Risk factors for urinary tract infection after dextranomer/hyaluronic acid endoscopic injection

Abstract

Purpose: Endoscopic injection of dextranomer/hyaluronic acid is an option for primary vesicoureteral reflux. Few groups have assessed the rate of urinary tract infection after dextranomer/hyaluronic acid injection. We reviewed our experience with dextranomer/hyaluronic acid injection, and determined the incidence of and risk factors for postoperative urinary tract infection. Materials and Methods: A retrospective cohort study was performed of all children with primary vesicoureteral reflux treated with dextranomer/hyaluronic acid from 2002 to 2007 at a single institution. Patient demographics and clinical outcomes were abstracted from the medical record. Risk factors for postoperative urinary tract infection, including female gender, preoperative vesicoureteral reflux grade, recurrent urinary tract infection, bladder dysfunction, nephropathy and persistent vesicoureteral reflux after surgery, were analyzed in a multivariate logistic regression model. Results: We treated 311 children, of whom 87% were female and 13% were male (464 renal units), during the study period. Mode of presentation was urinary tract infection in 85% of cases. Mean followup was 2.6 years. Postoperatively urinary tract infection developed in 40 patients (13%) and febrile urinary tract infection developed in 11 (3.5%). Of patients with urinary tract infection 26 had initially negative postoperative voiding cystourethrogram, of whom 16 underwent repeat voiding cystourethrogram and 9 showed recurrent vesicoureteral reflux. Five of these 9 patients had clinical pyelonephritis. Of assessed risk factors only preoperative recurrent urinary tract infection (OR 2.2, p = 0.03) and bladder dysfunction (OR 3.3, p = 0.001) were independent predictors of post-injection urinary tract infection. Conclusions: In our series urinary tract infection after dextranomer/hyaluronic acid injection was rare. Patients with recurrent urinary tract infections and bladder dysfunction preoperatively are at increased risk for urinary tract infection after treatment. Patients with febrile urinary tract infection after dextranomer/hyaluronic acid injection are at high risk for recurrent vesicoureteral reflux. Editorial CommentThis manuscript studies 311 children over a five-year period that had Dx/HA. Secondary causes of reflux and poor follow-up patients were excluded. Bladder dysfunction included patients with enuresis, frequency/urgency, or urge incontinence and when discovered, standard treatment was instituted prior to surgery. This behavior and dietary modifications were continued after surgery if the bladder dysfunction persisted. Antibiotic prophylaxis was continued until a follow-up VCUG at 2-3 months showed no further reflux. The results showed 87% of their patients were female and 85% presented with a UTI and 60.5% were febrile. 90% of their patients had Grade III reflux or less. Preoperative nephropathy was present in 62 patients (20%) and bladder dysfunction was present in 64 patients (21%). The mean patient age was 5.7 years with mean follow-up of 2.6 years. T...