title: The role of intraoperative cystography following the injection of dextranomer/hyaluronic acid copolymer.
abstract: OBJECTIVE
  Dextranomer/hyaluronic acid copolymer has become a popular bulking agent for subureteral injection in the treatment of vesicoureteral reflux. The success rates are lower compared to ureteral reimplantation, and, therefore, postoperative voiding cystourethrography is required. We sought to determine if post-injection intraoperative cystography can be useful in improving the success rate of injection and replacing the need for the 3 to 4-month postoperative voiding cystourethrogram.
  
  
  METHODS
  Dextranomer/hyaluronic acid copolymer was injected subureterally by a single surgeon until the orifice was crescentic at the dome of the bolus. Contrast material was instilled by gravity into the bladder until capacity was reached and was monitored fluoroscopically. No voiding phase was obtained. The procedure was deemed successful only in the absence of reflux. Postoperative voiding cystourethrography performed at 3 to 4 months postoperatively was used to determine whether antibiotic administration should be discontinued. The results of the 2 cystograms were compared.
  
  
  RESULTS
  A total of 41 patients (64 ureters) underwent subureteral injection. Intraoperative post-injection cystogram documented reflux eradication after a single injection in 96.9% of ureters and 95.1% of patients. Two boys had persistent reflux and 1 girl had new contralateral reflux after a single injection. In these cases additional bulking agent was injected and the reflux was confirmed by a second cystogram. There were 32 patients (52 ureters) who underwent intraoperative post-injection cystography plus postoperative voiding cystourethrography at 3 to 4 months. Postoperative voiding cystourethrography documented a 77% ureteral and 69% patient success rate. None of the patients with post-injection reflux had postoperative reflux at 3 to 4 months.
  
  
  CONCLUSIONS
  Intraoperative cystography following dextranomer/hyaluronic acid copolymer injection may help to determine immediate success and identify cases of new contralateral reflux. However, there is insufficient correlation with the standard 3 to 4-month postoperative cystogram to advocate replacing the current standard postoperative voiding cystourethrography with an intraoperative cystogram.
authors.affiliation: Division of Pediatric Urology, Schneider Children's Hospital and Smith Institute for Urology of North Shore-Long Island Jewish Health System, Long Island, New York, USA.
authors.forename: Lane S
authors.initials: LS
authors.lastname: Palmer
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D003911:Dextrans / Q000008:administration & dosage*; D005260:Female; D006801:Humans; D006820:Hyaluronic Acid / Q000008:administration & dosage*; D007223:Infant; D007267:Injections; D007432:Intraoperative Period; D008297:Male; D011134:Polysaccharides / Q000008:administration & dosage*; D012189:Retrospective Studies; D001743:Urinary Bladder / Q000000981:diagnostic imaging*; D014567:Urography; D014718:Vesico-Ureteral Reflux / Q000628:therapy*
chemical_list: D003911:Dextrans; D011134:Polysaccharides; C487487:dextranomer-hyaluronic acid copolymer; D006820:Hyaluronic Acid