title: Clinical outcome after endoscopic therapy for occult vesicoureteral reflux in females: preliminary results of a retrospective case series.
abstract: OBJECTIVE
  The aim of this study was to evaluate the clinical outcome after endoscopic therapy by injection of bulking agent in the treatment of occult vesicoureteral reflux (VUR) [no VUR on standard voiding cystourethrography (VCUG), but positive (99m)Tc-2,3-dimercaptosuccinic acid (DMSA) scan] in females who have recurrent febrile urinary tract infections (UTIs).
  
  
  METHODS
  A case series was retrospectively identified of 24 females (mean age 15.5 years) with negative VCUG, but renal scars in one (n = 4) or both (n = 20) kidneys on DMSA scan. Endoscopic injection was performed bilaterally in 20 (83.3%) and unilaterally in four patients (16.7%). The incidence of postoperative UTIs was documented with a mean follow-up of 2.5 years (range 1-6 years).
  
  
  RESULTS
  The mean renal part function (DMSA scan) on the left and right sides was 53.5% (15-74%) and 47.3% (26-85%), respectively. Twenty-one out of 24 patients (87.5%) showed no evidence of any febrile UTIs postoperatively. One patient (4.2%) experienced a further febrile UTI 6 months after treatment. Two other patients (8.3%) had one questionable afebrile UTI, 4 and 3 years after therapy. Pressure-flow electromyography confirmed a dysfunctional voiding pattern in 12 patients (50%) treated with pelvic floor therapy and behavioural interventions before endoscopic therapy.
  
  
  CONCLUSIONS
  Injection of bulking agent seems to be a suitable treatment for occult VUR in females to prevent further febrile UTIs. Patients with occult VUR should undergo a careful evaluation of possible urodynamic disorders such as dysfunctional voiding. These findings should be studied in prospective trials before drawing any conclusions.
authors.affiliation: Department of Urology, Medical University of Innsbruck , Innsbruck , Austria.
authors.forename: Renate
authors.initials: R
authors.lastname: Pichler
authors.forename: Isabel
authors.initials: I
authors.lastname: Heidegger
authors.forename: Barbara
authors.initials: B
authors.lastname: Schlenck
authors.forename: Wolfgang
authors.initials: W
authors.lastname: Horninger
authors.forename: Josef
authors.initials: J
authors.lastname: Oswald
mesh_terms: D000293:Adolescent; D002648:Child; D004576:Electromyography; D004724:Endoscopy / Q000379:methods*; D005260:Female; D006801:Humans; D015994:Incidence; D012008:Recurrence; D012189:Retrospective Studies; D016896:Treatment Outcome; D014552:Urinary Tract Infections / Q000517:prevention & control*; D014563:Urodynamics / Q000502:physiology; D013520:Urologic Surgical Procedures / Q000379:methods*; D014718:Vesico-Ureteral Reflux / Q000503:physiopathology / Q000601:surgery*; D055815:Young Adult
keywords: endoscopic therapy; occult vesicoureteral reflux; positive DMSA scan; recurrent febrile urinary tract infection; renal scar