The need for ureteric re-implantation during augmentation cystoplasty: video-urodynamic evaluation

OBJECTIVE To evaluate video-urodynamic (VUD) results before and after surgery in children with high-pressure, low-compliance bladders and vesico-ureteric reflux (VUR), who had augmentation cystoplasty with no antireflux surgery, hypothesising that in these patients, poor preoperative bladder dynamics is not always the cause of the associated VUR, as VUR persists in some patients. PATIENTS AND METHODS We assessed objective VUD criteria where antireflux surgery might potentially be necessary to avoid reflux after augmentation, and retrospectively evaluated the clinical consequences of persistent VUR and compared it to those whom VUR resolved. In all, 19 patients with VUR and hypocompliant bladders (mean age 11.4 years, range 5-21) had augmentation ileocystoplasty. Lower urinary tract function was assessed before surgery and at 3 and 6 months afterward with VUD. Symptomatic febrile urinary tract infections (UTIs) and progressive renal scarring on scintigraphy were retrospectively evaluated in all patients. RESULTS VUR persisted in nine patients despite a low-pressure bladder. In all patients with persistent VUR, VUD at 6 months after surgery showed that VUR started at low bladder volumes (mean 29.6 mL, range 19-52) and low pressures (mean 14.6 cmH(2)O, range 9.6-25) when compared to the group with no persistent VUR. Before surgery VUD showed that reflux started at the beginning of the filling phase (mean 14.8 mL, range 8-33) with very low intravesical pressures (mean 7.8 cmH(2)O, range 4-17) in these nine patients. During the follow-up febrile UTIs were significantly more frequent in the group with persistent VUR. One patient had progressive renal scarring on scintigraphy after cystoplasty. CONCLUSION Preoperative VUD findings might be a very important predictor of the spontaneous resolution of VUR. In these patients concomitant VUR should be corrected simultaneously during bladder augmentation if it starts at low pressures on preoperative VUD, as persistence of VUR can induce scarring from febrile UTIs.