Endoscopic Correction Of Reflux Research Articles

Duplex systems: Top-down or bottom-up approach?

Duplex systems can be complicated by reflux, ureterocele, obstruction (most commonly PUJ in a lower moiety) and wetting secondary to an ectopic ureteric insertion in girls. The decision making algorithm for selection of surgical approach is complex and there is no consensus. The authors described the outcomes following an upper urinary tract approach in 2011(1) and now compare these results in a similar group of patients managed using a lower approach. To assess whether a top-down or bottom-up approach results in different likelihoods for further surgery. A prospectively database was maintained for consecutive patients undergoing surgery for duplex systems by a single surgeon between 2003 and 2015. Patients were classified into 2 groups; Group 1 initial intention for upper urinary tract approach (heminephroureterectomy-HN) or Group 2 lower urinary tract approach (bladder reconstructive surgery-BRS). The requirement for further surgery was recorded-endoscopic incision (EI), bladder reconstructive surgery (BRS), endoscopic correction of reflux (ECR), heminephroureterectomy (HN). Indications for initial and subsequent surgery included urinary tract infection, VUJ obstruction and incontinence. Endoscopic incision was not performed for patients with an asymptomatic ureterocele. Statistical analysis consisted of Fisher's exact test with a 2 tail p value<0.05 being statistically significant. 79 patients underwent surgery for duplex systems. 39 patients had HN initially (Group 1) and 40 patients had BRS initially (Group 2). Further surgery was performed in 21% of patients from Group 1 (8 BRS) vs 5% of patients from Group 2 (1 redo BRS, 1 ECR). Significantly less additional surgical procedures were performed after BRS compared to HN (p=0.048). The presence of both reflux and ureterocele increases the chances of further surgery in those patients who had HN initially compared to BRS (p=0.01). No patients developed urinary retention or required intermittent catheterisation to improve bladder emptying. Bladder reconstructive surgery (BRS) reduces the requirement for further surgery compared to heminephroureterectomy (HN) in symptomatic patients with a duplex kidney and either dilating vesicoureteric reflux or ureterocele.

Endoscopic treatment of vesico-ureteric reflux in children of early age

The purpose of the study was to study the long-term results of endoscopic treatment of infants and young children with vesicoureteral reflux (VUR). Materials and methods . The analysis of the long-term results of endoscopic correction of reflux in infants and young children operated in the hospital from January 2015 to December 2018. Of these, up to 3 years there were 115 patients (67%), up to a year – 56 children (33%). The duration of follow-up was from 2 to 4 years. Polyacrylamide gel DAM+was used as an implant in 70% of cases (191 ureters). Endoscopic treatment with DAM+ was performed in 77 (70%) children from one to 3 years, as well as 23 patients (41%) of infancy. In other cases, used collagen, uradex. Introduction was carried out by methods of STING, HIT 1 and HIT 2. Results and discussion . Evaluation of the effectiveness of the use of drugs: collagen, DAM+, urodex. The type, degree of reflux, kidney function, presence of concomitant pathology were taken into account in the analysis of the correction results, and the effectiveness was evaluated by changing the degree of reflux and the course of the inflammatory process after 6 months – year after endoscopic correction. The disappearance of reflux after a single application of DAM+ took place in 86% of cases. Re-introduction of the implant was performed in 55 children, 3-fold – 20 at 3–4th degree of reflux. Neoimplantation of the ureter was performed in 9 patients with 4–5th degree of reflux, concomitant pathology of the upper urinary tract and signs of reflux nephropathy. Conclusion. The analysis of long-term results showed that the use of endoscopic techniques of reflux correction with the use of the domestic drug DAM+, including in infants, allows to completely cure reflux or reduce its degree to 1–2, providing optimal conditions for the maturation of the uretero-vesical segment.

Modern approaches to treatment of vesicoureteral reflux in children

Vesicoureteral reflux (VUR) currently remains one of the significant problems of pediatric urology. The main goal of treatment is to prevent MTCT recrudescing flow pyelonephritis of the renal parenchyma damage, hypertension and CKD. Recent decades have seen significant changes in views on standards of treatment of children with VUR. Debated, today questions about the effectiveness of long-term antibiotic therapy and surgical correction method. Endoscopic reflux correction was first proposed in 1881 Matouschek E., as an alternative to conservative therapy and open surgery. The purpose of the study - assessment of the effectiveness and long-term results of endoscopic reflux correction of the first four degrees, and its place in the overall strategy of treatment of vesicoureteral reflux in children.

Endoscopic correction of vesicoureteral reflux in children with solitary functioning kidney: insertion of a double-J stent to avoid transient ureteral obstruction.

Children with solitary functioning kidney, especially those with concomitant vesicoureteral reflux, are at increased long-term risk of kidney damage. Acute obstruction is a rare but relevant concern after endoscopic correction of vesicoureteral reflux and might be more symptomatic in children with solitary functioning kidney. We hereby report our experience and routine practice in using ureteral stents for prevention of the potential acute obstruction after endoscopic correction of reflux in children with solitary functioning kidney. A retrospective chart review was performed to find children with solitary functioning kidney that were endoscopically treated for vesicoureteral reflux. Solitary functioning kidney was defined as congenital or acquired (contralateral renal function <10 % in dimercaptosuccinic acid scan). Data regarding age, sex, grade and side of vesicoureteral reflux, and follow-up information were gathered. A tethered double-J stent was inserted after endoscopic bulking agent injection in all patients. Stents were removed using the extraction string at 2 weeks postoperatively. Between 2008 and 2015, a total of 28 patients (16 females) with solitary functioning kidney were treated endoscopically and underwent concomitant double-J insertion. Reflux was grade II in 12 (42.9 %), grade III in 10 (35.7 %), and grade IV in 6 (21.4 %) patients before treatment. No complication was encountered postoperatively or at removal of the stents using extraction strings. Considering devastating sequelae of acute obstruction following endoscopic management of reflux in children with solitary functioning kidney, routine use of double-J stents might be a feasible and safe approach.

Reply

The traditional management of children with vesicoureteral reflux (VUR) and ureteropelvic junction obstruction (UPJO) is pyeloplasty as the initial step, and if the high-grade reflux remains symptomatic after pyeloplasty, surgical correction of the reflux is the next step. 1 Maizels M. Smith C.K. Firlit C.F. The management of children with vesicoureteral reflux and ureteropelvic junction obstruction. J Urol. 1984; 131: 722-727 PubMed Google Scholar It was postulated that the nearby obstruction to the renal parenchyma might cause more renal damage, so it should be managed sooner rather than later. Moreover, in a few pediatric urology centers, this concept has ultimately been changed by surgical correction of reflux (ureteral reimplantation) initially, followed by pyeloplasty in persistent UPJO. 1 Maizels M. Smith C.K. Firlit C.F. The management of children with vesicoureteral reflux and ureteropelvic junction obstruction. J Urol. 1984; 131: 722-727 PubMed Google Scholar However, we hypothesized that the secondary UPJ kinking could be eliminated gradually by endoscopic correction of reflux without compromising the distal ureteric neurovascular bundles and distal ureteral fibrosis during the ureteric reimplantation. Editorial CommentUrologyVol. 81Issue 5PreviewConcurrent vesicoureteral reflux (VUR) and ureteropelvic junction obstruction (UPJO) represent a potential diagnostic and therapeutic dilemma because it can sometimes be difficult to determine if the UPJO is primary or secondary to VUR. In some series, a pyeloplasty rate of 75% has been reported in children who present with simultaneous VUR and UPJO.1 The management algorithm used in the treatment of patients with simultaneous VUR and UPJO therefore carries with it significant therapeutic and costs implications, especially in this era of robotic-assisted ureteropelvic junction repair. Full-Text PDF

Surgical management of vesicoureteral reflux in children

Vesicoureteral reflux (VUR) is the most common uropathy affecting children. Compared to children without VUR, those with VUR have a higher rate of pyelonephritis and renal scarring following urinary tract infection (UTI). Options for treatment include observation with or without antibiotic prophylaxis and surgical repair. Surgical intervention may be necessary in patients with persistent reflux, renal scarring, and recurrent or breakthrough febrile UTI. Both open and endoscopic approaches to reflux correction are successful and reduce the occurrence of febrile UTI. Estimated success rates of open and endoscopic reflux correction are 98.1% (95% CI 95.1, 99.1) and 83.0% (95% CI 69.1, 91.4), respectively. Factors that affect the success of endoscopic injection include pre-operative reflux grade and presence of functional or anatomic bladder abnormalities including voiding dysfunction and duplicated collecting systems. Few studies have evaluated the long-term outcomes of endoscopic injection, and with variable results. In patients treated endoscopically, recurrent febrile UTI occurred in 0–21%, new renal damage in 9–12%, and recurrent reflux in 17–47.6% of treated ureters with at least 1 year follow-up. These studies highlight the need for standardized outcome reporting and longer follow-up after endoscopic treatment.

Endoscopic Bulking Materials for the Treatment of Vesicoureteral Reflux: A Review of Our 20 Years of Experience and Review of the Literature

Purpose. We reviewed our 20 years of experience and the current literature regarding the long-term outcome of endoscopic treatment of vesicoureteric reflux (VUR) using the different tissue bulking substances with a special emphasis on the long-term efficacy. Material and Methods. Our own experience and the current literature on the long-term results after endoscopic treatment using various bulking agents were reviewed. Results. Short-term data following endoscopic treatment of VUR is similar to the various substances and comparable in the majority of the series to the success rate following open surgery. Recently, a relatively high recurrence rate was noticed especially with the use of dextranomer hyaluronic acid (Dx/HA) as a tissue augmenting material which raises the need for further search for alternative substances. Conclusions. Unfortunately, there is a significant shortage of evidence-based literature on the long-term followup after endoscopic correction of reflux with various substances. No doubt, there is a high recurrence rate during long-term followup after Dx/HA injection, and there is probably lack of proper evaluation regarding the long-term efficacy of other bulking materials. These facts demand long-term close observation and long-term studies beyond the routine protocols following endoscopic treatment of VUR and the correct parental counseling upon the endoscopic correction.

Die Behandlung des vesikoureteralen Refluxes im Kindesalter

The pathophysiology, evaluation and therapy of vesicoureteral reflux (VUR) were newly illuminated over the past years through different clinical studies and basic research. Our understanding of vesicoureteral reflux and the therapeutic spectrum of its treatment should therefore consistently undergo critical revision. The Swedish Reflux Study set up three different therapy options for small children with dilated VUR: antibiotic prophylaxis, endoscopic reflux correction and surveillance were prospectively analysed in a randomized fashion. The results are discussed in this work and completed with a statement about open operative reflux therapy.

Endoscopic Management of Vesicoureteral Reflux in Women Presenting With Pyelonephritis

Vesicoureteral reflux is not usually considered a major cofactor in acute pyelonephritis in women. However, there is a subset of individuals in whom reflux must be considered in the evaluation of acute pyelonephritis. We sought to evaluate the effectiveness of endoscopic treatment for vesicoureteral reflux in this subset of patients. We retrospectively reviewed the records of 13 female patients presenting with clinical pyelonephritis between 2001 and 2005. All of these patients had either a history of vesicoureteral reflux in childhood or a family history of reflux, or had previously undergone surgery for reflux. All patients underwent voiding cystourethrogram and dimercapto-succinic acid renal scan as part of the evaluation. Of the 13 individuals evaluated 9 had vesicoureteral reflux. Of these patients 5 had been operated on previously for vesicoureteral reflux, 2 had a strong family history of reflux and 2 had reflux as a child with documented resolution. Six of the 9 patients with reflux exhibited renal scarring on dimercapto-succinic acid renal scintigraphy. Endoscopic correction of reflux was done in all 9 patients and was successful in 8, as shown on voiding cystourethrogram at 3 months postoperatively. One patient required a second procedure, which was successful. Only 1 patient has had a subsequent episode of clinical pyelonephritis, and voiding cystourethrogram following treatment again revealed resolution of reflux. There is a subset of women presenting with acute pyelonephritis in whom vesicoureteral reflux is a risk factor. When documented, vesicoureteral reflux can be managed effectively with endoscopic treatment.

Correction of vesicoureteral reflux: where do we stand?

Newer techniques of molecular biology allow us to gain a better understanding of the molecular mechanism of primary urinary reflux. In recent years, diagnostic tools and treatment options for vesicoureteric reflux have dramatically changed. In this review, we want to focus on genetics, molecular biology, histology, clinical findings, diagnostic tools and newer surgical techniques for the treatment of vesicoureteric reflux published between 2003 and March 2004. Recent findings have demonstrated that the renin-angiotensin-aldosterone system does not seem to be responsible for the development of primary vesicoureteric reflux. Echo-enhanced ultrasound with contrast medium in the bladder, performed by an experienced investigator, could replace the voiding cystourethrogram in follow-up studies of patients treated conservatively for vesicoureteric reflux. The sensitivity and specificity of ultrasound is in the range of 70-100% in some studies compared with the standard voiding cystourethrogram. Endoscopic treatment of vesicoureteric reflux using Defux or Macroplastique has gained more and more popularity, with success rates ranging between 60 and 86%. The surgery is performed on an outpatient basis with minimal morbidity. Long-term results after open operative techniques have demonstrated cure of reflux in over 95% of cases. In the coming years, echo-enhanced ultrasound may replace the standard voiding cystourethrogram during follow-up and it may be used as an initial test in females with normal voiding patterns. Endoscopic reflux correction must be judged on the re-treatment rates and long-term success.

Endoscopic correction of reflux

Endoscopic correction of reflux

Results of endoscopic subureteral collagen injection for reflux correction in pigs and dogs

The efficacy of endoscopic correction of reflux with the use of Teflon has been proven, but there are safety concerns because of granuloma formation and particle migration. Using glutaraldehyde cross-linked (GAX-) bovine collagen as an alternate biomaterial, animal experiments were performed with 6 female pigs and 20 beagle dogs. Primary and experimentally-induced vesicoureteral reflux was treated by endoscopic injection of bovine GAX-collagen (Zyplast) submucosally at the ureteric orifice. Radiographic controls after 6, 8, or 12 months revealed successful reflux correction in 14 of 19 treated ureters of dogs. After the animals were killed, pathohistological evaluation demonstrated persistence of the collagen depot at the site of injection even after 12 months, although not in all cases, without inflammatory or foreign-body tissue reaction. No evidence of particle migration was found. Invasion of fibroblasts and fibrocytes into the collagen depot and capillary vessel formation appeared the same after the different time intervals, and there was no difference between the two animal species. The biocompatibility of purified bovine GAX-collagen makes it an alternative to Teflon for reflux correction.

The Endoscopic Correction of Reflux by Polytetrafluoroethylene Injection

Endoscopic subureteral injection of polytetrafluoroethylene (Teflon) was done in 38 patients (55 ureters) to correct vesicoureteral reflux. Followup excretory urograms and nuclear cystograms were available in 28 patients (40 ureters) 2 to 11 months after injection. Nearly 50 per cent of the patients had a neurogenic bladder. Injection was done for all grades of reflux, although the majority of cases had at least grade III reflux. After injection reflux either was eliminated or decreased in 76 per cent of the patients with neurogenic disease and in 87 per cent of those with a normally innervated bladder. This outpatient procedure is simple and brief to perform, and it is associated with minimal morbidity. As with any new antireflux technique longer followup is indicated.