Voiding cystourethrogram before pyeloplasty: to do or not to do?

Abstract

OBJECTIVE To assess the incidence of concomitant vesicoureteral reflux (VUR) in unilateral cases of ureteropelvic junction obstruction (UPJO) and to identify factors that predict VUR. METHODS Files of 381 pediatric patients who underwent unilateral pyeloplasty between 2000 and 2017 were retrospectively reviewed. A total of 270 patients with available data and ≥5 years of follow-up were eligible for this study. Demographic parameters, preoperative hydronephrosis grade, renal pelvis anteroposterior diameter (APD), renal parenchymal thickness (PT), split renal functions on MAG-3 scan and VUR status were noted. The patients were divided into two groups: those with concomitant VUR (group I, n: 24, 8.9%) and those without VUR (group II, n: 246, 91.1%). RESULTS Among 270 patients (205 boys, 75.9%) with a median age of 4 months (2-98), 197 (72.9%) had antenatal hydronephrosis. Median follow-up was 11 years (5-22). Among 24 patients with concurrent VUR, 6 (25%) had grade II VUR, whereas grade III-V VUR was detected in 18 (75%). Of these, 12 (50%) had ipsilateral VUR, 3 (12.5%) had contralateral, and 9 (37.5%) had bilateral VUR. In a median 137-month follow-up, spontaneous VUR resolution was observed in 6 (25%) patients, whereas 15 (62.5%) patients underwent endoscopic subureteral injection and 3 (12.5%) patients ureteroneocystostomy, respectively. Preoperative APD [35.5, (Inter Quantile Range) IQR (27.6-36.0) vs 26.5 IQR (25.0-35.0), P = .004] were significantly higher in group I, whereas group I had significantly lower PT [3.7, IQR (3.4-6.4) vs 5.8 IQR (4.4-6.1), P = .026]. Predictive factors for concomitant VUR were presentation with febrile UTI (odds ratio (OR): 2.769, P = .048), PT <3.95 mm (OR: 1.367, P = .043), and APD >28.8 mm (OR: 1.035, P = .001). CONCLUSION Our results indicated that concomitant VUR and UPJO might be detected in 1 out of every 11 patients undergoing pyeloplasty, while some type of surgical intervention for VUR was required in 75% of these patients. Thus, voiding cystourethrogram prior to pyeloplasty may be limited in those presenting with febrile urinary tract infection, having higher APD and lower PT on preoperative urinary ultrasonography.