title: Outcomes of a minimally invasive surgical approach to manage persistent high-grade vesicoureteric reflux post successful augmentation cystoplasty of patients with non-compliant bladder.
abstract: BACKGROUND
  Secondary vesicoureteric reflux (VUR) is a common problem associated with non-compliant bladders. Management of this disorder is debatable in literature. Many authors reported high resolution rate of VUR with augmentation cystoplasty (ACP) alone. Others showed significant residual VUR after ACP and recommend ureteric re-implantation (UR) at time of augmentation.
  
  
  OBJECTIVE
  Studying efficacy of endoscopic correction of persistent high-grade VUR (ECVUR) post successful ACP.
  
  
  METHODS
  Patients with non-compliant bladders and high-grade VUR are enrolled in the program of our institute, where they are initially managed conservatively. Those not responding are managed endoscopically using intravesical botulinum toxin A and ECVUR. Patients who are not candidates or failed this approach undergo ACP without UR. A total of 82 patients with non-compliant bladder underwent ACP between 2001 and 2011. Of those, 24 patients had high-grade VUR with 44 refluxing units (RU), 20 bilateral and 4 unilateral. The mean age at intervention was 7.62 years with a mean follow-up of 5.6 years. Patients with persistent high-grade VUR and recurrent breakthrough febrile UTI despite antibiotic prophylaxis following ACP were identified and enrolled in our prospective trial of interval ECVUR. Statistical analyses was performed to identify predictors of high-grade VUR resolution after ACP and ECVUR. A p value <0.05 was considered statistically significant (Table 1).
  
  
  RESULTS
  Of the 24 patients, 17 underwent ileocystoplasty and 7 underwent ureterocystoplasty. One of the patients that underwent ileocystoplasty found to have a blind ending RU that was excised. Of the 36 remaining RU, 21/36 (58.3%) showed complete resolution in the first follow-up cystogram, and 1 showed complete resolution after 1 year. Two patients, each with single RU, received repeat ACP because of poor compliance and/or inadequate bladder capacity post ureterocystoplasty and showed complete resolution of reflux post-operatively, which increased the resolution rate post ACP to 66.6% (24/36) (Table 2). Of the remaining 12 RU in 7 patients, 10 underwent trial of ECVUR. VUR resolved in 8 RU after the first trial and in another 2 after the second trial (Table 3). Parents of 1 patient with the remaining 2 RU preferred to continue with conservative management (Table 2).
  
  
  CONCLUSIONS
  VUR in patients with non-compliant bladder is usually secondary to high detrusor pressure, low compliance and small capacity. Whereas some investigators showed high resolution rate of VUR post augmentation without UR, claiming that by successfully augmenting the bladder, compliance will increase, detrusor pressure will decrease, and as a result, VUR will spontaneously resolve. Others showed high incidence of persistent VUR (47-57%) and recommend UR at time of ACP. In our study, the incidence of spontaneous resolution was 66.6% (24/36). In cases where VUR persists, ECVUR was performed. With this approach, VUR resolution increased to 94% (34/36). This study is limited by the small number of patients, lack of randomization and lack of comparison group in which patients undergo ACP with UR.
  
  
  CONCLUSIONS
  ACP without UR with interval endoscopic management seems to be an effective and adequate treatment for high pressure, non-compliant bladder as well as high-grade VUR when conservative management fails.
authors.affiliation: Division of Urology, Department of Surgery, College of Medicine and King Khalid University Hospital, King Saud University, PO Box 2925, 11461 Riyadh, Saudi Arabia; Department of Urology, College of Medicine and King Fahd Hospital of the University, University of Dammam, PO Box 40086, Alkhobar 31952, Saudi Arabia. Electronic address: sowayan81@gmail.com.
authors.forename: Ossamah
authors.initials: O
authors.lastname: Alsowayan
authors.affiliation: Division of Urology, Department of Surgery, College of Medicine and King Khalid University Hospital, King Saud University, PO Box 2925, 11461 Riyadh, Saudi Arabia.
authors.forename: Alaa
authors.initials: A
authors.lastname: Barham
authors.affiliation: Division of Urology, Department of Surgery, College of Medicine and King Khalid University Hospital, King Saud University, PO Box 2925, 11461 Riyadh, Saudi Arabia.
authors.forename: Naif
authors.initials: N
authors.lastname: Alqarni
authors.affiliation: Division of Urology, Department of Surgery, College of Medicine and King Khalid University Hospital, King Saud University, PO Box 2925, 11461 Riyadh, Saudi Arabia.
authors.forename: Mansour
authors.initials: M
authors.lastname: Alnazari
authors.affiliation: Division of Urology, Department of Surgery, College of Medicine and King Khalid University Hospital, King Saud University, PO Box 2925, 11461 Riyadh, Saudi Arabia.
authors.forename: Mahmoud
authors.initials: M
authors.lastname: Alsakharni
authors.affiliation: Division of Urology, Department of Surgery, College of Medicine and King Khalid University Hospital, King Saud University, PO Box 2925, 11461 Riyadh, Saudi Arabia.
authors.forename: Tamer
authors.initials: T
authors.lastname: Ewida
authors.affiliation: Division of Urology, Department of Surgery, College of Medicine and King Khalid University Hospital, King Saud University, PO Box 2925, 11461 Riyadh, Saudi Arabia.
authors.forename: Mahmoud
authors.initials: M
authors.lastname: Trbay
authors.affiliation: Pediatric Urology Unit, Urology Department, Assiut University Hospital, Assiut, Egypt.
authors.forename: Ahmad A
authors.initials: AA
authors.lastname: Elderwy
authors.affiliation: Division of Urology, Department of Surgery, College of Medicine and King Khalid University Hospital, King Saud University, PO Box 2925, 11461 Riyadh, Saudi Arabia.
authors.forename: Hamdan
authors.initials: H
authors.lastname: Alhazmi
authors.affiliation: Division of Urology, Department of Surgery, College of Medicine and King Khalid University Hospital, King Saud University, PO Box 2925, 11461 Riyadh, Saudi Arabia.
authors.forename: Khalid Fouda
authors.initials: KF
authors.lastname: Neel
mesh_terms: D000704:Analysis of Variance; D016009:Chi-Square Distribution; D002648:Child; D002675:Child, Preschool; D002908:Chronic Disease; D015331:Cohort Studies; D003558:Cystoscopy / Q000379:methods; D005260:Female; D006801:Humans; D008297:Male; D019060:Minimally Invasive Surgical Procedures / Q000379:methods; D020127:Recovery of Function; D012086:Reoperation / Q000379:methods; D012189:Retrospective Studies; D012720:Severity of Illness Index; D016896:Treatment Outcome; D001743:Urinary Bladder / Q000002:abnormalities / Q000601:surgery*; D001750:Urinary Bladder, Neurogenic / Q000150:complications / Q000175:diagnosis / Q000601:surgery*; D014563:Urodynamics; D013520:Urologic Surgical Procedures / Q000009:adverse effects* / Q000379:methods; D014718:Vesico-Ureteral Reflux / Q000209:etiology / Q000601:surgery*
keywords: Augmentation cystoplasty; Dextranomer/hyaluronic acid copolymer; Intravesical botulinum toxin A; Neuropathic bladder; Vesicoureteral reflux