Endoscopic Management Of Vesicoureteral Reflux Research Articles

Endoscopic management of vesicoureteral reflux secondary to myelomeningocele in children: a single-center experience

Vesicoureteral reflux (VUR) is present in up to 24% of children with neurogenic bladder secondary to meningomyelocele. Endoscopic management of VUR has been an emerging approach, especially since the continuous development of this technique has translated in comparatively high success rates. In this study, we assess the efficacy of subureteric injections of dextranomer/hyaluronic acid copolymer in managing VUR secondary to meningomyelocele in pediatric patients. All patients aged less than 12 years who underwent endoscopic management for secondary VUR of grades III–V due to meningomyelocele were observed. The diagnosis and classification of VUR was done via a MCUG. All patients underwent clinical assessment, renal function tests, urine microscopy with culture, KUB ultrasound, and dimercaptosuccinic acid (DMSA) scan before and after the intervention. A total of 19 children (38 renal units) were evaluated and followed up. The mean age at presentation and intervention was 44 ± 34.6 months and 45.7 ± 35.2 months. The most common grade of reflux at presentation was grade IV (42.1%) followed by V (26.3%). A complete symptomatic relief and treatment success was achieved in 29 renal units (76.3%) following a single injection. A second injection was sufficient to achieve symptomatic relief in the remaining nine renal units (23.6%). None of the patients required a third injection or open surgery. The endoscopic treatment of secondary VUR grades III, IV, and V due to meningomyelocele with dextranomer/hyaluronic copolymer paste in children younger than 12 years is safe and effective alternative minimally invasive surgery with low morbidity.

Endoscopic Management of Vesicoureteral Reflux and Long-term Follow-up

To report our experience with endoscopic management of vesicoureteral reflux (VUR) by injection of a tissue bulking substance - Dextranomer/ hyaluronic acid co-polymer at vesicoureteric junction. Retrospective analyses of case records. Pediatric Surgery department in a tertiary care government Institute. 500 children (767 renal units) consecutively referred to the out-patient department with vesicoureteral reflux noted on micturating cysto-urethrogram (MCU) over a period of 13 years (2004-2016). Preoperative VUR grading and renal scars on radionuclide scans were documented. Dextranomer hyaluronic acid copolymer was injected through a cystoscope at the vesicoureteral junction as a day care procedure under short anesthesia. Patients were followed (average duration 27.3 mo) with clinical assessment, periodic urine cultures and renal scans. Cessation of VUR and symptomatic relief / clinical success postoperatively at 3 months. Complete symptomatic relief was obtained in 482 (96.4%) patients. In 681 units where MCU was available, 614 (90%) units showed resolution of VUR. Endoscopic injection of tissue bulking substances at vesicoureteric junction to stop VUR seems to be an effective intervention.

Application of the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement to publications on endoscopic treatment for vesicoureteral reflux

Following an increasing number of submissions on endoscopic treatment of vesicoureteral reflux (VUR), the Journal of Pediatric Urology sought to establish a quality guideline that would enable reviewers to select the best papers for publication in the journal. The "Strengthening the Reporting of Observational Studies in Epidemiology" (STROBE) Statement, established in 2007, is a 22-item checklist designed to assist with clear reporting of observational studies. This checklist includes a description of methodological items and instructions on how to use them to transparently report observational studies. The aim of the present study was to apply the STROBE principle to observational studies about endoscopic management of VUR, and to establish a "check-list" to assist authors with good-quality submissions. The 22 STROBE criteria were listed and applied to publications on endoscopic treatment by utilizing examples from the current literature, with additional suggestions about how future studies could build upon the information already published on the subject. Based on this strategy, a checklist that is particular to endoscopic treatment studies was produced as a guideline for authors and reviewers. Application of the STROBE statement principles, in combination with key VUR data, will allow better quality submissions and a higher chance of positive reviews and acceptance rates.

The Long-term Incidence of Urinary Tract Infection After Endoscopic Management of Vesicoureteral Reflux

To evaluate the long-term urinary tract infection (UTI) rates after endoscopic correction of vesicoureteral reflux and the possible risk factors for urinary infection. A retrospective study of patients who underwent endoscopic management of vesicoureteral reflux at a single institution from 2001 to 2011 was performed. Patients were followed up for a minimum of 1 year. Voiding cystourethrograms were completed 3 months postoperatively. UTI questionnaire pertaining to the patient's UTI history before and after the surgery was mailed to each patient. Data were first evaluated looking only at culture-confirmed UTIs, and a second analysis included all patient-reported and culture-confirmed urinary infections. Factors considered in the analysis included sex, age, preoperative dimercaptosuccinic acid (DMSA) scan, reflux on postoperative voiding cystourethrogram, voiding dysfunction, and preoperative reflux grade. Data on 175 patients for a minimum of 1 year were collected. There were 34 of 175 confirmed UTIs after endoscopic management, and 11 confirmed febrile UTIs. There were no significant predictors of febrile or afebrile UTIs in this group. Fifty-three of 175 patients (30%) experienced any UTI, 19 of which were febrile (10%). In this group, recurrent reflux was the only significant predictor of UTI (P=.03) and febrile UTIs (P=.04). Patients with more UTIs preoperatively were more likely to have a postoperative febrile UTI. Rates of UTI and febrile UTI in endoscopic management are similar and no better than those for open ureteral reimplantation. Longer follow-up suggests an association of recurrent reflux and preoperative UTI rates as predictors of postoperative febrile UTIs. These patients benefit from closer postoperative observation.

Asymptomatic chronic partial obstruction of a normal ureter following dextranomer/hyaluronic acid copolymer (Deflux®) injection for grade I vesicoureteral reflux

Endoscopic management of vesicoureteral reflux with dextranomer/hyaluronic copolymer (Deflux®, Oceana Therapeutics, Inc., Edison, NJ, USA) has gained widespread acceptance with increasing success rates and minimal morbidity. Formation of a pseudocapsule and calcification are known histologic changes at the injection site. Postoperative ureteral obstruction has been reported in cases of severe voiding dysfunction, neurogenic bladder and abnormal ureteral anatomy. We present a case of chronic asymptomatic obstruction in a normal ureter following injection of 0.7 ml Deflux.

Does compliance status predict clinical status in patients undergoing endoscopic management of vesico-ureteral reflux?

Objective Previous studies of endoscopic management of vesico-ureteral reflux (VUR) have had non-compliance rates around 50%. We examined success rates of patients non-compliant with a delayed follow up protocol after endoscopic injection for VUR. Materials and methods Patients undergoing Double HIT, dextranomer/hyaluronic acid copolymer endoscopic injection for VUR were enrolled in a 1-year, delayed voiding cysto-urethrogram (VCUG) study. All patients non-compliant with the VCUG were contacted and information on their clinical status was collected. Non-compliant patients were re-scheduled for a VCUG. Results 49/54 (91%) patients underwent endoscopic injection for VUR and completed the 6-week ultrasound. At 1-year 49% (24/49) were non-compliant with a VCUG; 75% (18/24) were contacted and provided clinical information. All but one patient agreed to the VCUG. Patients compliant with the 1-year VCUG showed 96% (24/25) clinical and 92% (23/25) radiologic success rates. Non-compliant patients had an 89% (16/18) clinical success rate; 5 (21%) non-compliant patients underwent VCUGs with a 100% success rate. Conclusions Long-term compliance remains an issue for patients treated endoscopically for VUR, but compliance does not predict clinical status as both groups have favorable clinical outcomes. The repeat VCUG is a barrier to long-term follow up as only 21% of patients underwent the study.

Endoscopic management of vesicoueteral reflux in adult women

• To describe our endoscopic management of adult women with vesicoureteral reflux (VUR) and associated outcomes. • We retrospectively identified 19 adult women who presented for the endoscopic treatment of VUR from November 2001 to January 2008. • Each patient was diagnosed with VUR by voiding cystourethrogram or nuclear cystourethrogram after an episode of pyelonephritis or recurrent urinary tract infections with renal scarring on ultrasound. • A dimercaptosuccinic acid renal scan was performed prior to treatment. All patients underwent endoscopic treatment with dextranomer/hyaluronic acid copolymer (Deflux). Patients with bilateral VUR received bilateral injections during the same procedure. • Follow-up imaging was obtained and success was strictly defined as no degree of VUR. Patients with residual VUR received repeat endoscopic treatment. • Nineteen patients with a mean age of 22 years old (range 18-33 years old) underwent endoscopic treatment for VUR. A total of 79% (15/19) had pre-existing risk factors for VUR, including prior open anti-reflux surgery (26%), family history of VUR (26%) and childhood diagnosis of VUR (26%). • Imaging revealed that 47% (9/19) had renal scarring and 26% (5/19) had bilateral VUR. The success rate was 79% (19/24) after one treatment, 92% (22/24) after 5 patients received a second treatment, and 96% (23/24) after 2 patients received a third treatment. There were no perioperative complications. • Endoscopic management of VUR is both safe and effective in adult women.

Injection volumes of dextranomer/hyaluronic acid are increasing in the endoscopic management of vesicoureteral reflux

Dextranomer/hyaluronic acid (Deflux) has been increasingly used for the treatment of vesicoureteral reflux (VUR). Experience has shown that injecting more volume of material is necessary to achieve greater success. We evaluate trends in the number of vials being used to treat VUR using a multi-institutional database and data from patients treated at our own institution. Children of age 0-19 years in the Pediatric Health Information System (PHIS) database from 2003 to 2008 were extracted with a VUR diagnosis (ICD-9 593.7x) and subureteric injection procedure code (CPT 52327). We identified children with reflux treated with endoscopic injection at Seattle Children's Hospital from 2005 to 2008. Hospital trends of the number of vials used were evaluated using multivariate linear regression. From 2003 to 2008, we identified 4,078 endoscopic injection procedures in PHIS. There was a 33% increase in the average number of vials used per patient (p < 0.0001) with more than a threefold increase in the number of patients receiving three or more vials per procedure. All institutions increased the average vials used per patient with the most pronounced increase at the highest-volume centers. These trends were also present in the 186 children treated at our own institution. Over the study period there was an increase in the number of vials of dextranomer/hyaluronic acid being used per patient to treat children with VUR. This practice may improve success rates but will increase the cost of treatment due to the inherent expense of the material.

Renal Scarring and Urinary Tract Infection After Successful Endoscopic Correction of Vesicoureteral Reflux

We evaluated renal function and the incidence of urinary tract infection after successful endoscopic correction of vesicoureteral reflux. From 1988 to 2007, 169 male and 338 female patients (696 refluxing renal units) with a median age of 3.7 years underwent successful endoscopic correction of primary vesicoureteral reflux using polytetrafluoroethylene and dextranomer/hyaluronic acid copolymer. Reflux was grades I to V in 36 (5.2%), 178 (25.6%), 298 (42.7%), 163 (23.4%) and 21 refluxing renal units (3.1%), respectively. Renal ultrasound and (99m)technetium-dimercaptosuccinic acid scan were performed in all patients preoperatively, and in all patients and in 509 of 696 refluxing renal units (73%) postoperatively, respectively. All patients were followed 1 to 20 years (median 13). Preoperatively (99m)technetium-dimercaptosuccinic acid scan revealed scarring in 543 of 696 refluxing renal units (78%). Reflux resolved after 1 injection in 473 refluxing renal units (68%), in 161 (23%) after 2 and in 25 ureters (3.6%) after 3. In 37 refluxing renal units (5.4%) reflux improved to grade I, which required no further treatment. Renal deterioration was noted in 11 of 26 refluxing renal units with initially severe renal scarring (less than 20% uptake on (99m)technetium-dimercaptosuccinic acid scan). The remaining refluxing renal units in this group showed an insignificant 2.3% change in relative function after successful reflux correction (p >0.005). Patients with vesicoureteral reflux downgrading did not show new renal scars. Of the remaining 446 refluxing renal units 27 (6.1%) showed a greater than 5% decrease in relative function without new scarring. Eight children in the polytetrafluoroethylene group and 3 in the dextranomer/hyaluronic acid copolymer group (overall 2.2%) had febrile urinary tract infection after successful endoscopic correction, leading to reevaluation that resulted in the diagnosis of recurrent reflux in 8 (72.7%). A total of 28 children (5.6%) had afebrile urinary tract infection without recurrent vesicoureteral reflux. Our data show that successful endoscopic correction of vesicoureteral reflux is accompanied by a low incidence of new renal scarring and febrile urinary tract infection. Patients who initially have corrected reflux but who have a febrile urinary tract infection at long-term followup require prompt revaluation to rule out recurrent reflux.

Long-term results of endoscopic treatment of vesicoureteral reflux with the sub-ureteric injection of calcium hydroxyapatite

To review our long-term results of the sub-ureteric injection of calcium hydroxyapatite in the endoscopic management of vesicoureteral reflux (VUR) in children. A sub-ureteric injection of calcium hydroxyapatite was given to 14 children (23 ureteral units) affected by VUR grades I-V. All children were followed-up with monthly urine cultures, and a renal ultrasound was done on the postoperative 4th week, while the first voiding cysto-urethrogram (VCUG) control was performed on postoperative week 12. The children were followed-up with yearly renal ultrasound and monthly urine cultures, thereafter. Data from the patients' charts were retrospectively analyzed regarding the outcome of the procedures. Mean follow-up time was 52 months (47-60 months). VUR was cured in 47.4% of cases after a single injection. After the second injection the global success rate was 52.1%. Ureteroneocystostomy was performed on seven refluxing ureters of five children unresponsive to sub-ureteric injection therapy. One patient underwent nephroureterectomy because of a non-functioning kidney secondary to ureteral obstruction due to migration of material at the 23rd month postoperatively. Although favorable short-term success rates have been reported with the sub-ureteric injection of calcium hydroxyapatite without any side effects, our long-term results showed a low success rate, with the only reported serious morbidity.

Influence of Voiding Dysfunction on the Outcome of Endoscopic Treatment for Vesicoureteral Reflux

Influence of Voiding Dysfunction on the Outcome of Endoscopic Treatment for Vesicoureteral Reflux