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10. Lackgren G, Wahlin E, Skoldenberg E and Stenberg A: Long-term followup of children treated with dextranomer/hyal-uronic acid copolymer for vesicoureteral reflux. J Urol 2001;166: 1887.

11. Kirsch AJ, Perez-Bayfield MR, Smith EA and Scherz HC: Themodified sting procedure to correct vesicoureteral reflux:improved results with submucosal implantation within theintramural ureter J Urol 2004; 171: 2413.

12. Lendvay TS, Sorensen M, Cowan, CA, Joyner BD, MitchellMM and Grady GM: The evolution of vesicoureteral refluxmanagement in the era of dextranomer/hyaluronic acidcopolymer: a Pediatric Health Information System databasestudy. J Urol 2006; 176: 1864.

13. Lapoint SP, Barriera D, Leblanc B and Williot P: ModifiedLich-Gregoir ureteral reimplantation: experience of a Ca-nadian center. J Urol 1998; 159: 1662.

14. Elder J, Diaz M, Caldamone A, Cendron M, Greenfield S,Hurwitz R et al: Endoscopic therapy for vesicoureteral re-flux: a meta-analysis. I. Reflux resolution and urinary tractinfection. J Urol 2006; 175: 716.

15. Kobelt G, Canning D, Hensle T and Lackgren G: The cost-effectiveness of endoscopic injection of dextranomer/hyal-uronic acid copolymer for vesicoureteral reflux. J Urol 2003;169: 1480.

EDITORIAL COMMENTS

Open ureteral reimplantation is less morbid today than inthe past. At many centers children undergoing unilateral,bilateral, extravesical and transvisical reimplantation leavethe hospital within 24 hours. These authors focus on outpa-tient unilateral extravesical ureteral reimplantation. De-spite these advances, open reimplantation is more morbidthan endoscopic injection. Whether practitioners choose re-implantation or endoscopic injection is based on the likeli-hood of success, and the severity of the underlying reflux andits consequences. Using computer modeling, we demon-strated that it is unlikely for Dx/HA injection to be costequivalent to open reimplantation for higher grades andbilateral reflux.1 These authors have shown that at theircenter the cost of unilateral outpatient reimplantation islower than that of unilateral Dx/HA injection for any gradeof reflux. This effect will be magnified as injection successdecreases with increasing reflux grade.

It would be interesting to know the cost comparison forbilateral procedures. Presumably bilateral procedures arenot done on an outpatient basis but the cost of the implant isalso greater. With any cost analysis the assumptions pro-foundly affect the results. Using average percent recovery ofcharges rather than a more universal cost estimate makesthis more relevant locally than generally. Nonetheless, thisis a progressive approach to open reflux repair and a dem-onstration that excellent outcomes can be achieved in a costconscious manner.

Steven G. DocimoDepartment of Urology

Children’s Hospital of PittsburghPittsburgh, Pennsylvania

1. Benoit RM, Peele PB and Docimo SG: The cost-effectiveness ofdextranomer/hyaluronic acid copolymer for the managementof vesicoureteral reflux. 1: substitution for surgical manage-ment. J Urol 2006; 176: 1588.

Studies of this sort are difficult to interpret due to regional

differences in hospital costs, and other variables and as-

sumptions. The authors postulate that 11% of patientstreated endoscopically for VUR will go on to have a secondprocedure, which will fail in 20%. Currently this is not thecase and such an assumption may be flawed. In my practice40% of failures are reduced to grade I/V and are simplyobserved. The same is true of open surgery. As experience isgained with endoscopic injection, repeat injections should beinfrequent but when performed, the success rate has beenreported to be 90%.1

Another potential error is the use of 1.2 ml as an averagevolume for unilateral reflux, which implies that 0.8 ml isdiscarded. In practice this is seldom done. Unilateral refluxis usually treated with 1.0 ml (1 syringe including the needleflush), thus potentially reducing the cost of Dx/HA injectionfor unilateral cases in this analysis by more than $1,000,making it less expensive than open outpatient surgery.

Surgeons should choose the surgical approach most com-fortable for them and families. This study reveals that cost isnot significantly different between the 2 approaches andshould not be the reason to choose one approach over theother. At the end of the day the only difference between openand endoscopic surgery may be the presence or absence of ascar and as a result, parents are likely to choose the leastinvasive approach.2,3

Desite the limitations discussed by the authors, transfor-mation of a highly successful inpatient procedure into oneperformed on an outpatient basis is laudable. Efforts tomake open procedures less invasive and endoscopic injectionless expensive are tenable goals.

Andrew J. KirschChildren’s Healthcare of Atlanta

Emory University School of MedicineAtlanta, Georgia

1. Elmore JM, Scherz HC and Kirsch AJ: Dextranomer/hyaluronicacid copolymer for vesicoureteral reflux: success rates afterinitial treatment failure. J Urol 2006; 175: 712.

2. Ogan K, Pohl HG, Carlson D, Belman AB and Rushton HG:Parental preferences in the management of vesicoureteralreflux. J Urol 2001; 166: 240.

3. Capozza N, Lais A, Matarazzo E, Nappo S, Patricolo M andCaione P: Treatment of vesico-ureteric reflux: a new algo-rithm based on parental preference. BJU Int 2003; 92: 285.

REPLY BY AUTHORS

We did struggle with the best method for assessing thefinancial impact of both procedures, and selected the calcu-lation that would deal with real figures, or what is actuallypaid by insurance companies and families to have the pro-cedure done. While absolute payment amounts vary region-ally, we find it likely that the relative total system paymentfor open versus Dx/HA injection is comparable. Hopefullythis makes the comparison relevant to other regions.

Concern was raised about the 1.2 ml mean of Dx/HA usedfor unilateral injection. If one injects many orifices withhigher grade reflux, several will require greater than 1.0 mlto achieve the desired post-injection configuration. If one’spractice allows a mean use less than what we report, then-the mean cost of the Dx/HA group will decrease correspond-ingly. In addition, any decrease in Dx/HA purchase cost

would greatly affect the comparison.

ENDOSCOPIC SUBURETERAL INJECTION FOR UNILATERAL VESICOURETERAL REFLUX1630

We did include a speculative calculation of what the out-lay would be to achieve similar reflux resolution rates. El-more et al reported that only 15% of post-Dx/HA injectionpersistent reflux was grade I (reference 1 in comment),which would most likely be considered for observation and

not second injection. Our comparison, while clearly specula-

tive and definitely requiring some estimation, makes a de-cent approximation of what outlay can be expected toachieve similar resolution rates with both approaches. Inaddition to the absence or presence of a small scar in the openreimplant group is the long-term presence of an exogenous

substance within the bladder wall of the Dx/HA group.

DISCUSSION

Dr. Hal Scherz. I thought this was a nice review of the financial impact but I wanted to ask if you had any idea about theweight of each factor you used for your analysis, because at many institutions like ours we can get the patient in and out ofthe operating room between 20 and 25 minutes, which would significantly change your cost analysis for the anestheticcomponent of the endoscopy case, for example.

Dr. Kara Saperston. We did not look at the weight of the different variables. I think that is a good point and we will lookat that.

Dr. David Roth. You included an increased cost for the Deflux failures but you did not include any costs or possiblecomplications of the surgical arm. Did you look at that and what would be the impact if you did?

Doctor Saperston. In our cohort of 206 cases of which 180 were open there was only 1 rehospitalization. It was the nightof surgery but at an outside hospital, and so we were unable to get that cost data.