Is Configuration of the Orifice A Better Predictor of Success in Endoscopic Management of Vesicoureteric Reflux?: A Pilot Study

Abstract

Vinod Raj*, Ram Mohan Shukla, Maneesh Kumar Joleya, Pooja Tiwari, Shashi Shankar Sharma, Ashok K Laddha, Manoj Joshi and Brijesh K Lahoti

Introduction: Management of Vesico Ureteral Reflux (VUR) has always been dictated by grade of reflux, higher the grade of reflux, lesser the inclination towards Endoscopic Management Vesico Ureteral Reflux (EMVUR). Results published from world-wide have shown that large number of high-grade refluxes are amenable to EMVUR while results with all lower grades of reflux is not uniformly successful. So, there are more factors at play than just grade of reflux which contributes to successful EMVUR. With this in mind, we formulated two hypotheses. 1. The radiological grade of VUR does not always correlate to the cystoscopic configuration of the orifice. 2. The configuration of the orifice is a better predictor of success than grade of reflux in EMVUR. This is a pilot study to confirm our hypotheses.

Materials and methods: A retrospective observational study. Cases of primary VUR with breakthrough Urinary Tract Infection (UTI) on antibiotic prophylaxis were subjected to EMVUR. All cases treated by single surgeon at same institute. Data regarding age, gender, pre-operative Micturating Cysto-Urethrogram (MCU), intraoperative cystoscopic video, post-operative MCU were collected and only those patients with all above data included in analysis.

Observations: 48 Renal Refluxing Units (RRU) included which ranged between grade 2 to grade 4. Among these, 40 were treated successfully by EMVUR. Among 48 orifices, 33 were termed as suitable and 15 as unsuitable configuration. The success of EMVUR was statistically more significant when compared with configuration of orifice rather than grade of reflux.

Conclusion: This pilot study proved our hypotheses beyond doubt. Cystoscopic grading of ureteric orifice before EMVUR is necessary to predict successful outcome.