Objective: To evaluate the clinical factors that influence the outcome of endoscopically treated primary grade III and IV vesicoureteral reflux (VUR).
Materials and methods: Excluding secondary VUR and patients with incomplete follow up, a retrospective and prospective cohort observational study was performed on 90 children (130 renal units) with primary grade III or IV reflux treated endoscopically with Polytef or Macroplastique from March 1997 to January 2004. All patients underwent voiding cystourethrography (or galactose-based sonocystourethrography), dimercaptosuccinic acid (DMSA) scan, renal ultrasound and clinical exploration of micturition. Data were collected on age, gender, urinary tract infection (UTI), bilaterality, renal scarring, voiding dysfunction, and success rate. A new factor was defined, ureteral dilatation of the renal unit (not related to grade according to findings of pelvi-calyceal images), and graded by a single pediatric urologist blinded to its International Classification grade.
Results: The male-to-female ratio of patients was 2.91. Reflux was bilateral in 44.4%. There was UTI at presentation in 64 cases, and 21 newborns had been prenatally diagnosed (ratio M/F 5.2:1). We found a strong relation between the incidence of renal scarring at presentation and voiding dysfunction (P<0.01). Cure rate at first injection was 64%. While univariate analysis appeared to show a strong association between resolution at first injection and bilaterality, voiding dysfunction, nephropathy and ureteral dilatation grade, with simultaneous logistic regression, the only statistically significant predictor was the presence of high-grade dilatation vs low ureteral dilatation (P<0.001; OR 0.045; 95% CI 0.01-0.16). Progression of renal damage was noted especially in patients with voiding dysfunction (P=0.053), bilaterality (P=0.034), and severe ureteral dilatation (P<0.001).
Conclusions: The relationship between success rate of endoscopic treatment and grade of ureteral dilatation is demonstrated. Other factors significantly involved in the resolution of VUR are voiding dysfunctional syndrome, bilateralism of reflux, and scarring on initial DMSA. Gender, age, number of infections during follow up and prenatal diagnosis do not influence the outcome of endoscopic treatment.