Health-related quality of life in children with vesicoureteral reflux – Impact of successful endoscopic therapy

https://doi.org/10.1016/j.jpurol.2007.08.002Get rights and content

Abstract

Objectives

Endoscopic therapy for vesicoureteral reflux (VUR) using dextranomer/hyaluronic acid (Dx/HA) has become increasingly popular, but the subjective impact of this therapy and subsequent reflux resolution on health-related quality of life (HRQoL) remains unclear. The aim of this study was to address this issue.

Materials and methods

One hundred children (65 girls, 35 boys; mean age 4.46 years) cured of primary VUR by endoscopic treatment were retrospectively reviewed. The Glasgow children's benefit inventory (GCBI) – a validated, reproducible, post-interventional questionnaire consisting of four subscales – supplemented by sociodemographic and disease-specific questions was employed. The HRQoL benefit was calculated on a scale ranging from −100 (complete failure) to +100 (complete success) and correlated with supplementary data.

Results

Total response rate was 88%. Mean total GCBI score was 28.4 ± 20.3 representing a significant HRQoL amelioration. All GCBI subscores improved with the physical health subscale being most relevant. A gender-specific, significant difference in relative GCBI scores was discovered. Correlation with critical life events and time since operation proved the positive effect on HRQoL to be durable.

Conclusions

Resolution of primary VUR secondary to Dx/HA treatment significantly improves HRQoL. HRQoL is positively affected in many areas and not only in those directly associated with VUR. These improvements are not temporary, suggesting that successful Dx/HA therapy may be superior to medical management in terms of children's quality of life.

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.

Section snippets

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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    C.S. and I.S. contributed equally.

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