 (36.8)
2 (1.4)/45 (32.2)
5 (26.3)/2 (10.5) 14 (10)/39 (27.9)
2 (10.5)/3 (15.8) 30 (21.4)/19 (13.6)
6 (31.6)/4 (21.1) 44 (31.5)/26 (18.5)
5 (26.3)/3 (15.8) 50 (35.7)/11 (7.8)
6 (21.4)/10 (45.4) 7 (31.8)/9 (40.9)
7 (36.8)/6 (31.5) 43 (30.8)/56 (40)
22 (78.6)/18 (53.6) 15 (68.2)/13 (59.1) 12 (63.2)/13 (68.5) 97 (69.2)/84 (60)
UTI, urinary tract infection; VUR, vesicoureteral reflux.
* Mode of presentation that lead to the diagnosis before valve ablation and bladder neck incision. Of note, some patients had concomitant
signs or symptoms.
VUR grade before and after valve removal for the patients fulfilled the selection criteria (before/after) has been depicted. VUR grade of
patients in each group did not differ significantly before start the cohort (chi square test, P value ¼ .062). Other demographics of patients
also did not differ significantly.
Table 2. Spontaneous vesicoureteral reflux resolution on conservative management in group 1
Group 1: Conservative Management
First Year No (%)
VUR resolution*
Grade I
Grade II
Grade III
Grade IV
Grade V
VUR improvement*
Grade I
Grade II
Grade III
Grade IV
Grade V
Second Year No (%)
Third Year No (%)
10 (33.3)
2 (8.7)
24 (80.0)
9 (39.1)
1 (20.0)
10 (33.3)
2 (8.7)
Fourth Year No (%)
Fifth Year No (%)
Abbreviation as in Table 1.
* All the enrolled patients had data at least for approximately 1 year after valve ablation and bladder neck incision. For the patients with
more than 1 year follow-up vesicoureteral reflux (VUR) resolution or improvement has been defined with respect to the last voiding cystourethrogram. The resolution or improvement was stratified according to the voiding cystourethrogram results within 6 months after
ablation/bladder neck incision. Improvement denotes to the no VUR or nondilating VUR (I-II) if patients had higher grades of IV-V.
respect to grade (Table 2). In groups 2 and 3, VUR was
eliminated in 86.0% and 94.0% of patients, respectively.
Performing UNC led to a significant success in VUR
resolution compared with other groups (P ¼ .013).
Among patients in group 2, success in group 2b was
significantly greater than group 2a (90.9% vs 78.5%, P ¼
.029, Sup 3).
UROLOGY 83 (1), 2014
Infection and Renal Function
Group 2 experienced a longer UTI-free period (Fig. 1).
Of the patients, 28 of 71 (39.4%) in group 1, 2 of 28
(7.1%) in group 2a, 1 of 22 (4.5%) in group 2b, and 6 of
19 (31.5%) in group 3 experienced UTI during follow-up
(P <.001). Febrile UTIs were observed in 10 of 71
(14.0%), 1 of 28 (3.5%), 0 of 22, and 3 of 19 (15.7%) of
Figure 1. (A) Time to occurrence of new cases of UTI, febrile UTI, and CRF. Children in goup 2 experienced more time free of any
significant bacteriuria. (B) Left graph, % of EBC significantly decreased after ablation/BNI (P <.001, A arrow) and when VUR was
corrected with surgical therapy within second year one significant reduction slope was seen (P <.001; B arrow). Middle graph,
One significant reduction in Pdetmax (cm H2O) was observed after ablation/BNI (P <.001, A arrow). Another significant decrease
was seen after surgical intervention for VUR correction in group 2 and 3 (P <.05, B arrow). First slope of decrease was sharper
than second one indicates the pivotal role of ablation/BNI rather than surgical correction of VUR. Indeed, successful valve
removal is also associated with considerable improvement in VUR. Right graph, DO significantly decreased after valve ablation/
BNI (P <.001, A arrow). No significant changes were observed after VUR management using 3 modalities, so no B arrow has
been depicted. BNI, bladder neck incision; EBC, expected bladder capacity; DO, detrusor overactivity; Pdetmax, maximum
voiding detrusor pressure; UTI, urinary tract infection; VUR, vesicoureteral reflux. (Color version available online.)
patients in groups 1-3, respectively (P ¼ .126). Of the 10
patients in the conservative group with febrile UTI, 8
underwent endoscopic Deflux injection with concomitant autologous blood injection, in whom VUR was
eliminated successfully in 5, and VUR grade improved to
grade I in the remaining 3. New renal scarring was
detected in 3 of 71 (4.2%), 0, 0, and 1 of 19 (5.2%) in
groups 1-3, respectively (P ¼ .203). A total of 7 (9.8%), 2
(7.1%), 3 (13.6%), and 4 (21%) had CRF after ablation/
BNI (P ¼ .471), and last data of this cohort confirmed
that 18 of 64 (28.1%), 2 of 24 (8.3%), 3 of 21 (14.2%),
6 of 18 (33.3%) had CRF in group 1-3, respectively
(P ¼ .089).
Bladder Function
Serial UDS were available for 27, 7, 6, and 14 children in
groups 1-3, respectively. UDS demonstrated significant
decrease in Pdetmax after valve removal (P <.001, Fig. 1B,
middle graph). DO decreased significantly after ablation/
BNI (P <.001, Fig. 1B, right graph), and only 5 children
In our referral center, VUR was detected in 256 of children (78%) with PUV, which corresponds to previous
studies, reporting a 70% rate of secondary VUR among
PUV patients.15 It is recommended that patients presenting with PUV undergo VCUG before ablation/
BNI.16 Increased storage and/or voiding pressures caused
by lower urinary tract symptoms may lead to a spectrum of
in group 1 had persistent DO according to their final data.
Bladder compliance increased and EBC decreased during
follow-up. However, children in group 3 had lower
compliance and high values of % of EBC in comparison
with other groups (Figs. 1B, 3). No patient developed
myogenic failure after ablation/BNI except 3 boys in
group 3. After toilet training, only 2 (2.8%), 6 (21.4%), 3
(13.6%), and 5 children (27%) received diagnosis of DV
in groups 1-3, respectively (P ¼ .027). DV was successfully eliminated using a-adrenergic antagonist and
biofeedback in all of them except 2 patients in group 3.
UROLOGY 83 (1), 2014
Figure 2. Bladder compliance increased significantly after ablation/BNI in all groups with respect to their baseline data;
y ¼ (P <.001). Subsequently, it increases to normal level in all groups except group 3 that attain significance; * ¼ (P <.05).
BNI, bladder neck incision. (Color version available online.)
intravesical anatomic disorders possibly predisposing the
patient to VUR. These symptoms are reported to delay
spontaneous resolution of VUR and interfere with the
outcome of endoscopic and surgical treatment.17
In this study, all patients had undergone ablation/BNI
as the initial management. The authors perform BNI for
all PUV patients. Although it may not be a common
procedure, it is previously described that BNI concomitant with valve ablation reduces bladder hypercontractility effectively and prevents the development of
myogenic failure in patients with PUV. In addition, it
significantly decreases the need for anticholinergic
therapy and clean intermittent catheterization and is
recommended as the preferred treatment modality for
children with PUV. Primary bladder neck dysfunction is
usually associated with other forms of DV or might
present with lower urinary tract symptoms and might be
missed or treated incorrectly; this highlights the importance of performing BNI in the presence of PUV.6 In the
present series, VCUG obtained within 6 months after
ablation/BNI confirmed valve removal in all cases. No
complication such as urethral stricture or valve residual
was observed in immediate or repeat VCUGs. Spontaneous resolution of VUR was observed in 75 of patients
(34%); in addition, 57 of 140 (40%) experienced
improvement in VUR grade, from high (IV-V) to low (IIII), conferring to the secondary nature of VUR. This is
comparable with valve ablation without BNI in which
only 25% of reflux units improve to a lower grade16 and
highlights the benefits of BNI as a complementary
UROLOGY 83 (1), 2014
treatment modality for VUR secondary to PUV, in part
because of bladder function correction. However, 66% of
patients with the initial diagnosis of concomitant VUR
and PUV in whom only ablation/BNI was performed,
experienced VUR resolution during follow-up and presented better bladder outcome. This indicates that
a considerable number of patients will experience VUR
resolution in the long-term follow-up rather than in the
short-term; it may be because of improvement in bladder
function,6 as indicated by the absence of myogenic failure
in our patients (Figs. 1, 2). Resolution rate differed with
respect to the grade of VUR, implying that persistent
high-grade reflux after valve ablation/BNI could not be
corrected by conservative therapy alone and requires
further interventions. Reflux nephropathy and decreased
efficiency of ureteral urine transport caused by VUR are
detrimental in patients with PUV.1 Therefore, in cases
with persistent high-grade reflux after correction of
obstruction, attempts must be made to correct the concomitancy.15 However, VUR should be corrected only in
patients with recurrent febrile UTIs and deterioration in
renal function, because rigorous treatment with reimplantation may lead to myogenic failure (only 3 boys in
group 3 experienced myogenic failure in this study). In
this study, VUR was managed by applying 3 different
modalities as the following: observation, Deflux injection,
and open repair. In a recent study conducted by Fast
et al,18 no difference in the resolution of VUR was
observed among different grades of secondary reflux; this
finding is contrary to the results in primary cases;
additionally, they reported that despite primary grade V
VUR, secondary high grade VURs can resolve with
conservative therapy in some cases. The authors of the
present study also disregard UNC, because many children
who underwent UNC, were referred to our center because
of complications such as obstruction despite radiologic
elimination of VUR. However, we observed that
concomitant Deflux and autologous blood injection can
also eliminate VUR (90.9%) in children with febrile
UTIs or deterioration in renal function without predisposing children to myogenic failure. Accordingly,
patients in the conservative group in whom UTI was
manifested underwent endoscopic Deflux injection. In
addition, Deflux does not seem to harm compliance, with
or without autologous blood, and can be effective even in
higher grades of VUR. Therefore, in patients who
undergo breakthrough infections and interventions are
required for correction of the VUR, initial Deflux injection with/without autologous blood should be considered
before any open surgery which might deteriorate bladder
compliance. It bears mention that autologous blood
injection after Deflux implantation, previously developed
by the authors9,10,12,13 leads to clot formation and might
prevent leakage, migration, or shrinkage of the mound.
Moreover, the fibrin sealants in blood might contribute to
mound preservation. Although considered a subtle
change, 2 of the procedures reviewed here are not
acknowledged as the standard of care.
The mainstay of VUR treatment is to prevent renal
parenchymal damage and morbidity associated with
recurrent febrile UTIs.3,19 UNC was associated with
better outcome on radiological findings compared with
endoscopic and conservative therapy; however, no
improvement in renal function was observed, conversely,
it deteriorated in some cases. This could be explained by
the fact that all patients in this group had urologic concomitancy (UVJO or megaureter) before ablation/BNI
and also experienced postoperative complications;
therefore, a selection bias might have occurred. In addition, referral bias can be acknowledged, because observation of UVJO concomitant with PUV is a rare
combination, yet 16 cases were present in this study. In
this study, no significant difference in renal outcome in
terms of renal scarring was observed during our follow-up.
Meanwhile, the incidence of UTI in patients receiving
endoscopic Deflux injection concomitant with autologous blood was significantly lower compared with those
receiving UNC and conservative therapy, which were
approximately 15%. The authors hypothesize that low
compliance and complications jeopardizing bladder and
renal function might be responsible factors for the
occurrence of febrile UTIs and deteriorated renal function in patients with radiologic evidence of VUR
correction. In a recent study on 1551 children who had
undergone antireflux surgery, bowel and bladder
dysfunction, presenting before or after successful VUR
correction, were found to be important risk factors for
the development of febrile UTI.20 Interestingly,
DeFoor et al21 suggested that bladder dysfunction is
a strong predictor of end stage renal disease in children
with PUV. Once valve was removed successfully, all
patients experienced significant improvement of bladder
function, as observed on UDS and indicated by significant
decrease in Pdetmax and DO, accompanied by complete
resolution of myogenic failure (with the expectation of 3
cases in group 3). This finding is in accordance with other
studies and implies that improvement in urodynamic
variables and bladder function is dependent on valve
ablation rather than reflux correction; however, VUR
would be corrected after improvement in bladder function.6-22 All urodynamic parameters showed significant
resolution after ablation/BNI. Resolution in Pdetmax and
detrusor function showed significant correlation with both
obstruction and reflux resolution, conferring that reflux
might be secondary to obstruction and resolved after
ablation, whereas resolution in myogenic function, which
is interpreted from improvement in the residual and
bladder volume, was only correlated to obstruction relief.
Significant DV is observed in 13%-38% of boys after
valve ablation23 and 20% of children with primary VUR
will develop DV after toilet training.24 This study suggests
that 11.4% of children with persistent VUR after ablation/BNI will develop DV.
Several studies have reported the prognostic importance of voiding dysfunction in VUR cases.19,25,26
Glassberg et al27 reported that one-third of children
with DV or idiopathic DO disorder were found to have
VUR. In our study, a significant resolution in DV was
observed after intervention, which ranged from approximately 3% in group 1 to 27% in group 3; all were
successfully treated using a-adrenergic antagonist and
biofeedback, except 2 patients in group 3. Giurici and
Pennesi28 suggested investigation for BBD before correction of VUR in patients with VUR older than 3 years. As
it is believed that reflux and relapsing UTI can occur
secondary to BBD, hence correction of the dysfunction
results in spontaneous resolution of VUR without the
need for surgical interventions. Therefore, Oxybutynin
and baclofen for overactive bladder symptoms were
prescribed to all patients after ablation/BNI. In this study,
poor bladder compliance was not observed in those who
underwent concomitant Deflux and autologous blood
injection, whereas 31.57% of whom UNC was performed
experienced poor bladder compliance during the followup. It seems that bladder function is a key determinant
of renal outcome in children with VUR secondary to
PUV.29 Accordingly, attempts should be focused on
correction of bladder function rather than performing
invasive procedures for the correction of the radiologic
findings regarding VUR. In addition to possible selection
and referral bias that may have affected our results, other
limitations that should be acknowledged are as follows; as
serial VCUG studies were not pursued once VUR was
absent, unless the patient became symptomatic, we stayed
within the limits of detecting new-onset or recurrent
VUR. The small number of patients with UDS may
UROLOGY 83 (1), 2014
provide limitations when comparing LUT function
among groups.
Overall, conservative therapy can be regarded as the
mainstay of reflux treatment after successful valve
correction as it is associated with a 66% success rate and
no significant renal scarring. It provides the opportunity
to avoid invasive surgery and hospital stay. However,
when persistent high-grade reflux is observed after performing valve ablation/BNI and also for patients
noncompliance with repeat VCUGs or conservative
antibiotic prophylaxis, endoscopic injection (with
concomitant autologous blood) is recommended as the
mainstay intervention. Finally, UNC cannot guarantee
preservation of renal and bladder function even with
correction of VUR.
Once valve ablation/BNI has been performed, conservative antibiotic therapy is preferred for persistent VUR
secondary to PUV, as it has the benefit of low cost, no
surgical morbidity, and a 66% spontaneous resolution
rate. However, in persistent high-grade VUR with febrile
UTIs or deterioration in renal function, endoscopic
Deflux injection by performing concomitant autologous
blood injection technique is preferred. Rigorous approach
to persistent VUR with UNC may cause myogenic
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Supplementary data associated with this article can be found,
in the online version, at http://dx.doi.org/10.1016/j.urology.