Presence of dextranomer-hyaluronic acid (Deflux) mound on postoperative ultrasound does not predict resolution of vesicoureteral reflux.

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Introduction
Dextranomer-hyaluronic acid (Deflux) injection is an accepted treatment of vesicoureteral reflux (VUR), with success rates up to 85-90% in selected patients. Due to its lower success rates compared to open surgical correction of VUR, postoperative voiding cystourethrograms (VCUGs) are more frequently obtained after endoscopic treatment.
The deflux mound can often be seen on postoperative ultrasound. We sought to determine whether the presence or absence of this mound on ultrasound can predict resolution of VUR on postoperative VCUG.
Methods
An IRB approved retrospective study evaluating patients who underwent cystoscopy and injection of deflux from 2003 to the present was performed. Patient age, laterality and grade of VUR, volume of deflux injected, postoperative ultrasound findings - including presence of hydronephrosis and deflux mound- and presence of VUR on postoperative VCUG was recorded. Patients were omitted from the study if inadequate followup was available. Ultrasounds were reviewed and the presence of a deflux mound determined.
Results
Thirty-four patients underwent 39 cystoscopy and deflux injection procedures; 59 ureters were treated. Patient age at surgery ranged from 9 months to 11 years of age (mean 5.2 years). Documented duration of VUR preoperatively ranged from one month to 4 years (mean 2.27 years). Vesicoureteral reflux ranged from Grade I to V, with a mean preoperative VUR grade of 2.3. Deflux injection technique included hydrodistention, subureteric injection, and a combination of the two techniques. Mean time from surgery to first postoperative ultrasound was 16.9 weeks, and mean time to first postoperative VCUG was 16.5 weeks. After deflux injection, VUR resolved in 69% of ureters, while 31% demonstrated persistent VUR. In one patient a previously non-refluxing ureter developed VUR on postoperative VCUG.
Of the 40 ureters with a deflux mound on ultrasound, 11 ureters (27.5%) demonstrated persistent postoperative VUR while in 29 ureters (72.5%) VUR had resolved. This is similar to the frequency of persistent VUR in the entire cohort. Of 18 ureters without a deflux mound seen on ultrasound, 39% had persistent VUR and in 61% of ureters VUR had resolved. The mean grade of VUR in patients with persistent VUR was 2.7 compared the mean of the entire cohort, which was 2.3.
Conclusion
In this series of patients the presence of a deflux mound on initial postoperative ultrasound does not predict resolution of VUR. The results of this study support the need for a larger prospective study to evaluate further parameters. With larger prospective accrual we may find that deflux mound has predictive power when interpreted in the context of the other variables.

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