Evaluation of augmentation cystoplasty in childhood with reference to vesico-ureteric reflux and urinary infection.

OBJECTIVES To assess the non-operative treatment of vesico-ureteric reflux in patients with abnormal bladder compliance, to determine whether reduction in storage pressure by augmentation leads to cessation of reflux and whether symptomatic urinary tract infection worsens or renal function deteriorates if reflux continues after augmentation and clean intermittent catheterization (CIC). PATIENTS AND METHODS Thirty-nine children (17 boys, 22 girls) who underwent clam ileocystoplasty over a 5-year-period were evaluated. The mean age at operation was 9.7 years (range 1.5-17.5). Pre-operative assessment included renal imaging and slow fill video-cystometry. Vesico-ureteric reflux, if present, was graded I-V. The frequency and severity of symptomatic urinary tract infections were recorded. Cystometry was performed 6 months after reconstruction. Storage pressures below 20 cm saline were regarded as safe. The mean follow-up was 3.3 years (range 10 months-6.1 years). RESULTS Of the 17 renal units assessed for the outcome of reflux, 11 stopped reflux and one showed a lower grade. No patient showed worsening of upper tract dilatation or progressive renal scarring. Thirty-seven patients (95%) had symptomatic urinary tract infection pre-operatively. Following bladder augmentation, clean intermittent catheterization and trimethoprim prophylaxis, seven continued to have symptomatic infection. CONCLUSIONS Augmentation cystoplasty is effective in resolving reflux in a majority of the patients. This is achieved by reducing storage pressures to below 20 cm saline and emptying the bladder regularly by CIC. There is also a reduction in the incidence and severity of symptomatic urinary tract infections. Even when reflux persists there is no evidence of deterioration of the upper tracts or progressive renal scarring.