|Year : 2013 | Volume
| Issue : 1 | Page : 11-15
Vesicoureteral reflux: Endoscopic therapy and impact on health related quality of life
Saurabh Garge1, Prema Menon1, Katragadda Lakshmi Narasimha Rao1, Anish Bhattacharya2, Labeeb Abrar2, Monika Bawa1, Ravi P Kanojia1, Jai Kumar Mahajan1, Ram Samujh1
1 Department of Pediatric Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Nuclear Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
|Date of Web Publication||7-Feb-2013|
Katragadda Lakshmi Narasimha Rao
Professor and Head of Pediatric Surgery, P.G.I., Chandigarh-160012
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aim: To evaluate the health related quality of life (HRQOL) after endoscopic injection treatment for vesico ureteral reflux (VUR) in children. Materials and Methods : Fifty four children received treatment and were prospectively evaluated for their quality of life scores, according to resolution of reflux on cystograms and status of renal scars. Results: Of the 81 refluxing units, 72 (89%) had resolution of reflux whereas 9 (11%) did not resolve. The total average QOL was higher for the patients in the resolved group as compared to the non resolved group. Comparison of pre and post procedure renal DMSA scans in 44 patients showed status quo in 26, regression of scars in six, progression in two and formation of new scars in 6.The total increase in HRQOL was highest in regression group (67.91), and lowest in progression group (36.45). Conclusions: Successful endoscopic treatment of VUR is associated with improved quality of life, as indicated by higher HRQOL scores in the resolved group.
Keywords: Dextranomer/hyluronic acid polymer, health related quality of life, vesicoureteral reflux
|How to cite this article:|
Garge S, Menon P, Narasimha Rao KL, Bhattacharya A, Abrar L, Bawa M, Kanojia RP, Mahajan JK, Samujh R. Vesicoureteral reflux: Endoscopic therapy and impact on health related quality of life. J Indian Assoc Pediatr Surg 2013;18:11-5
|How to cite this URL:|
Garge S, Menon P, Narasimha Rao KL, Bhattacharya A, Abrar L, Bawa M, Kanojia RP, Mahajan JK, Samujh R. Vesicoureteral reflux: Endoscopic therapy and impact on health related quality of life. J Indian Assoc Pediatr Surg [serial online] 2013 [cited 2020 Jul 13];18:11-5. Available from: http://www.jiaps.com/text.asp?2013/18/1/11/107009
| Introduction|| |
Treatment for children with vesicoureteral reflux (VUR) ranges from, no treatment, long-term antibiotic prophylaxis, surgery, or a combination of antibiotic prophylaxis and surgery. , Numerous reports have investigated endoscopic injection treatment of dextranomer/hyluronic acid polymer (Dx/HA) (Deflux) in the context of primary VUR as well as of redo cases, underlining the efficacy of the procedure.  Consequently, Dx/HA is now considered to be a viable alternative to long-term antibiotic prophylaxis and even to open surgery. Endoscopic treatment provides a minimal invasive day care alternative for treatment of VUR.  The minimal invasive nature supersedes the cost constraints, and parents prefer to choose endoscopic treatment rather than open surgery. ,, In this study, we compared the health related quality of life of patients after endoscopic treatment for reflux, dividing them in groups according to the resolution of reflux and status of renal scars.
| Material and Methods|| |
Fifty four consecutive children (81 renal units) who received endoscopic subureteral Dx/HA injection treatment from January 2009 to December 2011 for primary VUR were prospectively followed. The major indication for Dx/HA treatment was, symptomatic VUR (grade II and grade III) with recurrent breakthrough infections. Grade I ureters were only treated in conjunction with bilateral cases. All patients included in the study had a febrile UTI or pyelonephritic changes leading to the diagnosis of VUR, and were on chemoprophylaxis prior to endoscopic therapy. We offered Dx/HA treatment primarily as an alternative to chemoprophylaxis and not to open surgery. Patients with associated complex anomalies (e.g.: ureteroceles, PUV, ureteral ectopia), previously failed ureteral reimplantation, severe renal scarring and neurogenic bladder dysfunction were excluded.
Demographic variables in the form of age, sex, height and weight of all these patients were recorded. The grading of reflux was noted on each side by a pre-operative micturating cystourethrogram (MCU). All patients were pre operatively assessed by a dimercaptosuccinic acid (DMSA) scan to assess the renal function and to detect any scarring in the presence of VUR. All the patients were followed up with MCU 3-months after the procedure and a DMSA after 1 year. All patients were also noted for resolution of VUR as well as for improvement in the symptoms. After a period of one year all the patients were assessed for progression or regression of previous scars along with appearance of new scars.
These patients were given a questionnaire to assess the change in the quality of life after the endoscopic injection procedure.  This questionnaire was designed to measure the benefit to the day-to-day health related quality of life (HRQOL) of a child that results from an intervention such as surgery. It has previously been validated and tested in pediatric patients being answered by parents or caretakers, since children lack the necessary skills in language and abstract reasoning to complete such an instrument themselves. ,, The Glasgow children's benefit inventory (GCBI) consists of 24 core questions with a five-point Likert score given to answer them. The total score is measured on a scale ranging from -100 (maximum harm) to +100 (maximum benefit) with 0 meaning no change at all. The GCBI questions are categorized into four subscales representing fields of daily life: (1) ''Emotion''(#3, 8, 9,11,17,19,20); (2) ''Physical health'' (#1,14,22,23,24); (3) ''Learning'' (#2, 4, 12,13,15,16); (4) ''Vitality'' (#5, 6, 7,10,18,21).
The HRQOL scores were compared with changes on MCU and DMSA scan after Dx/HA injection.
- The patients were segregated into two groups based on the postoperative MCU findings, i.e. resolved VUR and persistent reflux.
- The patients were divided into four groups based on DMSA findings: those with new scars, with progression of scars, with regression of scars and those
- with same status as pre op. The HRQOL scores of these patients were also compared.
| Results|| |
Fate of Renal Units: All patients were graded for reflux by MCU. There were 27 patients with bilateral and 27 patients with unilateral reflux, comprising a total of 81 refluxing units. Of the unilateral cases 16 had left sided and 11 had right sided reflux. There was grade 1 reflux in 6 units (7.5%); grade 2 in 8 units (9.8%), grade 3 in 18 units (22.22%), grade 4 in 20 units (24.7%) and grade 5 in 29 units (35.8%) [Figure 1]. Of the 81 refluxing units, 70 had resolution of reflux whereas 11 did not resolve. Out of these 11 patients, 3 had downgraded. They underwent redo deflux injection, following which reflux resolved completely in 2, but was persistent in 1. One patient was noted to have de-novo grade 1 reflux on the contralateral side with normal DMSA and was managed conservatively [Figure 2]. Of the total 54 patients, post operative DMSA was available in 44 patients. Six had development of new scars, 10 had regression of their scars in the form of improved function on DMSA, 2 had progression of scars and 26 patients had same DMSA status as found pre operatively. There was regression in 13 units (3 units with grade III, 6 units with grade IV, 4 units with grade V), progression in 4 units (all 4 units with grade V), new scar formation in 9 units (2 units with grade III, 3 units with grade IV, 4 units with grade V) and 39 units (4 units with grade I, 5 units with grade II, 7 units with grade III, 10 units with grade IV and 13 units with grade V) were similar to pre op status. The new scar formation occurred in 9 units of which there was resolution of reflux in 7 units, while the other 2 units had no resolution. Of the units which had persistent reflux with new scars both had grade V reflux. The patients with progression were both grade V reflux patients, which had resolved.
'GCBI' Questioniare and Quality of Life
The questionnaire was given to the parents for evaluation at an average period of 14.25 months (11months - 26 months) after surgery. The questionnaire was correctly answered and returned by 48 patients with a response rate of 89%.
Effect on hrqol0 scores based on mcu0 results: The total average QOL was higher for the patients in the resolved group as compared to the non resolved group. The highest improvement was in the 'vitality' aspect of QOL in the resolved group (66.66) and emotional and learning subscale (57.14 in both) in the non resolved group. The least improvement in average QOL was in physical health in both groups. (62.47 in resolved vs.42.85 in non-resolved group) [Figure 3] and [Table 1]
Effect on hrqol0 scores based on dmsa0 scan results [Figure 4] and [Table 1]: The highest improvement in average QOL scores was in regression and the status quo group. The QOL values improved least in the progression group. Out of all the variables the emotional aspect of QOL had maximum improvement, while physical health improvement was least. The total increase in HRQOL was highest in regression group (67.91), and lowest in progression group (36.45). The emotional subscale was highest in regression group (70) while it was lowest in the new scar group (32.14).The physical health subscale was highest in the regression group (66), while it was lowest in the progression group (15). The learning subscale was highest in regression group (73.33), while it was lowest in both the new scar and progression group (37.5). The vitality subscale was highest in the status quo (72.66) and lowest in the new scar group (37.15).
| Discussion|| |
Parents of children with vesicoureteral reflux have a variety of treatment options. ,, The success of endoscopic Dx/HA procedure is still not comparable to open surgery, and concern remains regarding long-term recurrence.  Parental satisfaction with the choice of subureteral injection therapy correlates with its success, and thus cautious optimism should be projected by physicians when discussing the role and outcome of this therapy in the management of VUR.  However, despite the limitations of poor success rates, various advantages in the form of minimal invasiveness and performance on day care basis have made endoscopic treatment an attractive option to caretakers.
Apart from the successful clinical outcome of a procedure from the various treatment modalities available, another key component of any treatment is the patient and parent perceptions of HRQOL and how the various management options affect it. , Due to the overwhelming advantages most parents primarily select endoscopic therapy,  but very less is yet known about the subjective impact of this minimally invasive treatment on children's well being in terms of their quality of life. , Generally, HRQOL is defined as ''the extent to which one's usual or expected physical, emotional, and social well being are affected by a medical condition or its treatment''. 
During follow up, we observed that caretakers of patients undergoing endoscopic treatment, in their first visit after the procedure, described a subtle improvement in the irritability and eating habits of the patient and found their child more playful and cheerful. These well informed parents were also satisfied with the fact that the procedure had safeguarded the kidney from further damage. They also were satisfied with the minimal invasive nature of the procedure and were happy to resort to their daily activities after an interruption of only a single day related to the day care procedure. These subjective impacts led us to conduct a study aiming to objectively measure the effects of VUR resolution and effects of renal scarring on HRQOL of patients treated endoscopically.
Very few studies have been found in the literature considering HRQOL in patients with vesicoureteral reflux. Schwentner et al found maximum improvement in the physical health aspect (61.57) of QOL in patients with resolved VUR, where as our patients showed maximum improvement in the vitality (66.66) sub scale and emotional (64.89) aspect. However the increase in physical health was also significant (62.47) which was also reflected in improvement in the weight and height gain achieved post operatively. The highest improvement was in the 'vitality' aspect of QOL in the resolved group (66.66) and emotional and learning subscale (57.14 in both) in the non resolved group. The least improvement in average QOL was in physical health in both groups. (62.47 in resolved vs. 42.85 in non-resolved group). Based on the DMSA results, the results were also highest for the regression and status quo group. The total increase in HRQOL was highest in regression group (67.91), and lowest in progression group (36.45). The emotional subscale was highest in regression group (70) while it was lowest in the new scar group (32.14). The physical health subscale was highest in the regression group (66), while it was lowest in the progression group (15). The learning subscale was highest in regression group (73.33), while it was lowest in both the new scar and progression group (37.5). The vitality subscale was highest in the status quo (72.66) and lowest in the new scar group (37.15).These values stressed on the fact that scarring and VUR are detrimental to the patients' well being.
In contradiction to the above, Yao et al found no major significant differences in QOL scores between patients with and without VUR and concluded that VUR per se acted as a benign entity, without affecting quality of life of children affected. They, however, stated that few patients had lower QOL because they were taking antibiotics and undergoing surveillance tests, such as radionuclide cystogram (RNC) or MCU.  Kiddoo et al, found that anxiety and social functioning scores were significantly worse in patients with VUR. The VUR group had worse scores in problem behavior, stomach complaints, and communication. They inferred that the diagnosis of VUR and its management does have an impact on gastrointestinal complaints, behavior, and communication, which may occur as a result of chronic medical intervention. 
There have been concerns regarding the cost effectiveness of endoscopic treatment. , Most of the parents opted for endoscopic treatment based on the high success rates and non invasive nature of the treatment, which dominated over the cost constraints. Over a period of time, it was perceived by parental experiences that stopping of antibiotics, decrease in the frequent urine cultures and other invasive investigations like MCUs and decrease in the follow up visits were also important in determining the quality of life of patients and parents. These enabled the parents to pursue their livelihood and patients were able to attend their classes regularly, which improved their school performances. It was observed that the children's overall vitality, their ability to learn and to concentrate, as well as their emotional capacities was ameliorated by eliminating long-term antibiotics in the presence of resolved VUR. The improvement in the HRQOL thus appears to contribute to the favorable cost effectiveness of endoscopic treatment. All these are reflected in the HRQOL scores.
| Conclusions|| |
Successful therapy of VUR and improvement in scarring as a consequence are important in improving the quality of life of patients with VUR. This positive effect is not restricted to physical well being and the mere absence of VUR, but can be detected in other areas of daily life such as emotionality, vitality and learning capacities. Whether the improved HRQOL is a reflection of decreased hospital visits, stopping of antibiotics and decrease in the frequency of invasive investigations or because of resolution of VUR and scars, still remains questionable. However, improvement of HRQOL should be kept as a priority making it an important indication for early endoscopic treatment.
| References|| |
|1.||Elder JS, Diaz M, Caldamone AA, Cendron M, Greenfield S, Hurwitz R, et al. Endoscopic therapy for vesicoureteral reflux: a meta-analysis. I. Reflux resolution and urinary tract infection. J Urol 2006;175:716-22. |
|2.||Fanos V, Cataldi L. Antibiotics or surgery for vesicoureteric reflux in children. Lancet 2004;364:1720-2. |
|3.||Capozza N, Lais A, Matarazzo E, Nappo S, Patricolo M, Caione P. Treatment of vesico-ureteric reflux: A new algorithm based on parental preference. BJU Int 2003;92:285-8. |
|4.||Schwentner C, Oswald J, Lunacek A, Schlenck B, Pelzer AE, Schwentner I, et al. Health-related quality of life in children with vesicoureteral reflux - impact of successful endoscopic therapy. J Pediatr Urol 2008;4:20-6. |
|5.||Yao DF, Weinberg AC, Penna FJ, Huang L, Freilich DA, Minnillo BJ, et al. Quality of life in children with vesicoureteral reflux as perceived by children and parents. J Pediatr Urol 2011;7:261-5. |
|6.||Kiddoo DA, Ajamian F, Senthilselvan A, Morgan CJ, Pinsk MN. Quality of life in children with vesicoureteral reflux. Pediatr Nephrol 2012;27:423-8. |
|7.||Kubba H, Swan IR, Gatehouse S. The Glasgow children's benefit inventory: A new instrument for assessing health related benefit after an intervention. Ann Otol Rhinol Laryngol 2004;113:980-6. |
|8.||Schwentner I, Schwentner C, Schmutzhard J, Radmayr C, Grabher G, Sprinzl G, et al. Validation of the German Glasgow children's benefit inventory. J Eval Clin Pract 2007;13:942-6. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
|This article has been cited by|
||Endoscopic treatment of vesico-ureteral reflux: Experience of 99 ureteric moieties
| ||Bajpai, M., Verma, A., Panda, S.S. |
| ||Journal of Indian Association of Pediatric Surgeons. 2013; 18(4): 133-135 |
||Conservative treatment of vesicoureteral reflux in a child 10 years
| ||Zastelo, E.S., Tush, E.V., Khaletskaya, O.V. |
| ||Sovremennye Tehnologii v Medicine. 2013; 5(3): 119-120 |