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Nine-year retrospective review of surgical treatment of vesicoureteral reflux (VUR): Comparison of three approaches
Miriam Harel, MD1, Katherine Herbst, MSc1, Renee Silvis, BS1, John H. Makari, MD2, Fernando A. Ferrer, MD2, Christina Kim, MD2.
1Connecticut Children's Medical Center, Hartford, CT, USA, 2Connecticut Children's Medical Center/University of Connecticut Health Center, Hartford/Farmington, CT, USA.

BACKGROUND:
Outcomes data regarding robotic ureteral reimplantation and Deflux injection for VUR compared to open reimplantation is still evolving. While some centers tend to favor one treatment modality over the others, we routinely offer and utilize all three approaches. We sought to analyze our nine-year experience in the surgical management of VUR.
METHODS:
We retrospectively reviewed all patients undergoing surgical intervention for VUR between 2001 and 2010. Treatment success was defined as complete resolution of VUR on postoperative voiding cystourethrography. Pearson Chi-Square was used for categorical comparisons, and t-test or Mann-Whitney U were used for continuous variables.
RESULTS:
Four hundred twenty-two patients (656 ureters) were identified. Patient characteristics and surgical outcomes are displayed in Tables 1 and 2.
Median age at time of surgery was 53 months (open reimplantation), 76 months (robotic reimplantation), and 78 months. (Deflux) Median length of follow-up was 17 months. (range 1-122 months) Most patients (59%) had preoperative VUR grades III-V. Postoperative VUR resolution rate was 90% (open reimplantation), 90% (robotic reimplantation), and 75%. (Deflux) Open reimplantation had a significantly higher VUR resolution rate than Deflux (p < 0.001) and a significantly longer length of hospitalization than robotic surgery. (p <0.001)
CONCLUSIONS:
Recent studies suggest that success rates of Deflux may be comparable to open reimplantation.1 In this study, we found significantly higher success rates with open reimplantation versus Deflux. While robotic reimplantation had high VUR resolution rates, comparison to open surgery or Deflux could not be performed due to smaller sample size of the robotic cohort. We continue to enroll in a prospective series of all VUR surgery at our institution which will result in more robust comparisons. Continued analysis of surgical outcomes is important for parental education and shared decision-making process.

1. Kalisvaart
JF, Scherz HC, Cuda S, et al. Intermediate to long-term follow-up indicates low risk of recurrence after Double HIT endoscopic treatment for primary
vesico-ureteral reflux. Journal of Pediatric Urology 2012; 8: 359-65.


Table 1- Patient characteristics
Variable (%, n)Open reimplantRobotic reimplantEndoscopic correctionTotal
Patients49% (238)3% (15)48% (231)100% (484)
Ureters51% (386)3% (21)46% (353)100% (760)
Female69% (167)93% (14)85% (196)77% (375)
Male31% (74)7% (1)15% (35)23% (109)
Preoperative VUR grade: I4% (16)5% (1)10% (35)7% (52)
II19% (71)29% (6)49% (174)33% (251)
III33% (123)52% (11)33% (115)33% (249)
IV27% (104)14% (3)6% (22)17% (129)
V16% (61)01% (3)9% (64)


Table 2- Surgical outcomes
Variable (%, n)Open reimplantRobotic reimplantEndoscopic correctionTotal
Post-op VUR
Resolved90% (284)90% (18)75% (241)83% (540)
Improved6% (20)5% (1)10% (32)8% (53)
Stable/Worsening3% (11)5% (1)15% (48)9% (61)
Development of contralateral VUR
Yes11% (8)25% (2)17% (17)15% (27)
No89% (66)75% (6)83% (82)85% (154)


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