Response to Commentary “The correlation between ureteric orifice morphology and primary vesicoureteral reflux grade and the impact on the effectiveness of endoscopic reflux correction”

Abstract

Thank you very much for your interest and valuable comments regarding our study entitled “The correlation between ureteric orifice morphology and primary vesicoureteral reflux grade and the impact on the effectiveness of endoscopic reflux correction” that was recently published in the Journal of Pediatric Urology [1]. We fully agree with your statement that the subjective evaluation of the ureteral orifices (UOs) morphology during cystoscopy does not have a significant role in modern clinical practice as an objective judgment of the UO morphology. We are also aware that some ancillary methods may substantially reduce this subjectivity. One of these methods is positioned instillation of contrast (PIC) cystography, which identifies patulous ureters that have the propensity to reflux [2]. Another approach that can be easily performed is the dynamic hydrodistension (HD) grading system, which has been shown to correlate with a radiographic grade on voiding cystourethrography (VCUG) much more precisely [3,4]. However, we highlight the limitations of pediatric urology centers in developing countries, such as ours in Bosnia and Herzegovina, which do not have all the necessary equipment in place, including fluoroscopic monitoring required for the performance of PIC cystography. However, the HD grading system has been gradually developed in our center from 2018 and it now represents the method by which we evaluate the morphology of UOs. We strongly believe that the results from the current study will positively impact current pediatric urology practice in our and other pediatric urology centers worldwide with a similar infrastructure and available resources.