Endoscopic Treatment Of Vesicoureteral Reflux Research Articles

Voiding cystourethrography in patients undergoing endoscopic decompression of duplex system ureteroceles: to do or not to do?

ObjectiveTo assess the role of voiding cystourethrography (VCUG) in patients with duplex system ureterocele (DSU) undergoing endoscopic decompression (ED).Materials and methodsThis is a retrospective study of 75 consecutive patients with DSU undergoing ED [median (range) age, 6 (1–148) months]. Patients were divided into 3 groups, 33 with a VCUG showing vesicoureteral reflux (VUR) before ED (VUR-group), 22 with a VCUG negative for VUR (No-VUR-group), and 20 who did not undergo a VCUG (No-VCUG-group). Secondary surgery (SS) rate was compared among groups.ResultsGroups were comparable for baseline characteristics. SS rate was 82% (27/33) in VUR-group vs. 32% (7/22) in the No-VUR-group (p = 0.0001), and 25% (5/20) in the No-VCUG-group (p = 0.001 vs. VUR-group, and 1 vs. No-VUR-group). In the VUR-group, 9 patients underwent preemptive endoscopic treatment of VUR during ED and SS rate was 44% (4/9) vs. 96% (23/24) in the remainder, p= 0.003. In the No-VCUG-group, a VCUG was performed during follow-up in 9/15 patients and showed reflux in all, although only 2 of these developed a (single) urinary tract infections.ConclusionsSS rate was significantly higher in patients with preoperative VUR. Instead, it was not significantly different between patients without VUR and those who did not undergo a VCUG before ED, despite all the latter who underwent a VCUG during follow-up had evidence of VUR generally in the absence of symptoms. In our opinion, a VCUG could be limited to patients developing symptoms after ED. If a VCUG is performed before ED, a preemptive treatment of VUR should be taken into consideration.

Intraoperative ultrasound-assisted endoscopic treatment of primary intermediate and high-grade vesicoureteral reflux in children in a long-term follow-up

Endoscopic treatment of vesicoureteral reflux (VUR) is an important minimally invasive surgical approach in patients undergoing surgical treatment of VUR. In our past experience, we observed that a bulking agent mound sagittal diameter of 10mm is the main predictor of effectiveness of the procedure. Moreover we noticed that the use of intraoperative ultrasound, allows the surgeon to better identify the site, volume and shape of the bulking agent injected, finally reducing operative time. We aimed to evaluate if the intraoperative ultrasound assistance could definitively improve effectiveness of the endoscopic procedure. We retrospectively compared two series treated with endoscopic procedures for intermediate and high grade primary VUR, respectively without (series A) and with (series B) intraoperative ultrasound (IO-US). In all patients VCUG was performed to assess VUR grade and to verify resolution or VUR downgrading during the follow-up. A total of 177 ureteric units were treated. Endoscopic procedures globally were effective in 68/96 ureters (70.8%) in series A and in 68/81 ureters (83.9%) in series B. No significant differences in effectiveness were observed comparing the series with regard to VUR grades, but a significant difference is shown (p<0.05) when grouping grades III-V VUR. No significance in differences of volume injected were detected, but operative time was significantly lower in series B (27.5min vs 19.6min, p<0.05). Mean sagittal mound diameter measured during cystoscopy in series B was 10.45mm (range 8.5-14.2mm). The intraoperative ultrasound assistance during endoscopic treatment of VUR could represent a valid tool for surgeons to better identify location, volume and shape of the bulking agent. Furthermore, the use of an objective parameter of evaluation of the implant can overcome the subjective intraoperative evaluation of the implant itself, improving results for experienced surgeons and reducing the learning-curve for inexperienced ones. Results of endoscopic injection of bulking-agent can be improved with intraoperative ultrasound, allowing at the same time a significant reduction of operative time.

The correlation between ureteric orifice morphology and primary vesicoureteral reflux grade and the impact on the effectiveness of endoscopic reflux correction

Early diagnosis and treatment of primary vesicoureteral reflux (VUR) are essential for preserving renal function. The study explored whether preoperative cystoscopic grading of refluxing ureteric orifices (UO) correlated with their shape in an institution with non-performance of hydrodistention of the UO in the diagnosis and grading of VUR. We also assessed the relationship between the UO shape and VUR grade with the effectiveness of endoscopic correction of primary VUR in children. This retrospective study included consecutive patients ≤15 years treated for primary VUR. The reflux grade was based on the results of preoperative voiding cystourethrography as mild, moderate, or severe. Fifty-one patients with 77 renal refluxing units (RRU) underwent endoscopic treatment with Deflux®. VUR was bilateral in 51% of patients. VUR was mild in 13%, moderate in 53%, and severe in 34% of cases. The patients with mild and moderate VUR had stadium-shaped UOs in 60% and 54% RRUs, respectively. Horseshoe-shaped UOs constituted 42% of UOs in patients with severe VUR, followed by 31% of golf-hole UOs. The reflux resolution rate after the first endoscopic injection was 84%. The preoperative VUR grade correlated with UOs shape (p<0.001). No significant correlation between UOs configuration and the outcome of endoscopic treatment was seen (p=0.452). The preoperative VUR grade negatively correlated with a favorable endoscopic treatment (p=0.043). Our data indicate ureteral orifice shapes are closely related to preoperative VUR grade. There was no correlation between the UO configuration and the success rate of endoscopic treatment of VUR, in contrast to the significant negative correlation between the VUR grade and the success rate of endoscopic treatment.

Outcomes after dextranomer/hyaluronic acid bladder neck injection in patients with urethral incontinence following bladder neck repair

Many patients who undergo surgery for bladder neck (BN) incompetence may still experience incontinence postoperatively. Dextranomer/hyaluronic acid (Dx/HA) is widely used for endoscopic treatment of vesicoureteral reflux in children; however, few studies have reported its use in treating incontinence after BN surgery. The aim of this study was to evaluate outcomes after Dx/HA bladder neck injection in patients with persistent outlet incompetency following BN Repair. We retrospectively reviewed patients at a single pediatric tertiary care center with history of prior bladder neck surgery and reported persistent incontinence who then underwent endoscopic bladder neck Dx/HA injection from 2013 to 2018 and had subsequent follow-up post-injection. We described primary outcomes of reported incontinence as "wet" (leakage similar to before injection), "improved" (wet but leakage improved), and "dry" (no leakage). Our secondary outcome was need for a secondary procedure after Dx/HA injection, including Dx/HA injection or bladder neck closure (BNC). At first follow-up (median 2.3 months post-op), 7/19 were wet, 6/19 were improved, and 6/19 were dry. At last follow-up (median of 34.7 months), only three patients (16%) were dry. Only one patient who received a single surgery for Dx/HA injection was "dry", though nearly 2/3rds (12) were initially "improved" in their continence. Overall, seven patients had another intervention or surgery after first injection. Five patients had multiple Dx/HA injections after first procedure, which resulted in dryness by last assessment in two of these. Four patients (21%) in the overall cohort required subsequent BNC. Longer-term follow-up in our study demonstrated that only one patient who received a single procedure of Dx/HA injection remained dry. Several studies had follow up for greater than 1 year after initial bladder neck Dx/HA injection; rates of dryness after a single surgery for injection were variable and reported between 20 and 40% over follow-up times ranging from 1.5 to 7 years (Alova et al., 2012; DaJusta et al., 2013; Lottmann et al., 2006a; Lottmann et al., 2006b; Kitchens et al., 2007). Our st udy does have inherent limitations. This study was performed at a single institution in a retrospective manner, with a single surgeon reviewing the medical record to determine operative techniques and continence outcomes. The patient population is small, although relatively comparable to other previously reported studies. Outcomes were based on documentation of patient reports and are therefore lacking in objectivity. In patients with prior unsuccessful BN repair, long-lasting dryness after single Dx/HA BN injection is unlikely, although one-third may demonstrate relatively durable improvement in incontinence.

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&lt;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&lt;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.

Continence management in children with severe caudal regression syndrome: role of multidisciplinary team and long-term follow-up.

Caudal regression syndrome (CRS) is a rare congenital abnormality including orthopedic deformities, urological, anorectal, and cardiac malformations. The clinical spectrum of CRS varies in severity, therefore multiple surgeries and complex medical care may be required with the efforts and support of a multidisciplinary team to ensure the most accurate treatment and the best outcome. The aim of our retrospective study was to evaluate the role of a multidisciplinary treatment and the long-term outcome in patients with severe CRS. Clinical, surgical and psychological data were collected for all patients with diagnosis of CRS, treated at our Pediatric Hospital from January 1995 to December 2020. Patients with a severe form of CRS according to Pang's classification were included in the study. All patients have been followed by a multidisciplinary team composed by urologists, neurosurgeons, neonatal and digestive surgeons, orthopedic surgeon, physiatrists and psychologists. On admission, patients were screened for CRS with sacrum, spine and legs X-ray, spine MRI, renal ultrasound, voiding cystography and urodynamic, and renography. Clinical data about bowel function were evaluated. During the study period, 55 patients with CRS were treated at our Institution. Six out of 55 (10.9%), presented with severe form of CRS (5 pts with type 1; 1 pt, with type 2) and represent our study group. Diagnosis of severe CRS was made at birth because of the typical deformities of the pelvis (fusion of the iliac wings), and of the lower extremities (undeveloped legs with flexion of the knees, clubfoot). All patients presented with neurogenic bladder, 4/6 (66.6%) with vesicoureteral reflux (VUR) and 2/6 (33.3%) with renal agenesia and contralateral ectopic hypoplastic kidney. Bowel symptoms occurred in 5/6 pts (83.3%). All patients were started with an earlier clean intermittent catheterization (CIC) regimen. In 3 patients oxybutynin has been effective or well tolerated, while in other 3 onabotulinumtoxin A has been used. Vesicoureteral reimplantation has been performed in 1 patient, 2 required endoscopic treatment of VUR. On long-term, 2 patients required bladder augmentation with ileum and appendicostomy (Mitrofanoff). Low adherences in CIC have been observed in three patients, mainly at puberty. Two patients presented with chronic renal failure. One patient reported suicide proposal. Regarding social life, only one is regularly performing sport activity. CRS is characterized by maldevelopment of the caudal half of the body with variable involvement of the gastrointestinal, genitourinary, skeletal, and nervous systems. Management of CRS includes a wide variety of interventions to address the full spectrum of possible anatomical abnormalities. Hence, a multidisciplinary team is also mandatory for a correct bladder and bowel management, in order to maintain continence and preserve renal function, improve quality of life and increase self-esteem.

Does pre-fellowship experience alter success rates of endoscopic treatment of vesicoureteral reflux during pediatric urology fellowship?

Learning curve is a well-known factor that affects the success rate of endoscopic injection for vesicoureteral reflux (VUR). To our knowledge, the significance of pre-fellowship training has not been studied. In the present study, our aim was to investigate the effect of pre-fellowship training on the endoscopic treatment success rates of pediatric urology fellows. A total of 78 patients aged 2-16 years (132 renal units) who underwent subureteric injection for the treatment of primary VUR by four pediatric urology fellows between 2014 and 2020 were retrospectively evaluated. Fellows were grouped into two as experienced and non-experienced according to the presence of pre-fellowship experience (defined as a minimum of 20 procedures). Patients in both groups were divided into two subgroups as non-dilating (grade I-II) and dilating VUR (grade III-V). Also, the change in success rate throughout the fellowship was analyzed. HIT or Double HIT method was used in all interventions. Experienced fellows carried out subureteric injection in 54 (40.9%) renal units while non-experienced fellows performed in 78 (59.1%). There was no success rate difference between experienced and non-experienced fellow groups in non-dilating VUR (100% vs. 88%, respectively p=0.268), whereas the success rate of the experienced group was significantly higher in dilated VUR (78.9% vs. 50.9%, p=0.006). Moreover, the amount of material used in the treatment of non-dilating VUR were similar between two fellow groups (0.6ml vs. 0.6ml, p=0.500), while experienced group achieved higher success rates in dilating VUR by statistically significant less amount of injected volume (0.7ml vs. 0.9ml, p=0.026).Overall complete VUR resolution rates were similar throughout the fellowship period in the experienced fellows (81.5% vs. 88.9%, p=0.444), while it significantly increased in the non-experienced group implicating the completion of the learning curve (51.3% vs. 74.4%, p=0.035). There has been no published reports on the effect of pre-fellowship experience on subureteric injection success. While many researchers reported on the importance of learning curve, various studies assessed the effect of injected volume on success rate implicating contradictory results. Furthermore, others indicated that the ideal technique providing accurate needle placement and obtaining proper depth during injection which is associated with surgical experience is more important than the injected volume in achieving success. Our results implicate that similar success rates in non-dilating VUR can be achieved regardless of previous subureteric injection training. However, higher failure rates may be expected when the procedures are performed by non-experienced pediatric urology fellows at the beginning of their fellowship in dilating VUR.

Endoscopic treatment of vesicoureteral reflux after kidney transplantation: outcomes and predictive factors of clinical and radiological success.

This study aimed to identify and describe the outcomes of different endoscopic treatments and the predictive factors affecting success in the treatment of symptomatic vesicoureteral reflux (VUR) after kidney transplantation. Patients who had undergone endoscopic injection treatment for symptomatic VUR detected by VCUG with at least 1-year follow-up were included in the study. Patients with dysfunctional and/or obstructive voiding patterns were excluded from the study. We retrospectively evaluated the patient's characteristics, operative information about the type of injection (one, two, or four-point) and the bulking agent (DX-HA, PPC), and perioperative data. Clinical success was defined as no febrile UTI, and radiological success was defined as the absence of VUR in VCUG 3months after the operation. Clinical success, radiological success, and encountered complications were statistically analyzed. A total of 76 patients were included in this study. The one-point, two-point, and four-point injection technique was applied to 32 (42.1%), 13 (17.1%), and 31 (40.7%) of patients, respectively. PPC and DX-HA were used as bulking agents in 54 (71.1%) and 22 (28.9%) patients, respectively. The clinical success rate was 73.7% (n = 56). In logistic regression analysis, a significant efficacy of the four-point technique was observed in the univariate analysis of clinical success (p = 0.042). The radiological success rate was 40.8% (n = 31). In the logistic regression analysis, DX-HA and PPC radiological success was attained in 4 (18.1%) and 27 (50%) patients, respectively (p = 0.01). Ureterovesical junction (UV) stricture developed in 5 (6.5%) patients. There was no difference between injection techniques and bulking agents in terms of the development of UV stricture (p = 0.32; p = 0.08). The success of endoscopic treatmentin patients with VUR after kidney transplantation can be increased by multiple injections. Furthermore, PPC can be used to obtain a higher radiological success.

A0782 - The long term result and efficacy of endoscopic treatment of vesicoureteric reflux using dextranomer / hyaluronic acid: Over 15-year experience in a single-center

A0782 - The long term result and efficacy of endoscopic treatment of vesicoureteric reflux using dextranomer / hyaluronic acid: Over 15-year experience in a single-center

Long-term results of endoscopic treatment in vesicoureteral reflux after kidney transplantation.

To assess the long-term clinical outcomes and identify factors predicting success of endoscopic treatment for symptomatic vesicoureteral reflux (VUR) after kidney transplantation. A retrospective chart review of all patients who had a symptomatic VUR after renal transplantation at our centre between January 2000 and December 2020 was performed. VUR was documented by retrograde cystography and was determined by at least one episode of acute graft pyelonephritis (AGPN). Endoscopic injections of polydimethylsiloxane (MacroPlastique™) or dextranomer/hyaluronic acid copolymer (Deflux™) were performed by expert urologists via rigid cystoscopy with a bevelled needle system. The results of endoscopic treatment were evaluated by cystography at three months. The primary endpoint was clinical efficacy as defined by the absence of AGPN during follow-up. Radiological success was defined by the absence of VUR at the three months follow-up cystography. Out of 2135 kidney transplantations, a total of 117 (5.5%) patients had symptomatic VUR: 100 (85.5%) underwent Deflux™ and 17 (14.5%) MacroPlastique™. Preoperative high-grade VUR was recorded in 71% of patients. One postoperative complication was observed, Clavien > II. After a median follow-up of 11.2years (IQR 6.5-14.4), clinical success was achieved in 73 patients (62.4%). Radiological success was obtained in 42 patients (36%). Multivariable analysis failed to identify predictors of endoscopic treatment success, which was independent of the preoperative grade of VUR and the type of bulking agent used. Endoscopic treatment of VUR is a simple and well-tolerated procedure with long-term clinical efficacy.

Usefulness of intraoperative voiding cystourethrogram as an indicator of success in the endoscopic treatment of vesicoureteral reflux.

Up until now, serial voiding cystourethrogram (SVCU) has been regarded as the gold standard technique in the diagnosis of vesicoureteral reflux (VUR). The aim of intraoperative SVCU during endoscopic treatment is to detect those patients eligible to receive more biosynthetic material as a result of persistent VUR. The objective of this study was to assess the usefulness of SVCU as a predictor of treatment success. An analytical, retrospective study of patient medical records was carried out. Patients included had undergone endoscopic VUR surgery from 2000 to 2019, and they were measured in ureteral units. VUR persistence at intraoperative SVCU following treatment was compared with SVCU results after 3 months. Of a total of 167 ureteral units undergoing surgery, persistent reflux immediately after surgery was observed in 17 cases (10% of the sample). Only 3 cases had other urological malformations. In the SVCU carried out after 3 months, reflux was found in 38% of the sample (64 cases). When comparing the results, intraoperative SVCU demonstrated a specificity of 92.6%, and a sensitivity of 15.6%. Given the low sensitivity (15.6%) of intraoperative SVCU to detect cases of persistent reflux in the mid-term, and considering the risks associated with radiation in the pediatric population - which is extremely sensitive to it -, intraoperative SVCU should be ruled out as a useful indicator of endoscopic treatment success.

Extravesical reimplantation of an extravesical-ectopic ureter from the upper pole of a duplicated kidney

Extravesical ureter ectopia is a rare cause of urinary incontinence. We are reporting a case of a 3-year-old girl with urinary incontinence. The girl was observed and treated for recurrent urinary tract infection (UTI) against the background of left-side duplication of the upper urinary tract and vesicoureteral reflux (VUR). Two-time endoscopic treatment using a dextranomer/hyaluronic acid allowed to eliminate VUR on both sides and achieve stable clinical and laboratory remission of UTI. After potty training, the child had a constant drip of urine along with normal urination. The examination revealed extravesical ureter ectopia of the left duplicated kidney upper pole and a bladder space-occupying mass with hyperdensive inclusions in the projection of the vesical trigone on the left, which we regarded as a result of the migration of the implant and the appearance of histopathological changes in it. The presence of a bladder space-occupying mass determined the choice of the surgical technique in favor of the formation of a ureterocystoanastomosis with a duplicated ectopic ureter and the removal of a bladder space-occupying mass. When managing patients after endoscopic treatment of VUR, it should be considered the possibility of morphological changes in the bulking agent due to the accumulation of calcium and uric acid salts.

Magnetic Agarose Microspheres/Hyaluronic Acid Hydrogel as a Trackable Bulking Agent for Vesicoureteral Reflux Treatment.

Vesicoureteral reflux (VUR) is one of the most common congenital anomalies in the kidney and the urinary tract. Endoscopic subureteral injection of a bulking agent has become popular in VUR treatment due to its high success rates, few complications, and a straightforward procedure. In this study, a novel magnetic bulking agent was prepared by embedding Fe3O4 magnetic nanoparticles in cross-linked agarose microspheres with diameters of 80–250 μm and dispersing the magnetic microspheres in a hyaluronic acid hydrogel. The bulking agent has good biocompatibility and biosecurity validated by the tests of cytotoxicity, in vitro genotoxicity, animal irritation, skin sensitization, acute systemic toxicity, and pathological analysis after the injection of the bulking agent extract solution into healthy mice as well as injection of the bulking agent into VUR rabbits. The VUR rabbits were created by incising the roof of the intravesical ureter to enlarge the ureteral orifice. The success rate of the bulking agent in treating VUR rabbits using a subureteral transurethral injection technique was 67% (4/6) or 80% (4/5, excluding the unfinished rabbit), and no migrated particles were found in the organs of the rabbits. The transverse relaxation rate of the bulking agent was 104 mM−1s−1. After injection, the bulking agent was long-term trackable through magnetic resonance imaging that can help clinicians to inspect the VUR treatment effect. For the first time, this study demonstrates that the bulking agent with a long-term stable tracer is promising for endoscopic VUR treatment.

Bladder Dysfunction and Re-Absorbable Bulking Agent Affect Success Rate in Children Underwent Endoscopic Treatment for Vesicoureteral Reflux: A Long-Term Follow-Up Study.

This paper is designed to evaluate the results (at long-term follow-up of) children affected by dilating VUR. Our attention was focused on how VUR grade, laterality, bladder dysfunction (BD), the double renal system, and the type of bulking substance may affect VUR resolution in the long-term period. The charts of 93 children with dilating VUR who underwent endoscopic treatment (ET) and with a minimum post-operative follow-up of 7 years were reviewed (mean follow-up time was 9.6 + 1.4). The majority of patients had severe and bilateral VUR. Polydimetilsiloxane or hyaluronic acid/dextranomer (PDS or Ha/Dx) were used as bulking agents. VUR persistence following endoscopic injection was independent with respect to grade, laterality, duplex renal system, and BD. However, the rate of VUR persistence was significantly higher in children with BD. Children treated with Ha/Dx had a higher rate of VUR persistence. This research demonstrated that ET of VUR is also effective at very long term follow up (and without the development of significant complications). We also showed that patients treated with absorbable bulking agents such as Ha/Dx may experience a higher recurrence rate at the long-term follow-up). We also confirm that the only preoperative condition affecting VUR recurrence was bladder dysfunction.

Endoscopic treatment of primary vesicoureteral reflux in children with two different bulking agents, high success and low complication rates: Comparison of Dexell and Vantris

Introduction and objectivesTo compare the results in terms of efficacy and safety of the endoscopic management for vesicoureteral reflux (VUR) in two different standardized primary VUR cohorts treated with Dexell and Vantris. Patients128 refluxing renal units (RRU) in 87 patients with primary VUR (64 females, 23 males). Patients with secondary VUR and severe bladder and bowel dysfunction were excluded. A total of 22 continent children with mild bladder-bowel dysfunction underwent bladder-bowel training before the implantation. All procedures were performed in the presence of sterile urine using a conventional subureteral transurethral injection technique. ResultsThere were no statistically significant differences between groups in terms of mean age, sex, RRU side, 99mTc-DMSA uptake, and reflux grade. The overall resolution rates based on the number of RRUs for up to three endoscopic treatments were 80% (56/70) in Dexell group and 94.8% (55/58) in Vantris group (P = .012). No postoperative recurrences or vesicoureteral junction obstructions were seen in any group. ConclusionsDexell and Vantris provided an effective and safe endoscopic VUR treatment in the early and mid-term follow up of children with primary VUR. The effectiveness of these substances, which can produce different mass effects with different particle sizes, in safe VUR resolution, needs further investigations.

A systematic review of outcomes of Deflux® treatment for vesicoureteral reflux following pediatric renal transplantation

Vesicoureteral reflux (VUR) after renal transplant in the pediatric population may be associated with an increased incidence of urinary tract infection (UTIs) leading to increased morbidity, including graft dysfunction and graft loss. The non-orthotopic location of the transplanted ureter, and lack of submucosal tunnel may pose challenges in correcting the VUR using endoscopic injection techniques. Herein we report the results of a systematic review evaluating the outcomes of endoscopic treatment of VUR using Deflux® in this population. Pubmed and Embase databases were searched from October 2001 to April 2019. Full-text English articles involving patients less than 18 years old at the time of transplant, with a diagnosis of VUR post-transplantation, who underwent Deflux® treatment were included. Figure1 outlines our PRISMA-compliant search strategy. We found 6 eligible studies describing Deflux® treatment outcomes in 67 pediatric patients with post-transplant VUR where voiding cystourethrogram (VCUG) confirmed the diagnosis and resolution of VUR. The mean success rate was 36.8%. Ureteral obstruction occurred in 7/67 cases (10.4%). In all these 7 cases of obstruction, ureteric stenting was the initial management, but was only successful in 1 patient. Open ureteroneocystostomy (UNC) was performed in 4/7 cases, while 2/7 were managed expectantly (unknown outcomes). Persistent VUR with UTI despite Deflux® were reported in 20 out of 67 cases. Of these, 7 were managed with prophylactic antibiotics, and 13 with UNC. Success rates were consistently low for UNC after failed Deflux® in comparison to redo UNC in transplant ureters without prior injection. Low success rates are seen following injection techniques for VUR after pediatric renal transplant. Although an appealing option, Deflux® may prove counterintuitive due to the high rate of obstruction and suboptimal results if open reimplantation is required. A multi-institutional prospective study with a larger population size may further elucidate these results.

The color Doppler twinkling artifact of implants after endoscopic treatment of vesicoureteral reflux in children: A common finding with high potential for misdiagnosis

Endoscopic treatment of vesicoureteral reflux (VUR) is a common therapeutic procedure in children. Over the last years several studies reported on calcified deflux implants that were misinterpreted as ureteral stones leading to unnecessary diagnostic and therapeutic procedures. Based on an own case, where a calcified implant with a strong twinkling artifact was misdiagnosed as a ureteral stone, the purpose of our study was to evaluate the sonographic imaging appearance of implants after endoscopic VUR repair with special emphasis on the color twinkling artifact. In 40 children (mean age 9.5 years) with 62 treated ureteral units follow-up sonography was performed after a mean time interval of 48.8 months after surgery. The injected deposit was evaluated with B-mode sonography and color Doppler sonography and deposit volume, posterior acoustic shadowing and the appearance and extension of the twinkling artifact were evaluated. 47 of 62 injected units (75.8%) could be identified on follow-up sonography. In 13 of 47 units (27.7%) posterior acoustic shadowing was noted. On color Doppler sonography a twinkling artifact appeared in 26 of the 47 visible cases (55.3%). There was a statistically significant correlation between a positive twinkling sign and the deposit age. In conclusion our study shows that the twinkling artifact is a common finding in follow-up sonography of children after endoscopic treatment of VUR. As the twinkling artifact is a sensitive imaging sign for the detection of ureteral calculi the risk of misinterpretation and mistreatment is given.

Tratamiento endoscópico del reflujo vesicoureteral primario en niños con dos materiales diferentes. Tasa de éxito alta y tasa de complicaciones baja: comparación entre Dexell y Vantris

Introduction and ObjectivesTo compare the results in terms of efficacy and safety of the endoscopic management for vesicoureteral reflux (VUR) in two different standardized primary VUR cohorts treated with Dexell and Vantris. Patients128 refluxing renal units (RRU) in 87 patients with primary VUR (64 females, 23 males). Patients with secondary VUR and severe bladder and bowel dysfunction were excluded. A total of 22 continent children with mild bladder-bowel dysfunction underwent bladder-bowel training before the implantation. All procedures were performed in the presence of sterile urine using a conventional subureteral transurethral injection technique. ResultsThere were no statistically significant differences between groups in terms of mean age, sex, RRU side, 99mTc-DMSA uptake, and reflux grade. The overall resolution rates based on the number of RRUs for up to three endoscopic treatments were 80% (56/70) in Dexell group and 94.8% (55/58) in Vantris group (p = 0.012). No postoperative recurrences or vesicoureteral junction obstructions were seen in any group. ConclusionsDexell and Vantris provided an effective and safe endoscopic VUR treatment in the early and mid-term follow up of children with primary VUR. The effectiveness of these substances, which can produce different mass effects with different particle sizes, in safe VUR resolution, needs further investigations.

Outcomes of complex robot-assisted laparoscopic ureteral reimplantation after failed ipsilateral endoscopic treatment of vesicoureteral reflux

Endoscopic injection (EI) has been considered a minimally invasive option with high success rates. However, in clinical settings where EI has failed, and after repeat injections or worsening clinical presentation, different treatment modalities may be offered. Open ureteral reimplantation has emerged as a safe option in patients who have failed EI for VUR treatment. Currently there is limited literature describing success of complex robot-assisted laparoscopic ureteral reimplantation (RALUR) following primary EI for vesicoureteral reflux (VUR). We aim to describe our surgical technique and outcomes using RALUR approach following failed EI for VUR. We hypothesize RALUR can be a safe, salvage option in patients who have failed EI for VUR in the setting of recurrent VUR or ureterovesical junction obstruction (UVJO). A single site, retrospective study using electronic medical records of all patients who underwent RALUR between 2013 and 2019 following history of previous ipsilateral EI using dextranomer/hyaluronic acid (DHA) for diagnosis of vesicoureteral reflux (VUR) was conducted. Primary outcomes were radiographic resolution and/or clinical resolution. A total of 17 RALUR procedures were reviewed in 16 patients. There were 14 females (87.5%) and 2 males (12.5%). Seven patients had two prior EI. Median (range) age at time of RALUR was 10.1 (5.7-17.9) years, and the average time between EI and RALUR was 5.9 years [1-13]. The average VUR recurrence grade after failed EI was 3 (ranges 2-4) on preoperative VCUG. History of bilateral EI using dextranomer/hyaluronic acid (DHA), was observed in 14 patients. Surgical diagnosis at time of RALUR included persistent VUR (N=10) or symptomatic ureterovesical junction obstruction (UVJO, N=6). Mean console times were 102min (range 70-240min) for RALUR vs 128min (range 70-180min) for cases requiring ureteral tailoring. Six complications occurred in 16 patients (37.6%): Using the Clavien-Dindo classification scale, four patients (25%) were grade I, one (6.3%) grade II, and one (6.3%) was grade IIIb, which required additional procedures for ureteral obstruction. RALUR after failed EI should be considered a reasonably safe and effective surgical approach in older children with persistent VUR or acquired UVJO.

Incidence and risk factors for calcification after dextranomer/hyaluronic acid (Dx/HA) copolymer injection for vesicoureteral reflux

Since the first case of dextranomer/hyaluronic acid (Dx/HA) implant calcification in 2008, concern about the long-term sequelae of Dx/HA injection has been growing. According to previous reports, the incidence of Dx/HA calcification 4 years after injection would be around 2%. The primary aim was to estimate the incidence of Dx/HA implant calcification after endoscopic treatment of vesicoureteral reflux in pediatric patients. Secondary objectives were to establish risk factors and to perform a survival analysis after Dx/HA injection. Patients undergoing Dx/HA endoscopic injection from 2007 to 2014 were prospectively registered. The database included clinical, surgical and radiological outcomes. Patients that showed Dx/HA implant calcification during follow-up were compared to those who did not. Univariable and survival statistical analyses were performed. 30 implants calcified over 355 ureters endoscopically treated. Age at first treatment was lower in patients with implant calcification (2.4±1.3 years vs 3.6±2.5 years; p<0.005). The risk of implant calcification was 8.45% (95% CI: 5.96-11.85%). Median follow-up was 7.6 years (IQR: 5.2-9.5). The incidence rate was 12.06 cases per 1000 ureters-year. The period of highest hazard of implant calcification was between 3 and 5 years after injection. The only risk factor related to implant calcification was the age at first injection: relative risk of implant calcification was 4.4 (95% CI: 1.6 to 12.4; p=0.002) for patients first treated before the age of 3.5 years. The risk and the incidence rate of Dx/HA implant calcification were higher than previous data. The period of highest hazard and detection of implant calcification were consistent with previous reports. Patients first treated before the age of 3.5 had shorter survival time without implant calcification. These are the first data about risk factors and survival function of Dx/HA implant calcification. However, our conclusions about the clinical significance of Dx/HA implant calcification were limited because the patients with implant calcification were asymptomatic. Further studies with larger sample and longer follow-up should confirm the clinical significance and life-long tendency of Dx/HA implant calcification. The risk and the incidence rate of Dx/HA implant calcification were higher than expected. The hazard of calcification was higher between 3 and 5 years after injection. The risk was especially higher in patients treated before the age of 3.5. Caution should be taken not to confuse implant calcifications with ureteric stones. A 5-year follow-up would set a better understanding of the actual incidence and clinical significance of implant calcification.