Predictability of success of endoscopic vesicoureteral reflux treatment utilizing clinical risk factors and intraoperative injection characteristics.

Introduction: The guidelines lack clarity on how to follow the patients after endoscopic treatment for vesicoureteral reflux (VUR). The most discussed question is the need for voiding cystourethrogram (VCUG). Risk-based approaches that consider patient characteristics, disease severity, or factors related to the surgery itself could reduce its use, but a satisfactory predictive model has not yet been established. We hypothesized surgeons can predict the treatment success evaluating the procedure and risk factors and analyzed the assessments of five experts on the subject.

Materials and methods: Clinical data of 50 patients (75 renal units) from 2015 to 2021 were analyzed. Detailed medical history (including DMSA, USG, VCUG reports, voiding symptoms, presence of febrile UTI, etc.) and video records of the procedure were evaluated blindly by five expert surgeons. Experts evaluated the injection volume, needle placement site, and mound appearance using a 5-point Likert scale. Based on these assessments, they predicted the likelihood of surgical success and if there was a high risk for obstruction (yes/no).

Results: Consistent responses among evaluators were observed for needle placement site (p < 0.001), but not for injection volume and mound appearance (p = 0.055, p = 0.077, respectively). The scores provided by all evaluators for needle placement site, injection volume, and mound appearance were consistent with their predictions for success (p < 0.001 for all). However, none of the scores given by the evaluators for the three parameters were consistent with actual success (p > 0.05 for all) and predictability for success or obstruction was low for all evaluators (p > 0.05 for all).

Conclusion: The assessment of the operation videos even accompanied with a comprehensive medical history including all known risk factors does not aid in predicting outcomes for endoscopic VUR treatment. Our study highlights the need for better criteria to recommend individualized management strategies and the insecurity of categorizing surgeries as "high-risk" or "safe" based solely on the intraoperative satisfaction.