Health-related quality of life in children with vesicoureteral reflux – Impact of successful endoscopic therapy
Introduction
VUR is a common condition affecting approximately 1% of all children. VUR is associated with recurrent UTI, pyelonephritis, hypertension and finally end-stage renal disease [1]. The purpose of identifying and treating this condition is the prevention of these long-term sequelae. Traditionally, treatment options included antibiotic prophylaxis awaiting spontaneous resolution and open surgical correction [1]. Open surgery has been shown to be highly effective but sometimes associated with complications [2]. Endoscopic correction of VUR was first described by Matouschek, who used polytetrafluoroethylene paste as a bulking agent [3]. Puri and O'Donnell have further popularized this access with promising results [4]. Major concerns have arisen regarding particle migration, leading to the development of other materials such as collagen, chondrocytes, silicone and others [2]. Stenberg and Läckgren were the first to describe the application of dextranomer/hyaluronic acid copolymer (Dx/HA) [5]. Since then, there has been increasing enthusiasm for this material culminating in the final approval by the Food and Drug Administration. Numerous reports have investigated Dx/HA in the context of primary VUR as well as of redo cases, underlining the efficacy of the procedure [6], [7], [8], [9]. Consequently, Dx/HA is now considered to be a viable alternative to long-term antibiotic prophylaxis and even to open surgery. Recently, Kirsch and co-workers presented their hydrodistension modification yielding cure rates as high as 92% for primary low-grade VUR [10]. Due to these overwhelming advantages most parents primarily select endoscopic therapy [11], but nothing is yet known about the subjective impact of this minimally invasive treatment on children's well being in terms of their quality of life (HRQoL). 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” [12]. This definition incorporates widely accepted aspects of quality of life: subjectivity and multidimensionality [13]. Due to the different communication skills in various age groups, assessment of HRQoL status might sometimes be difficult or impossible in paediatric patients. Given the hazards of limited communication skills, HRQoL is frequently assessed externally by the parents/primary caretaker responding as a proxy for their affected child [14]. Outcome research focusing on individual HRQoL amelioration has become a major issue in paediatric medicine, but there is a tremendous lack of available data on paediatric urological conditions [15], [16]. The purpose of this pilot study was to evaluate the impact of successful endoscopic Dx/HA therapy, subsequent VUR resolution and the influence of associated factors (chemoprophylaxis and VCUGs) on the HRQoL of affected patients. We applied a validated and reproducible questionnaire – the Glasgow children's benefit inventory – being suitable for all types of paediatric surgical procedures [17], [18]. HRQoL was further characterized using subscale measurements and sociodemographic as well as symptom-specific correlations in order to achieve an initial patient stratification.
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Materials and methods
One hundred consecutive children (160 ureterorenal units) who received Dx/HA treatment for primary VUR were retrospectively identified from our hospital's database. Only those children who were radiographically free from persistent VUR were included in the study. The cohort comprised 65 girls and 35 boys with a mean age of 4.46 years (±2.63, 1–12) at surgery. Reflux grades were I in 16, II in 99 and III in 45 ureterorenal units. Sixty children had bilateral VUR. The major indication for Dx/HA
Results
The questionnaire was correctly answered and returned by 88 patients. There were five children who had changed residence without valid forwarding address while seven did not respond. Of the responders, 96.6% of the parents rated the questionnaire to be clear and comprehensible. Internal consistency and test–retest reliability were 0.84 and 0.94 underlining the questionnaire's validity. The mean total GCBI score was 28.4 ± 20.3 (0–87.5) indicating a significant increase in overall HRQoL. This
Discussion
Due to its efficacy and practicability the endoscopic approach has become a reasonable alternative in the treatment regimen for VUR [6], [7], [8]. In contemporary literature, cure rates for low-grade VUR exceed 90% and these positive effects have been shown to be durable even in long-term follow up [10], [20]. Recent studies have provided some evidence that low-grade VUR does not require any treatment, which has caused much discussion among paediatric urologists. The difficult task of
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Integrative review and evaluation of quality of life related instruments in pediatric urology
2021, Journal of Pediatric UrologyCitation Excerpt :The initial query of electronic databases and hand searching yielded 5377 unique articles, 101 of which were identified for full-text screening after title and abstract review. Of these, 43 studies were included for data abstraction and 22 unique instruments were identified [9–22, 23–35, 36–55] (PRISMA diagram in Appendix B). Children's median age was 11 years old (IQR 8.3–13.1, mean: 10.5, SD 3.1).
Can Distal Ureteral Diameter Predict Reflux Resolution after Endoscopic Injection?
2015, UrologyCitation Excerpt :Basically, there have been 2 dominant theories for evolving of reflux; one is the weak antireflux function due to the congenitally immature muscles that go from the vesical trigone to the terminal ureter. The other is the short submucosal ureter.10 Consequently, the length and the diameter of the submucosal ureter may be a large part of the primary VUR.
Long-term incidence of febrile UTI after DxHA treatment of VUR
2014, Journal of Pediatric UrologyCitation Excerpt :Indeed recurrent fUTI can cause great anxiety for the family, particularly when the patient is aged less than 3 years. In a recent study, Schwentner et al. [21] evaluated health-related quality of life in 100 children cured of VUR by endoscopic therapy using the Glasgow Children's Benefit Inventory questionnaire. With a response rate of 88%, they observed a significant and durable improvement in children's quality of life, with a significant difference (p = 0.001) between the score at one year post treatment (average 23.95) and at four years (average 59.72).
Selective endoscopic treatment of the non-refluxing contralateral ureter prevents new contralateral vesicoureteral reflux
2013, Journal of Pediatric UrologyCitation Excerpt :With a 10% chance of NCVUR, approximately two-thirds of patients would be subjected to a potentially unnecessary contralateral injection. On the other hand, successful endoscopic VUR treatment was shown to correlate with significant improvement in quality of life, as measured by a validated post-surgical questionnaire [22]. Consequently, the higher cost of prophylactic injection needs to be weighed against the inconvenience of continued antibiotic prophylaxis, surveillance with VCUGs, and anxiety toward future surgical treatment.
Development and initial validation of a disease specific quality of life survey for children with vesicoureteral reflux
2012, Journal of UrologyCitation Excerpt :Our instrument was created by a collaborative team of survey design specialists and pediatric urologists, and was validated by a number of tests to ensure strong reliability. Thus, we could overcome limitations of previous studies, which failed to establish an instrument for precise comparison of HRQoL in the setting of different management options.4,6 Children with VUR reported high HRQoL in most categories during surveillance, preoperatively and postoperatively.
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C.S. and I.S. contributed equally.