Learning From the Learning Curve: Factors Associated With Successful Endoscopic Correction of Vesicoureteral Reflux Using Dextranomer/Hyaluronic Acid Copolymer

Purpose

Conflicting reports exist regarding the parameters guiding successful correction of vesicoureteral reflux using dextranomer/hyaluronic acid copolymer. We performed logistic regression analysis to evaluate the effect of injected volume while adjusting for other factors potentially associated with success following dextranomer/hyaluronic acid copolymer injection.

Materials and Methods

Between July 2003 and June 2006, 126 consecutive patients (34 boys and 92 girls) with a mean ± SD age of 6.5 ± 3.7 years with primary vesicoureteral reflux (196 refluxing ureters) underwent injection for febrile urinary tract infections. Success was defined as complete reflux resolution. Age, gender, laterality, preoperative vesicoureteral reflux grade, surgeon experience, dextranomer/hyaluronic acid copolymer volume, time to surgery from initial presentation and preoperative treatment for lower urinary tract symptoms were analyzed.

Results

Vesicoureteral reflux grade was I to V in 7 (3.5%), 53 (27%), 91 (46.4%), 30 (15.3%) and 15 renal units (7.6%), respectively. The success rate after 1 injection was 50% by patient and 59.2% by ureter. Mean injected volume was 0.9 ± 0.27 ml in those who had a successful injection vs 0.67 ± 0.24 ml in those in whom injection failed (p <0.001). The success rate after 1 injection was 78.9% using 0.8 ml or greater dextranomer/hyaluronic acid copolymer compared to 31.7% with less than 0.8 ml. Multivariate analysis confirmed that higher dextranomer/hyaluronic acid copolymer volume (p = 0.001), lower preoperative grade (p = 0.013), surgeon experience (p = 0.025) and treatment for lower urinary tract symptoms (p = 0.009) were associated with successful correction of vesicoureteral reflux.

Conclusions

Our analysis strengthens the previously reported association of surgeon experience and vesicoureteral reflux grade with successful endoscopic vesicoureteral reflux correction. The data also revealed an association between injected volume and vesicoureteral reflux correction even while controlling for other variables, highlighting its importance as a true success modifier.

Key Words: ureter, vesico-ureteral reflux, dextranomer/hyaluronic acid copolymer, urination disorders, endoscopy

Abbreviations and Acronyms: Dx/HA, dextranomer/hyaluronic acid copolymer, HIT, hydrodistention implantation technique, IT, injection therapy, LUTS, lower urinary tract symptoms, STING, subtrigonal polytetrafluoroethylene injection, UTI, urinary tract infection, VUR, vesicoureteral reflux