Can endoscopic injection (ei) of dextranomer/hyaluronic acid (dxha) be performed at time of pyeloplasty in treating vesicoureteral reflux (vur) with coexisting uretropelvic junction obstruction (upjo)?
Purpose There is paucity of data regarding the order and optimal management of VUR with coexisting UPJO. We explored the feasibility of simultaneous correction of both pathologies in one operative session taking advantage of the minimally invasive nature, the reasonable success rate and the extremely low incidence of ureteral obstruction associated with treatment of VUR by EI. Material and Methods From October 2002-January 2009, 14 children (15 renal units,9 boys and 5 girls, age range 10-48, median 26 months) were diagnosed with dilating VUR and coexisting UPJO as suspected by discrepancy between ureteral and pelvic dilatation associated with poor flow of the dye to the latter and persistent hold up that was further confirmed on nuclear renogram with a catheter in-situ. EI with DxHA and a dismembered pyeloplasty drained exclusively by a nephrostomy were performed at the same operative session. A nephrostogram was performed 7-10 days postoperatively in the first 3 patients. In the following, the nephrostomy was clamped on day 10 and if the child showed no clinical evidence of obstruction or leakage it was removed. Sonographic follow-up was performed at 4,8,12 months and yearly thereafter and a VCUG was done at 4 months. Results Follow-up range was 8-72 months (Median 36). None developed clinical evidence of obstruction or leakage after nephrostomy clamping. UPJO was successfully corrected in all patients as evidenced by appreciable reduction in their hydronephrosis. VUR resolved initially in 9 units (60%). Repeat injections in 2 and a formal open reimplant in 4 were needed to reach a definitive cure. Conclusions In dilating VUR with coexisting UPJO, a reasonable proportion of affected children can be cured in a single operative session by a dismembered pyeloplasty and EI with DxHA. The latter does not seem to increase the perioperative morbidity or negatively affect the late results of pyeloplasty. The proposed risk of devascularizing the ureter if operated upon simultaneously at both poles is virtually eliminated.