title: Endoscopic therapy for vesicoureteral reflux: a meta-analysis. I. Reflux resolution and urinary tract infection.
abstract: OBJECTIVE
  Current American Urological Association treatment guidelines for vesicoureteral reflux do not include any recommendations pertaining to endoscopic therapy (subureteral injection of bulking agent). We performed a meta-analysis of the existing literature pertaining to endoscopic treatment to allow comparison with reports of open surgical correction.
  
  
  METHODS
  We searched all peer reviewed articles published through 2003 pertaining to endoscopic treatment of vesicoureteral reflux. A total of 63 articles were double reviewed by 9 pediatric urologists, and the data were tabulated on data retrieval sheets. A mixed effects logistic regression model was used to obtain overall estimates of event probabilities (eg reflux resolution, ureteral obstruction) together with their 95% confidence intervals. Individual study estimates were obtained with overall estimate and observation characteristics using empirical Bayes calculations. Differences between or among specific groups were assessed using the F-test.
  
  
  RESULTS
  The database included 5,527 patients and 8,101 renal units. Following 1 treatment the reflux resolution rate (by ureter) for grades I and II reflux was 78.5%, grade III 72%, grade IV 63% and grade V 51%. If the first injection was unsuccessful, the second treatment had a success rate of 68%, and the third treatment 34%. The aggregate success rate with 1 or more injections was 85%. The success rate was significantly lower for duplicated (50%) vs single systems (73%), and neuropathic (62%) vs normal bladders (74%). The success rate was similar among children and adults. Following a previous failed open reimplantation endoscopic treatment was successful in 65% of patients. After endoscopic treatment with variable followup pyelonephritis developed in 0.75% of patients and cystitis in 6%. There were few reports of renal scarring following treatment.
  
  
  CONCLUSIONS
  Endoscopic treatment provides a high rate of success in children with reflux that decreases with increasing grade, although multiple treatments may be necessary. Future reports of endoscopic therapy should include rates of urinary tract infection and renal scarring.
authors.affiliation: Division of Pediatric Urology, Rainbow Babies and Children's Hospital, Cleveland, Ohio 44106, USA. jack.elder@case.edu
authors.forename: Jack S
authors.initials: JS
authors.lastname: Elder
authors.forename: Mireya
authors.initials: M
authors.lastname: Diaz
authors.forename: Anthony A
authors.initials: AA
authors.lastname: Caldamone
authors.forename: Marc
authors.initials: M
authors.lastname: Cendron
authors.forename: Saul
authors.initials: S
authors.lastname: Greenfield
authors.forename: Richard
authors.initials: R
authors.lastname: Hurwitz
authors.forename: Andrew
authors.initials: A
authors.lastname: Kirsch
authors.forename: Martin A
authors.initials: MA
authors.lastname: Koyle
authors.forename: John
authors.initials: J
authors.lastname: Pope
authors.forename: Ellen
authors.initials: E
authors.lastname: Shapiro
mesh_terms: D002648:Child; D006801:Humans; D012074:Remission Induction; D018666:Ureteroscopy; D014552:Urinary Tract Infections / Q000150:complications*; D014718:Vesico-Ureteral Reflux / Q000150:complications* / Q000601:surgery*