Is Availability of Endoscopy Changing Initial Management of Vesicoureteral Reflux?

Department of Urology, Children's Hospital Boston, Boston, Massachusetts 02115, USA.
The Journal of urology (Impact Factor: 4.47). 08/2009; 182(3):1152-7. DOI: 10.1016/j.juro.2009.05.049
Source: PubMed


The optimal management of vesicoureteral reflux continues to be controversial. Since dextranomer/hyaluronic acid copolymer implants were approved in 2001 for endoscopic antireflux surgery, the perception that endoscopy is less morbid than open surgery, combined with concerns over potential adverse effects of prophylactic antibiotics, has led some to advocate endoscopy as initial therapy for reflux. We examined whether the availability of endoscopy has changed the management of reflux.
The i3 Innovus database (Ingenix, Eden Prairie, Minnesota) contains longitudinal claims data on more than 39 million patients spanning a 5-year period. We analyzed children diagnosed with vesicoureteral reflux (ICD-9 code 593.7, plus claim for radiographic or nuclear cystogram within 90 days) and at least 1 year of followup. We assessed patient characteristics, and diagnostic and therapeutic interventions. We evaluated surgical trends, including the changing use of endoscopic vs open antireflux surgery.
Among 9,496 children meeting inclusion criteria 1,998 (21%) underwent antireflux surgery during the study period (2002 to 2006). Median followup for surgical cases was 894 days. Of patients undergoing antireflux surgery 1,046 (52.4%) underwent an open procedure and 952 (47.6%) underwent endoscopy. Females were more likely to undergo endoscopy (52% vs 33% of males, p <0.0001), as were children older than 5 years (53% vs 45% of those younger, p = 0.0002). Of patients undergoing surgery 1,234 (62%) were treated early (within 12 months of diagnosis). During the study period the rate of newly diagnosed reflux cases managed by early surgery increased from 12.0% to 17.3% (Mantel-Haenszel chi-square test p <0.0001). This increase was primarily due to a more than doubling of patients undergoing early endoscopy (4.2% in 2002 vs 9.7% in 2006, p <0.0001). The rate of newly diagnosed cases managed by early open surgery did not change significantly (p = 0.3446).
During a 5-year period after dextranomer/hyaluronic acid was introduced for endoscopic therapy the number of children newly diagnosed with vesicoureteral reflux treated with early antireflux surgery increased primarily due to increased use of endoscopy. This finding suggests that despite the lack of evidence of benefit, endoscopy is increasingly viewed as first line therapy for reflux.

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    • "However, if the duration of prophylactic antibiotic use were to exceed 3 years, 60% of the parents would choose endoscopic treatment over open surgery, although the child may have to undergo repeat injections, with a 20% risk of persistent reflux. Meanwhile, the increased use of endoscopic treatment have not resulted in decreased use of open antireflux surgery13,14), indicating a shift in surgical indications in some centers or regions37). "
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    ABSTRACT: Endoscopic treatment is a minimally invasive treatment for managing patients with vesicoureteral reflux (VUR). Although several bulking agents have been used for endoscopic treatment, dextranomer/hyaluronic acid is the only bulking agent currently approved by the U.S. Food and Drug Administration for treating VUR. Endoscopic treatment of VUR has gained great popularity owing to several obvious benefits, including short operative time, short hospital stay, minimal invasiveness, high efficacy, low complication rate, and reduced cost. Initially, the success rates of endoscopic treatment have been lower than that of open antireflux surgery. However, because injection techniques have been developed, a recent study showed higher success rates of endoscopic treatment than open surgery in the treatment of patients with intermediate- and high-grade VUR. Despite the controversy surrounding its effectiveness, endoscopic treatment is considered a valuable treatment option and viable alternative to long-term antibiotic prophylaxis.
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