title: Should the presence of congenital para-ureteral diverticulum affect the management of vesicoureteral reflux?
abstract: OBJECTIVE
  The presence of congenital para-ureteral diverticulum (PUD) has been presumed to lower the resolution rate of vesicoureteral reflux (VUR). PUD is considered an important cause of distortion of the vesicoureteral junction and persistence of VUR. Early surgery has been recommended based on this assumption. However, the scientific evidence supporting this approach is weak. We have been managing this group of patients more conservatively in the last 7 to 8 years on the premise that the presence of PUD is not per se an indication for surgery. To test this hypothesis, we performed a retrospective cohort study to compare the outcome of VUR in children with and without PUD.
  
  
  METHODS
  We identified 141 consecutive patients with VUR associated with PUD between 1990 and 2004. Of the patients 57 with duplication, ureterocele, neurogenic bladder or outlet obstruction were excluded from study. Median age of the remaining 84 patients at diagnosis was 2.9 years and 56 (69%) were males. Reflux was bilateral in 4 patients, and low (I to II), intermediate (III) and high (IV to V) grade in 39%, 35% and 26%, respectively. Followup was 3 to 168 months (median 47). The outcome was compared to a control group of 95 patients (150 units) with primary VUR and no PUD. The baseline parameters and followup were comparable in both groups.
  
  
  RESULTS
  Overall, VUR resolved in 43%, persisted in 27% and was surgically corrected in 30% of the units with PUD. In the 25 patients (26 units) who underwent surgical intervention breakthrough urinary tract infection or new renal scars were the indication in only 5. The remainder were operated on because of persistent VUR and the presence of PUD, mainly before 1997. The incidence of breakthrough urinary tract infection or new renal scar was similar in the controls (6% in PUD group vs 10% in controls, p = 0.7). The resolution rate was 60% for low grade, 39% for intermediate grade and 22% for high grade VUR. These figures were not significantly different from those of the control group in which the resolution rates were 52%, 28% and 33% for comparable grades (p = 0.9). Kaplan-Meier analysis and log rank test did not show any difference in resolution of VUR in the 2 groups (p = 0.84). Multivariate analysis identified grade as the only variable affecting resolution (p = 0.028). The size of PUD did not affect the likelihood of resolution.
  
  
  CONCLUSIONS
  The outcome of VUR is similar in children with or without PUD. Therefore, treatment of these patients should not differ. Surgery should be reserved for patients with breakthrough infection or renal scar progression.
authors.affiliation: Division of Urology, University of British Columbia, Vancouver, Canada.
authors.forename: K
authors.initials: K
authors.lastname: Afshar
authors.forename: R
authors.initials: R
authors.lastname: Malek
authors.forename: M
authors.initials: M
authors.lastname: Bakhshi
authors.forename: F
authors.initials: F
authors.lastname: Papanikolaou
authors.forename: W
authors.initials: W
authors.lastname: Farhat
authors.forename: D
authors.initials: D
authors.lastname: Bagli
authors.forename: A E
authors.initials: AE
authors.lastname: Khoury
authors.forename: J L
authors.initials: JL
authors.lastname: Pippi-Salle
mesh_terms: D016009:Chi-Square Distribution; D002675:Child, Preschool; D004240:Diverticulum / Q000601:surgery; D005260:Female; D006801:Humans; D008297:Male; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D014513:Ureter / Q000002:abnormalities* / Q000601:surgery; D014718:Vesico-Ureteral Reflux / Q000151:congenital* / Q000601:surgery