Endoscopic Correction Of Vesicoureteral Reflux Research Articles

Endoscopic correction of vesicoureteral reflux after chemodenervation of the detrusor with botulinum toxin in a child with a neurogenic bladder and myelodysplasia. Case report

Endoscopic correction of vesicoureteral reflux after chemodenervation of the detrusor with botulinum toxin in a child with a neurogenic bladder and myelodysplasia. Case report

Endoscopic correction of vesicoureteral reflux after chemodenervation of the detrusor with botulinum toxin in a child with a neurogenic bladder and myelodysplasia. Case report

Correction of vesicoureteral reflux in children with neurogenic bladder (NB) and myelodysplasia is rather challenging due to the presence of two aggravating factors. The first is the trabecularity of the bladder due to chronic ischemia and dysfunction of the closing contraction of the ureteral orifice up to complete deconfiguration of the ureterovesical junction, and the second is the neurogenic hyperactivity of the detrusor with hypertonicity, intravesical hypertension, and a significant decrease in the effective volume of the bladder. These pathophysiological mechanisms reduce to zero the effectiveness of open reimplantation of the ureter to create an anti-reflux mechanism, becoming, on the contrary, the cause of reflux aggravation and the development of ureterohydronephrosis. As a result, the correction of reflux in NB becomes impossible without stabilization of detrusor contractility, elimination of intravesical hypertension, and correction of spastic changes in the bladder. Clinical follow-up of a patient with this disorder for 10 years convincingly proves the effectiveness of step-by-step correction of NB and vesicoureteral reflux while adhering to the order of treatment methods.

Does Autologous Blood Injection Following Dextranomer/Hyaluronic Acid Copolymer Implantation in Treating Vesicoureteral Reflux Affect the Microsphere Particle Leakage?

Objectives: It has been shown that concomitant autologous blood and dextranomer/hyaluronic acid (Deflux®) injection, hydrodistension autologous blood injection technique (HABIT), had a better mound preservation and treatment success compared to the hydrodistension injection technique (HIT) in vesicoureteral reflux (VUR) correction. In this study, we aimed to show microscopically whether the concomitant injection of autologous blood decreases the leakage of Deflux® particles. Methods: Children with VUR who underwent HIT or HABIT between March 2020 and January 2023 were enrolled. Following the completion of the procedure on each ureter, the bladder was irrigated for 3 to 5 min, and the retrieved sample of irrigation fluid was evaluated for dextranomer particle count as “immediate leakage”. A Foley catheter was placed, and a urine sample after 12 h was collected as “early leakage”. Results: A total of 86 children with a median age of 3.0 years (interquartile range = 4.6) were included. Overall, 66 patients underwent HABIT, and 20 children underwent HIT. Rupture was observed in five patients during the procedure, and re-injection was conducted successfully in these cases. Immediate, early, and total particle leakage in the first 12 h of the injection were significantly less in the HABIT group compared to the HIT group. In the regression analysis, only the injection technique (HIT/HABIT) and rupture were significantly associated with the total particle leakage in the first 12 h. Conclusions: Immediate injection of autologous blood into the mound following an endoscopic correction of VUR in children is associated with significantly less Deflux® particle leakage from the injection site regardless of the VUR grade. We hypothesize that a concomitant blood injection into the Deflux® mound will create a blood clot while the needle is kept in situ and help to stabilize the mound and decrease treatment failure by minimizing particle leakage from the injection site.

Validation of a hands-on porcine bladder model for endoscopic correction of vesicoureteral reflux with bulking agents

Validation of a hands-on porcine bladder model for endoscopic correction of vesicoureteral reflux with bulking agents

Teflon Injections (STING) Mimicking Distal Ureteric Stones

This case report highlights the potential diagnostic pitfalls associated with subureteral transurethral injection (STING) of non-biodegradable materials like Teflon, which has been utilised for endoscopic correction of vesicoureteral reflux (VUR). A 27-year-old female with a history of VUR presented with left-sided loin pain, vomiting, and dysuria, which were initially thought to be due to distal ureteric stones. However, noncontrast computed tomography (CT) revealed the presence of calcific densities in the region of the distal ureter and vesicoureteric junction (VUJ) bilaterally, likely as a sequelae of previous Teflon injection treatment. A conservative management approach was undertaken, and follow-up evaluations, including MAG3 renograms, showed normal drainage and stable split renal function. This case emphasises the importance of a comprehensive medical history and vigilance in avoiding unnecessary imaging or surgical interventions for patients with a previous history of STING.

ПРЕДИКТОРЫ УСПЕХА ЭНДОСКОПИЧЕСКОЙ КОРРЕКЦИИ ПУЗЫРНО-МОЧЕТОЧНИКОВОГО РЕФЛЮКСА У ДЕТЕЙ

Predicting the outcome of endoscopic correction of vesicoureteral reflux (VUR) is an urgent problem in pediatric urology because the identification of predictors for the effectiveness of endoscopic treatment of VUR will optimize the strategy for examination and treatment of the disease. The purpose of the research was to evaluate the statistical impact of various predictors on the success of endoscopic correction of VUR; to predict the clinical outcome by creating a mathematical model. Materials and methods used: a single-center experimental uncontrolled study was conducted in Sept. 2017 - Feb. 2022. The results of treatment of 150 pediatric patients (240 renal units) aged from 1 month till 7 years old who underwent endoscopic correction of VUR are presented. The following indicators were evaluated as predictors: gender, age of the disease manifestation, bilateral/unilateral VUR, grade of VUR, ureteral diameter ratio (UDR), cystography initial confirmation of VUR, expansion of the pelvicalyceal system and ureter according to ultrasound, the presence of urinary tract infection. Results: according to the data obtained, when comparing the grade of VUR, cystography initial confirmation of VUR, UDR, expansion of the pelvis and ureter depending on the result of treatment, the statistically significant differences have been found (p<0.001). A prognostic model has been developed to determine the probability of the outcome of endoscopic correction of VUR using the binary logistic regression method. The area under the ROC curve was 0.985±0.007 with 95% CI: 0.967-1.000. The resulting regression model was statistically significant (p<0.001). The sensitivity and specificity of the model were 96.4% and 95.3%, respectively. Conclusion: the results of the research show that UDR and the initial confirmation of VUR have greater predictive power for the success of the endoscopic urethroplasty compared to the grade of VUR alone. The use of the predictors and predictive modeling can help improving the selection of candidates for the endoscopic correction of VUR and developing personalized treatment tactics.

Efficacy of botulinum toxin in a patient with neurogenic detrusor overactivity

Neurogenic detrusor overactivity is a dangerin terms of the formation of vesicoureteralreflux, pyelonephritis, and chronic kidney disease. The standard treatment for neurogenic detrusor overactivity is intermittent catheterization of the bladder in combination with M-cholinoblockers, which is not always sufficient. In the article, the authors briefly outlined the physiological basis of intradetrusor injections of botulinum toxin in neurogenic detrusor overactivity in patients with myelodysplasia who underwent surgery for spinal hernias, tumors of the spinal canal, as well as patients with spinal trauma. The technology of intradetrusor injections of botulinum toxin is shown, possible complications are described. The effectiveness of intradetrusor injections of botulinum toxin is shown by a specific clinical example — a description of the medical history of a child who has a history of surgical treatment for a spinal hernia in the newborn period. After the operation, neurogenic detrusor overactivity was revealed, insensitive to treatment with M-cholinoblockers. Complications were vesicoureteral reflux and recurrent pyelonephritis. The results of cystometry before and after double administration of botulinum toxin are shown. Detrusor hypertension was stopped, pyelonephritis remission was achieved, trabecularity of the bladder mucosa was stopped. Simultaneously with the introduction of botulinum toxin, endoscopic correction of vesicoureteral reflux was performed.

Treatment of vesicoureteric reflux in children

Aim. To study the efficacy of endoscopic correction of vesicoureteric reflux in children using bulk synthetic material.Material and methods. From 2016 to 2020, we studied the results of treatment of 63 children with vesicoureteric reflux. The children ranged in age from 6 months to 17 years. The degree of vesicoureteral reflux was as follows: grade I was observed in 2 (3.1%) patients, grade II in 16 (25.3%), grade III in 30 (47.6%), grade IV in 13 (21.98%), and grade V in 2 (3.1%). Among 63 patients with CKD, grade I was found in 26 (41.3%), grade II - in 16 (25.4%); grade III - in 13 (20.6%); grade V - in 2 (3.1%). - III stage - 13 (20,6%); IV stage - 8 (12,7%); IV stage - 4 (12,6%). - (12,7%), and there were no patients with V stage of CKD were absent. Unilateral vesicoureteric reflux was noted in 45 (71.4%) children, bilateral - in 18 (28.5%) children. Endoscopic intravesical correction of vesicoureteral reflux was performed by suburethral injection of “Dam+”.Results and discussion. Summarizing the results of our study, it should be noted that positive results were achieved concerning the relief of urinary tract infection, elimination of urine outflow from the upper urinary tract, improvement of renal function after PMR correction using “Dam+”. Positive results of VUR correction amounted to 75,01%.Conclusions. Endoscopic correction of VUR is one of the effective and low-traumatic methods of treatment. Application of the biocompatible synthetic material “Dam+” in the correction of vesicoureteric reflux contributes to positive results.

Predicting the outcomes of a single endoscopic correction of vesicoureteral reflux using a dextranomer/hyaluronic acid copolymer: selection of the optimal predictive model

Introduction. Endoscopic dextranomer/hyaluronic acid copolymer (DxHA) injection is the most commonly used minimally invasive method of surgical treatment of vesicoureteral reflux (VUR) in children.Purpose of the study. To estimate the accuracy of logistic prognostic models and artificial neural network for prediction a single endoscopic injection DxHA in VUR.Materials and methods. We used endoscopic DxHA in 582 patients (783 ureteric units) of all grades reflux (I - 20, II - 133, III - 443, IV - 187), 53 ureters had complete duplication. A total effectiveness of surgery was 53.2%. A binary logistic regression model and an artificial neural network (multilayer perceptron) were created, taking the following as independent variables: grade of reflux, the patient's age and sex, the ureteral duplication and ureteral dilatation index.Results. The univariate logistic regression showed that the selected predictors were strongly related to the outcome of the treatment. Binary logistic regression and neural network developed high accuracy of the predictions, area under ROC-curve was 0,7 for logistic regression model (a sensitivity of 70.7%, and a specificity of 66.3%) and 0.74 for artificial neural network (a sensitivity of 85.5%, a specificity of 65.3%). Synaptic neural network weights and logistic regression parameters were used in a scoring model to predict the outcome of a single endoscopic injection of DxHA in 2 independent hospitals. An outcomes analysis using predictive models in independent clinics showed a good quality of prediction both with the use of logistic regression (75% and 90% of the correct prognosis) and using a neural network (89.7% and 77% of the correct prediction).Conclusion. An artificial neural network and a binary logistic regression model are an effective tool to assist urologists in identifying and applying endoscopic treatments for VUR in children.

Endoscopic Correction of Reflux Utilizing Polyacrylate Polyalcohol Bulking Copolymer (Vantris) as a Tissue Augmenting Substance: Lessons Learned Over the 10 Years of Experience.

Objectives: To prove the hypothesis that modifying the endoscopic correction of vesicoureteral reflux (VUR) technique (STING procedure) and sharpening its contraindications, lead to increased success rate and decline in the complication rate. Materials and Methods: All patients that underwent endoscopic correction of VUR utilizing Vantris were divided into two groups according to procedure date; before 2015 and 2015-2019. Indication for treatment included persistent high-grade VUR or breakthrough infections. Contraindications included voiding dysfunction, active infection and since 2015 suspicion for obstructive/refluxing ureterovesical junction (UVJ) presented by "beak" sign on voiding cystourethrography (VCUG). Follow-up regiment included ultrasound and VCUG at predetermined intervals. Results: The first group included 215 (158 girls and 57 boys) children with mean age of 4.8 ± 2.8 years who underwent endoscopic correction between 2009 and 2015 and the second group included 42 children (28 girls and 14 boys) with mean age of 3.9 ± 2.1 years who underwent surgery between 2015 and 2019. In the first group, VUR was unilateral in 74 patients and bilateral in 132 comprising 338 renal refluxing units. In the second group, VUR was unilateral in 14 patients and bilateral in 30 comprising 74 RRUs. In the first group reflux was corrected in 317 (94.9%) RRUs after a single injection, after the second in 7 (2.1%) RRUs. In seven (2.1%) RRUs, reflux downgraded to Grade I-II. Three RRUs (0.9%) failed endoscopic correction and required ureteral reimplantation. Nine (2.7%) RRUs developed UVJ obstruction. In the second group reflux was corrected in 61 (82.4%) RRUs after a single injection, after the second in 12 (16.2%) RRUs. In one (1.4%) RRU, endoscopic correction failed and required ureteral reimplantation. None of the patients developed UVJ obstruction. Reflux correction has led to the significant decrease of febrile urinary tract infection (UTI) in both groups. Conclusions: Our data indicate that endoscopic injection utilizing Vantris is safe and long durable procedure. Although utilizing the proper technique and contraindication criteria, the rates of post procedural VUJ obstruction is null.

Do Volume of Injection and Learning Curve Influence the Results of Endoscopic Correction of Vesicoureteric Reflux Using Dextranomer/Hyaluronic Acid? A Single Surgeon Experience.

Background: Available reports regarding the technical factors for successful endoscopic treatment (ET) of vesicoureteric reflux (VUR) using dextranomer/hyaluronic acid copolymer are inconclusive. We studied single-surgeon data to evaluate the association of injected volume and surgeon experience with success after ET for VUR. Materials and Methods: Fifty-eight children (87 ureters) with grades 2-4 primary VUR were included. Success was defined as complete resolution of reflux on follow-up imaging. Volume of injection between success and failed groups was analyzed; volume of injection was further studied using receiver operating characteristic curve (ROC) analysis. Patients were then divided into two groups: group 1 (early experience) and group 2 (later experience). Both groups were compared for age, grade of reflux, volume of injection, and success. Results: Overall success of one injection was 76%. The mean volume of injection was significantly larger in successful ureters than failed ureters (P = .008). On ROC analysis, the volume of 0.75 mL (area under curve 0.747, 95% confidence interval 0.60-0.89) had a good discriminative ability to predict success of the injection procedure. Furthermore, a volume cutoff of 0.8 mL demonstrated significant influence on success (success 14/25 ureters for <0.8 mL and 36/42 ureters for 0.8 mL or more volume of injection, P = .0097), whereas no difference in success was observed with a cutoff volume of 0.9 mL (P = .2480). When the patients were divided into two groups based on surgeon experience, group 2 demonstrated better success than group 1 (84% versus 65%, P = .04). Both groups were comparable for age (P = .09), grade of reflux (0.46) and the median volume of injection was similar (0.8 mL) in both the groups. Conclusions: We found that a minimal volume of 0.75 mL dextranomer/hyaluronic acid injection may be required to achieve success of ET in moderate grade primary VUR. Success also improved with increasing surgeon experience.

EFFICIENCY OF THE ENDOSOPIC CORRECTION OF HIGH-GRADE VESICOURETERAL REFLUX IN CHILDREN

Introduction. The endoscopic correction of vesicoureteral reflux in children has become a basic treatment technique. Its effectiveness in the low-grade reflux is high. High-grade refluxes are an indication for antireflux reconstructive plastic surgery. The article analyzes outomes of endoscopic treatment of patients with high-grade retrograde urine reflux. Material and methods. A total number of 307 patients (409 ureters) with IV-V grade of vesicoureteral reflux were treated. 156 girls and 151 boys, aged 4 months - 12 years, had the endoscopic correction with Dextranomer and Copolymer of Polyacrylic Polyvinyl Alcohol (PPC). The renal parenchyma damage was assessed with DMSA scan; urinary tract infection - with clinical and laboratory findings (febrile temperature and bacteriuria). Outcomes of treatment were evaluated with micurating cystography performed six months later. It revealed either no reflux or its lower grade - grade one. Average follow-up period was 5. 5 years. Results. The effectiveness of endoscopic correction of vesicoureteral reflux after the first injection was 68.7%. The second injection was effective in 48.9%. Febrile urinary tract infection after the treatment went down up to 6.2%. Marked bacteriuria remained high - 55.3%. Renal parenchyma structural and functional damage was noted in 38.9% of older children; mild and moderate degrees of damage prevailed (45.6% and 40.8%, respectively). Conclusion. The endoscopic correction of high-grade vesicoureteral reflux is recommended as the first line treatment for retrograde urine reflux. This technique is highly effective and minimally invasive.

Risk factors for obstructive complications after endoscopic correction of vesico-ureteral reflux using polyacrylate polyalcohol copolymer

Use of polyacrylate-polyalcohol copolymer (PPC) after endoscopic correction (EC) of vesico-ureteral reflux (VUR) is highly effective but is associated with a higher risk of obstructive complications (OC) compared with other implants. We undertook a STROBE compliant retrospective investigation and studied the OC risk factors to increase the practical safety of PPC.Overall, 798 patients (464 [58.1%] girls and 334 [41.9%]) boys) from 5 hospitals in whom PPC was routinely used were evaluated retrospectively. The patients were subdivided into 2 groups. Group I consisted of 754 (94.5%) children (449 [59.5%] girls and 305 [40.5%] boys) without OC. Median age was 41 months [Q1: 18.0; Q3: 81.0]. Group II comprised 44 (5.5%) patients (29 [65.9%] boys and 15 [34.1%] girls) experiencing OC, and their median age was 21.5 months [Q1: 12.0; Q3: 43.0]. Clinical and renal ultrasound examinations were carried out 1 day and 1 month after EC, and then every 6 months after EC. At the follow-up examination approximately 6 months after EC, voiding cysto-urethrography (VCUG) was performed. All patients with OC underwent diuretic renography.OC occurred in 44 (5.5%) of 798 children, in some cases as late as 60 months after endoscopic injection of the bulking agent PPC for correction of VUR. Univariate analysis revealed that younger age (P < .001), higher grade of VUR (P < .001), male gender (P < .001), second injection (P = .003), and EC injection using hydrodistension implantation technique (HIT; P < .001) represented significant risk factors. At multivariate analysis, only male gender (P = .0078), younger age (P = .0044), HIT technique (P < .0001), and second injection (P = .04) represented significant risk factors for the occurrence of OC.We identified young age, male gender, high reflux grade, HIT technique, and second endoscopic injections as factors associated with the risk of OC after EC of VUR using PPC as a bulking agent. Thus, patients who have undergone EC with PPC must be monitored sonographically for occurrence of OC for at least 60 months after the intervention.

Urinary biomarkers of latent inflammation and fibrosis in children with vesicoureteral reflux.

To investigate the urinary levels of TGF-β1, VEGF, and MCP-1 as potential biomarkers of latent inflammation and fibrosis in the kidney before and 6months after correction of vesicoureteral reflux (VUR) in children. A total of 88 patients (mean age 26months) with VUR were divided into three groups: group A-patients with grades II-III VUR, conservative treatment; group B-patients with grades III-V VUR, endoscopic correction of VUR; group C-patients with grades III-V VUR, ureteral reimplantation after failed endoscopic correction. Control group included 20 healthy children. Biomarker levels were measured by ELISA. 99mTc-DMSA scintigraphy and renal histology were performed if possible. At admission, TGF-β1 was close to control in all study groups, VEGF increased with severity of the disease, and MCP-1 increased in group C. Six months after correction of VUR, despite clinical and laboratory improvement, TGF-β1 and MCP-1 increased while VEGF decreased compared to the admission values in all groups; no amelioration of renal scarring was detected either by 99mTc-DMSA scintigraphy or renal histology. The results support our hypothesis that successful correction of VUR is not sufficient to stop or reduce the latent inflammatory and fibrotic processes that have already started in the kidney regardless of the reflux grade and treatment option. Measuring the urinary levels of TGF-β1, VEGF, and MCP-1 may aid in the development of non-invasive, pathophysiologically relevant approach to diagnosis and monitoring of kidney injury and fibrosis in children with VUR.

Ureteral Obstruction After Endoscopic Treatment of Vesicoureteral Reflux: Does the Type of Injected Bulking Agent Matter?

Endoscopic injection of bulking agents for the treatment of vesicoureteral reflux (VUR) has become a therapeutic alternative to antibiotic prophylaxis and ureteral reimplantation. Although considered as a safe and efficient procedure, several studies have reported cases of ureteral obstruction (UO) after endoscopic correction of VUR. This review article evaluates the present VUR literature to estimate the incidence of UO following endoscopic injection of different substances, while also discussing the impact of injection technique and implant volume. Twenty-five publications were identified that provided detailed information on 64 females and 32 males (age range, 7months-48years) that developed UO after endoscopic treatment of VUR using dextranomer/hyaluronic acid (Dx/HA), polyacrylate polyalcohol (PP), polydimethylsiloxane (PDMS), calcium hydroxyapatite (CaHA), polytetrafluoroethylene (PTFE), or collagen. There was some variation in the reported incidence of UO among these materials: Dx/HA (0.5-6.1%), PP (1.1-1.6%), PDMS (2.5-10.0%), CaHA (1.0%), and PTFE (0.3%). Postoperative UO was described following subureteric transurethral injection (STING), intraureteric hydrodistension implantation technique (HIT), combined HIT/STING and double HIT. The injected volume ranged widely, also depending on the type of bulking agent: Dx/HA (0.3-3.0mL), PP (0.3-1.2mL), PDMS (1.0-2.2mL), CaHA (0.4-0.6mL), and PTFE (1.5-2.0mL). The timing of UO varied from immediately after the procedure to 63months. Over half of patients showed asymptomatic hydroureteronephrosis on follow-up imaging, whereas the remaining presented with symptoms of acute UO or fever. UO remains a rare complication after endoscopic correction of VUR, generally reported in less than 1% of treated cases, which appears to be independent of the injected substance, volume, and technique. However, long-term follow-up is recommended as asymptomatic or delayed UO can occur, potentially leading to deterioration of renal function.

Interventions for primary vesicoureteric reflux.

Interventions for primary vesicoureteric reflux.

Avoiding routine postoperative voiding cystourethrogram: Predicting radiologic success for endoscopically treated vesicoureteral reflux.

Variability in the success rates for the endoscopic correction of vesicoureteral reflux (VUR) has prompted a debate regarding the use of routine postoperative voiding cystourethrogram (VCUG). This study examines the predictive performance of intraoperative mound morphology (IMM) and the presence of a postoperative ultrasound mound (PUM) on radiologic success, as well as investigates the role of using these two predictive factors as a composite tool to predict VUR resolution after endoscopic treatment. This retrospective study included children with primary VUR who underwent endoscopic correction with a double hydrodistension-implantation technique (HIT) and dextranomer/hyaluronic acid copolymer. IMM was assessed intraoperatively. The presence of a PUM and VUR resolution were assessed by postoperative ultrasound (US) and VCUG, respectively. Radiologic success was defined as VUR resolution. A total of 70 children (97 ureters) were included in the study. The overall radiologic success rate was 83.5%. There was no statistically significant association between radiologic success and IMM (85.2% with excellent and 87.5% with "other" morphology; p=0.81). The sensitivity and specificity of PUM for radiologic success in this study was 98% and 71%, respectively, while the sensitivity and specificity of the combined prediction model were 81.9% and 85.7%, respectively. We objectively demonstrated that IMM was a poor predictor of radiologic success and should be used with caution. In addition, the performance of a combined prediction model was inferior to the presence of a PUM alone. As such, selective use of postoperative VCUG may be guided solely by the presence of a PUM.

What are the predictive factors leading to ureteral obstruction following endoscopic correction of VUR in the pediatric population?

It is extremely important to not only address the short-term success following endoscopic correction of vesicoureteral reflux (VUR) but also the long-term efficacy and safety of the tissue augmenting substance utilized for endoscopic correction. This study retrospectively evaluated all cases of ureterovesical junction (UVJ) obstruction following endoscopic treatment of VUR over the last 5 years utilizing two tissue augmenting substances, with special emphasis on the safety of Vantris®, and performed clinical and histological review of these patients. The study population comprised 2495 patients who underwent endoscopic correction of VUR utilizing Deflux® (1790) and Vantris® (705). Tissue sections were stained with hematoxylin & eosin and trichrome, and examined under a light microscope. Nine primary obstructive megaureters after ureteral re-implantation served as controls. Nine (0.5%) children (three female and six male) in the Deflux group and nine (1.3%) (five females and four males) in the Vantris group developed UVJ obstruction and required ureteral re-implantation. Obstruction developed during the period ranging 2-49 months (average 16 months) following endoscopic correction. The primary reflux grade was III in seven, IV in six, and V in six children. The mean volume of the injected material in all obstructed patients was 1.2±0.6cc (mean±SD). Histopathological analysis revealed a pseudocapsule composed of fibrous tissue and foreign-body giant cells surrounding the Vantris implant in all patients. The distal part of the ureters demonstrated significant ureteral dilatation without ureteral fibrosis. In all patients, additional biopsies from the muscularis propria adjacent to the injection site were examined and showed no significant abnormalities. There was an increased collagen deposition in the juxtavesical segment of the obstructive ureters following Deflux and Vantris injections, and of primary obstructive megaureter. No significant difference was found in the tissue response between Deflux and Vantris patients and controls. Statistical analysis of the nonhomogeneous population demonstrated higher obstruction rates in patients from the Vantris group. However, no statistical difference was demonstrated regarding the obstruction rate in the homogenous group with relation to gender, age and reflux grade group of patients. Moreover, univariate analysis revealed that Grade V reflux, the presence of beak sign on the reviewed pretreatment, and inflamed bladder mucosa upon injection were significant independent risk factors leading to obstruction. This study suggested that the underlining ureteral pathology lead to UVJ obstruction following Vantris injection. There was increased collagen deposition in the juxtavesical segment of the obstructive ureters following Vantris injection. Furthermore, these findings were similar to those discovered in patients who underwent endoscopic correction with Deflux, and in patients who required ureteral reimplantation due to primary obstructive megaureter. Additional biopsies from the muscularis propria adjacent to the injection site showed no significant abnormalities, ironing out the fact that Vantris did not led to adverse tissue reaction following injection. Univariate analysis further ironed out the hypothesis that underlying ureteral pathology was responsible for the increased incidence of UVJ obstruction and demonstrated that Grade V reflux, the presence of beak sign on the reviewed pretreatment VCUG, and inflamed bladder mucosa upon injection were significant independent risk factors leading to obstruction. Data showed that Vantris injection did not lead to any different ureteral fibrosis or inflammatory changes to the tissue augmenting substances utilized in past and present clinical practice, and therefore did not seem to increase the incidence of UVJ obstruction. High reflux grade, presence of obstructive/refluxing megaureter and inflamed bladder mucosa were the only statistically significant and independent predictive factors for UVJ obstruction following endoscopic correction of VUR.

The effect of prior endoscopic correction of vesicoureteral reflux on open ureteral reimplantation: Surgical outcomes and costs

Endoscopic injection of a bulking agent is a common first-line approach to the treatment of vesicoureteral reflux (VUR). While early outcomes are comparable to open ureteroneocystotomy, 5-25% of children will eventually develop recurrent reflux necessitating repeat injections or open ureteral reimplantation. To determine whether prior endoscopic injection of a bulking agent impacts outcomes of subsequent open ureteral reimplantation. Using a retrospective cohort design, radiographic and clinical outcomes of open ureteral reimplantation were compared between patients with and without prior endoscopic correction of reflux. Surgical and hospitalization data were also compared between groups and a cost comparison was performed to assess differences in healthcare costs between the two cohorts. Units of analysis included total ureters or total patients. For certain variables, subanalysis of unilateral versus bilateral reimplantation was included. A total of 258 patients underwent open reimplantation for VUR between 2007 and 2016 by five pediatric urologists. Final analysis (see Summary Table) included 192 patients with pre-operative and postoperative voiding cystourethrogram (VCUG) and follow-up data at a median 4.95 months. Among 317 reimplanted refluxing ureters, radiographic resolution was reached in 26/27 (96.3%) patients with and 279/290 (96.2%) without prior endoscopic treatment (P=0.981). Clinical success was achieved in 17/17 (100%) patients with and 174/175 (99.4%) without prior endoscopic treatment (P=0.755). There were no statistically significant differences between duration of surgery or length of hospital stay. There were no statistically significant differences between total charges, total costs, and operating room (OR) costs between groups. This study indicated that prior endoscopic injection of a bulking agent did not impact the outcomes or costs of subsequent open ureteroneocystotomy. While prior studies have demonstrated tissue changes associated with injection of a bulking agent, these did not seem to significantly impact the difficulty of later open surgery or the success rates compared to patients who proceeded directly to open correction of reflux. Open ureteral reimplantation for recurrent VUR after failed endoscopic injection of a bulking agent was safe and effective, with comparable outcomes and costs to open surgery in patients without prior endoscopic correction.

Endoscopic correction of vesicoureteral reflux in children

Introduction: Dextranomer/hyaluronic (Dx/HA) acid is the only tissue-augmenting agent approved by the Food and Drug Administration (FDA) for the vesicoureteral reflux (VUR) treatment. Objectives: We aimed to evaluate short-term outcomes of the Dx/HA in patients who had undergone subureteric injection. Patients and Methods: In this study, 30 patients with VUR diagnosis who had indications for open surgery were enrolled in the study. Patients underwent subureteric Dx/HA injection. Additionally patients underwent a one-year follow up period, subsequently. Follow up included urine analysis, urine cultures and kidney and urinary tract ultrasonography study. Results: Of a total 30 patients, 8 patients (27%) were male and 22 patients (73%) were female. The mean age of patients was 25.19 ± 0.70 months. Postoperative VUR resolution was observed in 28 patients (93.3%). Moreover, during one year follow up, urinary tract infection (UTI) was not reported in patients. However, recurrent VUR was detected in 8 patients (27%) during ultrasonography follow up. Analysis showed no significant difference of recurrence in VUR between males and females (P = 0.285) and VUR severity (P = 0.1). There was a significant relationship between recurrent UTI history before intervention and VUR recurrence after subureteric injection (P = 0.007). Conclusion: Dx/HA acid subureteric injection provides acceptable resolution rate among VUR patients, but its biodegradability causes VUR recurrence during one-year follow up.