Minimally invasive treatment for vesicoureteral reflux in children: a selective approach with effective cure for all

Abstract

Purpose We report a minimally invasive treatment protocol for vesicoureteral reflux (VUR) in infants and children with a selective use of dextranomer/hyaluronic acid copolymer (Deflux) injection for mild grades or uncomplicated VUR and pneumovesicoscopic ureteric reimplantation for severe grades or complicated VUR. Material and methods Children presenting with persistent primary VUR (Grade II - V) refusing antireflux surgery were recruited. At entry, each patient had a voiding cystourethrogram (VCUG), renal ultrasonogram (US), isotopic renogram (DMSA).The minimally invasive management protocol included 1) endoscopic sub-ureteric injection for milder grades (Grade II -III, Grade IV unilateral) and 2) endoscopic Cohen's cross-trigonal ureteral reimplantation with CO2 pneumovesicum for dilating (Grade IV Bilateral to Grade V) VUR, associated with UTI and multiple pyelonephritic renal scarring. Resolution of VUR was confirmed by VCUG at a minimum follow up period of 6 months after the procedure. Results One hundred and seventeen patients (45 bilateral) were treated. Endoscopic sub-ureteric injection was given to 24 children (M/F: 8/16, Mean age: 5.75 ± 3.61yrs,72 refluxing ureters) and Endoscopic cross-trigonal ureteric reimplantation was successfully performed in 93 children (M/F: 72/21, Mean age: 5.1 ± 5.61, 90 refluxing ureters). Follow-up cystogram showed complete resolution of VUR in 69 ureters (96%), and in 89 ureters (99%), in those who underwent subureteric injection and ureteric reimplantion respectively. VUR downgraded in 1 (underwent surgical intervention) and persisted in 3 ureters treated with subureteric injection and were treated successfully by repeat injection. Conclusions This new minimally invasive treatment algorithm with a combined and selective use of Deflux injection for mild grades of VUR and endoscopic pneumovesical ureteral reimplant for severe VUR offers a very effective cure for all grades of VUR. The very high cure rate alleviates the need for follow-up VCUG's and long term antibiotic treatment.