Mound Calcification after Endoscopic Treatment of Vesicoureteral Reflux: A Normal Variant of Mound Appearance?

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Background:
Endoscopic treatment of vesicoureteral reflux (VUR) has gained popularity and is frequently employed as a first line therapy for this condition. Reports of potential long term complications from this treatment modality are lacking. We review the development of mound calcification in a cohort of patients undergoing endoscopic treatment of VUR with autologous chondrocytes.
Methods
All patients who underwent endoscopic treatment of VUR with autologous chondrocytes at our institution were included in this study. All available renal and bladder ultrasounds, as well as any other radiographic studies of the urinary tract (CT, VCUG) were reviewed by a staff radiologist (H.P.) and two urologists (P.G., D.D.) to assess for the presence of mound calcification. Mode of presentation was also assessed. Statistical comparison between groups was performed by paired sample t-test and the Fisher’s exact test. Univariate and multivariate analysis was used to identify potential risk factors for development of mound calcification.
Results
Ten out of 27 (37%) of our patients developed mound calcifications at a median 2.1 years after injection (range 1-5 yrs). Total median follow-up period was 9 years (7-11). Figure 1 shows the typical appearance of a calcified mound after endoscopic treatment for VUR. More females than males (40% vs 28% respectively) developed calcifications although this was not statistically significant. Of the 10 patients with mound calcifications 7 presented with gross or microscopic hematuria, with or without flank pain. Three of these were initially though to have uretero-vesical junction stone(s). The remaining 3 were found incidentally. Hydroureteronephrosis was absent in all patients with mound calcifications. Univariate and multivariate analysis showed no relationship between the presence or absence of calcification when controlled for gender, initial reflux grade, amount of autologous chondrocytes injected, number of injections used and total follow-up time from initial injection.
Conclusions
Mound calcifications have now been reported after endoscopic therapy of VUR with autologous chondrocytes as well as Deflux®. The etiology of these calcifications remains unknown. Furthermore, it is unclear whether mound calcification after endoscopic treatment will have any associated morbidity in long-term follow-up. Urologists and patients should be aware that mound calcification is a potential risk after endoscopic treatment for VUR and may represent part of a spectrum of possible post-operative mound appearance.

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