Intraoperative ultrasound-assisted approach for endoscopic treatment of vesicoureteral reflux in children

Purpose Despite minimal invasiveness and high success rate, guidelines still prescribe voiding Cystourethrogram (VCUG) after endoscopic treatment for vesicoureteral reflux (VUR) in children. The aim of this paper was to analyze whether intraoperative ultrasound (IO-US) could improve surgical accuracy and perioperative counseling, thus potentially decreasing the need for postoperative VCUG. Methods We selected children treated for moderate to high grade VUR, renal scarring or repeated infections under antibiotic prophylaxis from January to December 2015. Endoscopic injection was combined with IO-US to detect optimal needle placement and to guide mound formation. IO-US findings were compared to surgeon opinion and postoperative VCUG, performed 3 months after surgery. All patients were followed-up for 1 year. Results A significant relationship was found between IO-US mound height (p = 0.003) or localization (p < 0.0005) and VCUG. Success of endoscopic treatment vs persistence of reflux groups had a mean mound height of 10.62 ± 1.36 mm and 8.39 ± 1.08 mm respectively (p < 0.0005). Height maintained a significant correlation with success in simple and multivariable regression analysis. ROC curve determined ≥ 9.8 mm as predictor of reflux resolution (95% CI 0.825 to 0.998; p < 0.0001). Conclusions IO-US facilitates pediatric urologists to find an optimal location, to reach a volcano mound morphology and height, thus increasing intraoperative accuracy. IO-US also helps evaluating high-risk recurrence and guiding prognostic counseling. Type of study Treatment study. Level of evidence II.