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Introduction

Endoscopic injection of subureteric bulking agents (SBAs) provides a minimally invasive surgical option for the treatment of vesicoureteral reflux. We evaluated the correlation between ureteral jet angle (UJA) demonstrated by preoperative ultrasound and the successful treatment of vesicoureteral reflux with SBAs.

Methods

This is a retrospective study of pediatric patients treated with SBAs for vesicoureteral reflux. Inclusion criteria were preoperative and postoperative voiding cystourethrogram (VCUG) and preoperative ultrasound that demonstrated ureteral jets. Resolution of reflux was defined as complete absence of reflux on postoperative VCUG. Patients with missing radiographic studies, repeat SBAs, or patients with duplicated collecting systems were excluded. Preoperative UJAs were measured by ultrasound in the transverse plane as the angle between the ureteral jet and the trigonal ridge. Mean UJAs were compared using the t-test. The electronic medical record was reviewed for pertinent clinical and radiographic parameters.

Results

We identified 68 refluxing renal units in 48 patients. Median age was 6 years old (range 2-11). Majority of patients were female (89.5%). 70.7% of patients were dysfunctional voiders. 47 renal units had low-grade reflux (grade 1 and 2) while 21 had high-grade reflux (grades 3, 4, and 5). The mean preoperative UJA in patients with resolution of reflux after SBA was 60.4° (std. 24.7) compared to a preoperative UJA of 85.4° (std. 45.6) with persistent reflux postoperative, p=0.0097 (Figure 1). When stratified by grade of reflux, resolution of low-grade reflux demonstrated an acute preoperative ureteral jet angle (64.4° +/-27.7) compared to patients with persistent reflux (98.15° +/- 45.33), p=0.0039. This effect was not seen in children with high-grade reflux (21 renal units). Dysfunctional voiders displayed the same trend in mean preoperative UJA. Mean preoperative UJA with resolution of reflux was 61.9° (SD+/- 26.1) and 100.6° with persistent reflux (SD +/- 50.3) in this subpopulation, p=0.0004. No significant difference was seen in nondysfunctional voiding children (20 renal units). No association was seen with UJA and the development of febrile UTI postoperatively.

Conclusions

In our study sample, an acute preoperative UJA measured by renal US was associated with resolution of reflux with SBAs. Further investigation into the prognostic utility of UJA is warranted.

Funding

None