title: Effective endoscopic diagnosis and treatment of pediatric occult vesicoureteral reflux with intermediate to long-term follow-up.
abstract: OBJECTIVE
  Recurrent febrile urinary tract infections (fUTIs) in children with non-diagnostic voiding cystourethrogram (VCUG) are challenging, as misdiagnosis can lead to renal damage and increased morbidity. We compared fUTI rates before and after endoscopic treatment of patients with suspected occult VUR.
  
  
  METHODS
  Between January 2009 and December 2012, children with history of fUTI and non-diagnostic VCUG(s) underwent endoscopic ureteral hydrodistention (HD) and injection of dextranomer hyaluronic acid co-polymer (Dx/HA). fUTI rates before and after intervention were evaluated. Demographics, imaging and endoscopic findings were assessed.
  
  
  RESULTS
  Thirty-four children (mean age 5.4±2.8 years) underwent bilateral Dx/HA injection for occult VUR. Average follow-up was 28.8 months. Seventeen children had renal scarring. Mean ureteral HD grade was 2.2/3. HD grade for ureters associated with renal scarring was significantly (p<0.05) higher (2.6/3) than those without scarring (2.0/3). Mean injected volume was 1.2 mL. Ureters associated with renal scarring (n=21) required significantly (p<0.05) higher volumes (1.4 mL) than those without scarring (n=47; 1.1 mL). Prior to intervention, the fUTI rate was 0.15/patient/month compared to just 0.02 after treatment (p<0.0001).
  
  
  CONCLUSIONS
  Incidence of fUTIs significantly decreased following treatment, supporting the use of Dx/HA injection in carefully selected children when the suspicion for occult VUR is high.
authors.affiliation: Department of Pediatric Urology, Emory University, Children's Healthcare of Atlanta, Atlanta, GA, USA. Electronic address: angarlen@gmail.com.
authors.forename: Angela M
authors.initials: AM
authors.lastname: Arlen
authors.affiliation: Department of Pediatric Urology, Emory University, Children's Healthcare of Atlanta, Atlanta, GA, USA.
authors.forename: Kristin M
authors.initials: KM
authors.lastname: Broderick
authors.affiliation: Children's Healthcare of Atlanta and Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University School of Medicine, Atlanta, GA, USA.
authors.forename: Traci
authors.initials: T
authors.lastname: Leong
authors.affiliation: Department of Pediatric Urology, Emory University, Children's Healthcare of Atlanta, Atlanta, GA, USA.
authors.forename: Liisa L
authors.initials: LL
authors.lastname: Dewhurst
authors.affiliation: Department of Pediatric Urology, Emory University, Children's Healthcare of Atlanta, Atlanta, GA, USA.
authors.forename: Eleonora
authors.initials: E
authors.lastname: Filimon
authors.affiliation: Department of Pediatric Urology, Emory University, Children's Healthcare of Atlanta, Atlanta, GA, USA.
authors.forename: Aaron D
authors.initials: AD
authors.lastname: Weiss
authors.affiliation: Department of Pediatric Urology, Emory University, Children's Healthcare of Atlanta, Atlanta, GA, USA. Electronic address: akirschmd@gmail.com.
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Kirsch
mesh_terms: D002675:Child, Preschool; D003911:Dextrans / Q000008:administration & dosage*; D003937:Diagnosis, Differential; D004724:Endoscopy / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D006820:Hyaluronic Acid / Q000008:administration & dosage*; D007267:Injections; D008297:Male; D012189:Retrospective Studies; D013997:Time Factors; D014718:Vesico-Ureteral Reflux / Q000175:diagnosis* / Q000628:therapy*
chemical_list: D003911:Dextrans; C487487:dextranomer-hyaluronic acid copolymer; D006820:Hyaluronic Acid
keywords: Diagnosis; Occult vesicoureteral reflux; Pyelonephritis; Urinary tract infection