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Is Routine Voiding Cystourethrogram Necessary following Double HIT for Primary Vesicoureteral Reflux?
Angela M. Arlen, MD, Hal C. Scherz, MD, FAAP, FACS, Eleonora Filimon, RN, Traci Leong, PhD, Andrew J. Kirsch, MD, FAAP, FACS.
Emory University/Children's Healthcare of Atlanta, Atlanta, GA, USA.

Background
Current AUA guidelines recommend voiding cystourethrogram (VCUG) following endoscopic treatment of vesicoureteral reflux (VUR). Double HIT (hydrodistention implantation technique) utilizes dynamic ureteral hydrodistention to monitor injection progress and has high success rates. We evaluated clinical and radiographic success of children undergoing Double HIT to determine the necessity of postoperative VCUG.
Methods
Children with history of febrile urinary tract infection (fUTI) who underwent Double HIT for primary VUR between 2009 and 2012 were identified. Patients were stratified as high or low clinical and radiographic risk. Demographics, VUR grade, presence of BBD, and preoperative fUTIs were assessed. Children were categorized as high clinical risk if they had ≥3 fUTIs or documented bladder bowel dysfunction (BBD). High radiographic risk included those <2 years of age or with grade IV-V VUR. Initially, all children underwent postoperative VCUG (“routine” group), while only those with an indication (high radiographic risk or clinical failure) did so during the latter portion of the study (“indicated” group). Clinical success was defined as no postoperative fUTI and radiographic success defined as negative postoperative VCUG. Average clinical follow-up was 34.7 ± 17.2 months. Children with secondary VUR, prior anti-reflux surgery or aberrant anatomy were excluded. Logistic regression analysis was performed to identify predictors of clinical and radiographic success.
Results
Two hundred and twenty-two children (198 girls, 24 boys) underwent Double HIT at a mean age of 4.1 ± 2.7 years. Mean maximum VUR grade was 3.04 ± 0.81 with the following breakdown: grade 1 (n = 5), grade 2 (n = 44), grade 3 (n = 114), grade 4 (n = 53) and grade 5 (n = 6). Sixty-eight children (30.6%) had BBD. Fourteen children (6.3%) experienced postoperative fUTI after discontinuing antibiotic prophylaxis, for a clinical success rate of 93.7%. One hundred and fourteen patients (51.4%) underwent postoperative VCUG; 76 were “routine” and 38 were “indicated”. There was no difference in clinical success among the different risk groups. Of children classified as low clinical/radiographic risk, 96.6% did not have a postoperative fUTI, compared to 91.1% for high risk patients (p=0.771). Odds of clinical success for the routine VCUG group was 9.9 times higher than for indicated VCUG cohort (95% CI 2, 50). Controlling for age, the odds of radiographic success for the routine cohort was 13 times higher than for the indicated group (95% CI 4.2, 40). Of the 27 radiographic failures, 8 (29.6%) experienced a minimum 2 grade improvement in VUR. Nine children (4.1%) underwent additional procedures, including repeat Double HIT in 6 (2.7%) and ureteral reimplantation in 3 (1.4%). Of those undergoing a secondary procedure, 5 had persistent VUR and fUTI while 4 had surgery based on postoperative VCUG findings alone.
Conclusions
Long-term clinical success following Double HIT for primary VUR is high with the vast majority (96%) of children avoiding additional or more invasive surgical procedures. Unless indicated by high grade, young age or clinical failure, postoperative VCUG should be considered an option in children undergoing endoscopic treatment of primary VUR using the Double HIT method.


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