Vesicoureteral reflux (VUR) occurs in patients with neurogenic bladder, which is a high-pressure and low-compliant bladder. High-grade VUR leads to recurrent urinary tract infections (UTIs), and thus causes severe renal failure. Initially, as conservative treatment, clean intermittent catheterization (CIC) and anticholinergic therapy were generally conducted. Intravesical injection of botulinum toxin A is also effective to improve bladder compliance and capacity. Endoscopic antireflux surgery may be useful when bladder capacity and compliance are near normal. If these conservative managements are ineffective, augmentation cystoplasty (AC) is generally accepted as one of the standard therapeutic options. Regarding the treatment of VUR in patients with neurogenic bladder, whether ureteral reimplantation should be simultaneously performed with AC for patients with VUR is controversial. It is accepted that VUR in neurogenic bladder is predominantly a secondary reflux, which is caused by small bladder capacity, poor bladder compliance, and dysfunctional voiding. We have not routinely performed ureteral reimplantation with AC because these refluxes could improve when a low-pressure system is created. The aim of this study was to evaluate the need for ureteral reimplantation with AC for patients with VUR.

This study included 19 patients (10 male, 9 female) who underwent AC for neurogenic bladder with VUR between March 1983 and March 2016 in our hospital. A minimum follow-up of 5 years after AC was necessary for inclusion in this study. All patients had been treated conservatively with CIC and anticholinergic agents. The indications for AC for neurogenic bladder were low bladder compliance, urinary incontinence, recurrent febrile UTIs (pyelonephritis, prostatitis, and epididymitis), high-grade VUR, and deterioration of renal function (CKD stage ≥ 3, or sequential deterioration of split renal function in renal scintigraphy), despite the conservative therapies. The changes in VUR grade, urodynamic findings, and postoperative complications were evaluated retrospectively. We evaluated the renal function by periodic inspection of serum creatinine level and estimated glomerular filtration rate; eGFR. The present study was approved by the Scientific Ethics Committee of Hokkaido University (# 020-0093).

A total of 19 patients with a median age at surgery of 14 years (range 3-38 years) were included. Median follow-up from AC surgery was 14.8 years (range 5.7-30 years). Ureteral reimplantation was performed for only one patient in the very early stage of our experience. VUR was found in 19 patients, involving 27 ureters before surgery. In a total of 27 ureters, reflux grade was V in 6, IV in 9, III in 5, II in 6, and I in 1. Postoperative videourodynamics showed that the reflux resolved in 23 ureters (85%), was downgraded in 3 ureters (11%), and was unchanged in 1 ureter (4%) (Table 1). There were no cases in which VUR deteriorated. On videourodynamics, the bladder capacity at which VUR occurred was significantly increased from 60 ml to 404 ml (p < 0.05), whereas detrusor pressure at the onset of VUR was not significantly different (Table 2). Regarding the renal function, eGFR and CKD stage was checked at the last visit. The median eGFR was 95 ml/min/1.73m2 (range 3.3-154) in 19 patients. Chronic kidney disease: CKD stage 1 in 11, stage 2 in 5, stage3 in 1, stage 4 in 0, stage5 in 2 patients were observed respectively. Chronic renal failure (CKD stage ≥ 3) developed in 3 patients (16%) during follow-up; 2 of 3 the patients developed stage 5 CKD and were started on renal replacement therapy. However, these 3 patients with renal failure have no VUR after the operation.

This retrospective study showed that almost all cases of VUR were resolved or downgraded without ureteral reimplantation. Because there have been very few prospective, randomized studies, there is no conclusive evidence about the usefulness of ureteral reimplantation with AC, therefore, whether ureteral reimplantation should be done simultaneously with AC has been controversial. Several previous studies have shown that ureteral reimplantation should be performed in patients with low-pressure or high-grade VUR, ureterovesical junction obstruction, and severe upper urinary tract dilation. On the other hand, there is a possibility that these complicated procedures result in prolonged operative time and increased surgical stress. Moreover, we should also consider the risk of ureteral stricture as a postoperative complication. Although VUR occurred at low detrusor pressure after AC, the frequency of VUR was considered to be less than at pre-operation, because bladder capacity was greatly increased. In addition, renal function has been well maintained in most cases during follow-up period. Appropriate CIC after AC is important to prevent VUR, febrile UTI, and to protect upper urinary function.

Although it is still controversial, from our study, we conclude that routine ureteral reimplantation is not necessary with AC in patients with VUR.