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New Contralateral Vesicoureteral Reflux After Unilateral Reimplantation: Predictive Factors and Clinical Outcomes

Sunday, October 21, 2012: 9:49 AM
Grand Ballroom B (Hilton Riverside)
Katherine C. Hubert, M.D., M.P.H.1, Paul J. Kokorowski, M.D., M.P.H.1, Lin Huang, Ph.D2, Michaella M. Prasad, M.D.1, Ilina Rosoklija, M.P.H.1, Alan B. Retik, M.D.1 and Caleb P. Nelson, M.D., M.P.H.1, (1)Department of Urology, Children's Hospital Boston, Boston, MA, (2)Clinical Research Program, Children's Hospital Boston, Boston, MA

Purpose

Although unilateral ureteral reimplantation for vesicoureteral reflux is highly successful, a few patients will develop new contralateral vesicoureteral reflux (C-VUR). There are few data regarding risk factors for C-VUR, and its clinical significance is uncertain. We examined predictors and clinical outcomes of C-VUR.

Methods

We reviewed all patients who underwent non-tapered unilateral reimplantation for primary VUR at our institution (1/90 – 12/02), and identified those with C-VUR on postoperative cystogram. We analyzed the association of patient/procedure characteristics with incidence of C-VUR, postoperative urinary tract infection (UTI), and time to resolution of C-VUR.  Multivariable models were developed to control for variables associated with incidence and time to resolution of C-VUR in patients with >1 postoperative cystogram. VUR was graded on a 3-point scale.

Results

395 patients (77.2% female) had non-tapered unilateral reimplantation at a median age of 5.3 years. Preoperative VUR was grade 1 in 2.8%, 2 in 56.6%, 3 in 40.6%.  Overall technical success rate (no VUR on reimplanted side) was 95.4%.  Post-reimplantation, 39 patients had new C-VUR (9.9%): grade 1 in 7, grade 2 in 27, grade 3 in 5. (Five patients with C-VUR also had ipsilateral VUR). On multivariate analysis, younger age (<=6 years: OR 3.7, 95% CI 1.5-9.2, p=0.006) and low observed bladder capacity (BC) as % of predicted BC [(<50% predicted BC: OR 6.3, 95% CI 1.3-31.5, p=0.02) and (50-100% predicted BC: OR 1.7, 95% CI 0.8-3.7, p=0.1)] were significant predictors of C-VUR.  Gender, race, clinical presentation, preoperative VUR grade, surgical technique and duplex system were not associated with C-VUR.  Among the 39 with C-VUR, median follow-up was 51.8 months. 12/39 patients (31%) had no subsequent cystography; of these, 4 were grade 1, 7 were grade 2, 1 was grade 3. Of 27 with subsequent cystography, C-VUR resolved in 23 (85.2%) at a median of 21.5 months; the 4 with persistent CVUR were all grade 2. Only 2 patients had reimplantation for CVUR.  Of the 39 with C-VUR, 4 (10.3%) had postoperative febrile UTI (median 26 months postoperatively). All had resolution of C-VUR on subsequent imaging (median 9.5 months post-UTI). 

Conclusion

Few factors reliably predict C-VUR after unilateral reimplantation, but younger patients and those with low observed BC (vs. predicted) may be at increased risk.  However, a majority of C-VUR will resolve spontaneously, and the clinical course is typically benign.