Endoscopic Treatment Of Vesicoureteral Reflux Research Articles

V53 - Endoscopic treatment of vesicoureteral reflux in adult patients: Suspension technique with Vantris

V53 - Endoscopic treatment of vesicoureteral reflux in adult patients: Suspension technique with Vantris

Endoscopic Treatment for Vesicoureteral Reflux in Recurrent Urinary Tract Infections in Kidney Transplant: Experience of One Center

Vesicoureteral reflux (VUR) after renal transplantation in adult patients has been reported. In renal transplant recipients, symptomatic urinary tract infection can cause high morbidity despite improved immunosuppressive and antibiotic treatment. In our country there have been few reported cases about use of copolymer of dextranomer and hyaluronic acid (DX-HA) injection in a renal transplant. We present 3 cases of recurrent or complicated infections with evidence of high-grade VUR, which were treated with DX-HA. Only 1 case had a partial remission; however, there were no episodes of urinary tract infection in 12 months of follow-up. Suburethral injection is an endoscopic treatment modality with low morbidity in our country.

Factores implicados en el fracaso tardío del tratamiento endoscópico del reflujo vesicoureteral

IntroductionThe short-term results of endoscopic treatment of vesicoureteral reflux (VUR) are excellent. Over time, however, a number of patients have been identified for whom VUR reappeared after being resolved with this technique. The aim of this study was to analyse the factors related to this event. Material and methodsA retrospective, analytical, case-control study included 395 ureteral units with primary VUR treated successfully at our centre, with a minimum follow-up of 3 years. We identified cases in which VUR reappeared and analysed the demographic variables, those related to VUR (grade, laterality, initial study) and those related to the operation (materials used). ResultsWe identified 77 ureteral units with recurrence in the 395 included units (19.5%). The recurrence rate was 29.7% for the patients treated with dextranomer/hyaluronic acid (Dx/HA), 20.2% for those treated with polydimethylsiloxane (MP) and 12.2% for polytetrafluoroethylene (PTFE). The onset of recurrence rose to 35% for patients treated before 1 year of age and those with gradeV VUR. Urinary dysfunction symptoms also increased the recurrence rate to 34.9%. ConclusionThe use of resorbable dextranomer/hyaluronic acid material was related to recurrence in the endoscopic treatment of VUR. The high-grade reflux and treatment at an early age, as well as the presence of urinary dysfunction, are also factors associated with recurrence.

New bulking agent for the treatment of vesicoureteral reflux: Polymethylmethacrylate/dextranomer.

PurposeThe aim of this study was to report preliminary results of endoscopic treatment of vesicoureteral reflux in children with a single injection of a new bulking agent, cross-linked dextran and polymethylmethacrylate mixture.Materials and MethodsWe performed a single-center, single surgeon, prospective, off-label study using polymethylmethacrylate/dextranomer to treat vesicoureteral reflux. All patients underwent endoscopic injection, followed by renal ultrasound and voiding cystourethrogram at 3 months postoperatively to identify de novo or worsening hydronephrosis and vesicoureteral reflux correction (to Grade 0 or I).ResultsEighteen patients underwent injection of polymethylmethacrylate/dextranomer at our institution between April 2013 and December 2013. Ten were males and eight were females, with a median age of 58 months (range, 6 months to 5 years). Vesicoureteral reflux was unilateral in three patients and bilateral in 15, for a total of 33 renal refluxing units. Vesicoureteral reflux was Grade I in one renal refluxing unit, Grade II in 12, Grade III in 16, and Grade IV in four. Mean injected volume was 0.86 mL. Reflux was corrected in 23 renal refluxing units (69.7%) according to the 3-month voiding cystourethrogram. Complications included urinary retention in one patient. Mild pyelectasis was noted in one patient at 3 months, which spontaneously resolved 3 months later.ConclusionsOur short-term data show that polymethylmethacrylate/dextranomer injection can be used to treat vesicoureteral reflux with comparable efficacy to other substances currently used and a low rate of complications. Long-term follow-up is required to confirm the usefulness of this material in treating vesicoureteral reflux.

Efikasnost endoskopske metode lečenja u odnosu na otvorenu hiruršku korekciju vezikoureteralnog refluksa

Introduction: Vesicoureteral reflux (VUR) represents the retrograde flow of urine from the bladder to the upper urinary tract. It can be managed by continuous antibiotic prophylaxis of the urinary tract infections until spontaneous resolution occurs, surgical ureteral reimplantation (ureteroneocystostomy), or endoscopic treatment by injecting bulking agents. The aim: To assess the efficacy of the endoscopic treatment of VUR in comparison to the ureteroneocystostomy. Material and methods: The first group included 300 children with VUR, II to IV grades managed by endoscopic injection from 2005 to 2015, and second group included 300 patients who underwent surgical treatment for the IV or V grade of VUR from 1997 until 2009. The results of treatment and complication rate were analysed and compared. We did the same analysis considering the total number of ureteral units. Results: Of total of 300 patients treated endoscopically, in 281 (93.67%) patients the reflux was completely resolved; in 10 (3.33%), the reflux was downgraded (decreased for one or two grades) and in 9 (3%) the intervention was unsuccessful. In 430 ureteral units, full resolution was achieved in 402 (93.49%) units; in 10 (2.33%), the reflux was downgraded and in 18 (4.65%) the reflux didn't resolve. In 300 patients who underwent open surgery, in 290 (96.7%) the reflux was resolved; in 8 (2.67%), the reflux was downgraded from the V/IV to the grades I to III; in 2 (0.66%) the operation was unsuccessful. Out of 480 ureteral units, in 463 (96.46%) units the reflux was resolved; in 13 (2.71%), the grade of reflux was reduced, while in 4 (0.83%) units the reflux was persistent. Recorded success rate didn't show any statistically significant difference between these two groups. The length of hospital stay was significantly shorter and the number of complications was lower in the group of patients treated by endoscopic injection. Conclusion: Comparable success rate, shorter hospital stay, and fewer complications make the endoscopic treatment more preferable option.

Endoscopic Treatment of Vesicoureteral Reflux in Infants. Can We Do It and Should We Do It?

To evaluate the outcomes of endoscopic treatment of vesicoureteral reflux (VUR) performed on infants, and to discuss the possible role of this approach in selected cases. A retrospective analysis was conducted on the patients who underwent endoscopic injection of a bulking substance for VUR in our institution, and a comparison was made with patients treated during infancy and those treated later in life. A total of 463 ureteral units were included (296 children), of whom 47 were patients less than 1 year of age (infants, INF group); the remaining 416 were included in a second group (children, CHL). In this study, the percentage of high-grade VUR and presence of reflux nephropathy were significantly higher in younger patients. Both early failure and recurrence rate were significantly higher in the INF group when compared with the CHL group. No complications were observed in the INF group. Endoscopic treatment of VUR is feasible in patients less than 1 year of age. The effectiveness is lower than when patients are treated at a later age but was still over 80% in our series. There were no complications reported related to the procedure itself or to the general anesthesia. Once it is known that endoscopic treatment of VUR can be performed, controversy arises about the indication of treating patients with VUR. Careful selection of VUR cases that are less likely to spontaneously resolve, presence of breakthrough infections, and parental preference, all play a role in the decision-making process.

Urinary excretion of EGF and MCP-1 in children with vesicoureteral reflux.

ABSTRACTPurpose The aim of this study was to investigate the urinary concentration of epidermal growth factor (EGF) and monocyte chemotactic protein-1 (MCP-1) as reflux nephropathy (RN) biomarkers before and after endoscopic treatment of moderate to severe vesico-ureteral reflux (VUR).Materials and methods A prospective study was carried out on 72 children with moderate to severe VUR. All patients underwent endoscopic treatment using Macroplastique® or Deflux®. Vesico-ureteral reflux resolution was tested by post-operative voiding cystourethrography after 3 months and 2 years. Follow-up urinary samples were collected at that time. Control samples were taken from healthy children with no clinical evidence of renal and bladder disease and no history of UTI.Results In VUR patients, pre-operative urinary EGF levels had a down-regulation when compared to controls. Following successful VUR repair, urinary EGF levels of VUR children progressively increased only at long term follow-up but without returning to normal levels. Urinary MCP-1 levels were highly expressed in pre-operative samples and decreased markedly during early post-operative measurements. Urinary MCP-1 levels did not further decreased in late post-operative follow-up. In fact, these levels remained significantly higher when compared to controls.Conclusions Urinary levels of EGF and MCP-1 may become useful markers for monitoring the response to surgical treatment in VUR patients. Although endoscopic VUR treatment is effective in reducing the inflammatory response, the persistence of significant abnormal levels of inflammatory cytokines (such as urinary MCP-1) at long term follow-up suggests that surgery alone may not completely treat the chronic renal inflammation evidenced in these children.

Controversies Regarding Management of Vesico-ureteric Reflux.

The primary goal in the management of a child with urinary tract infection (UTI) is to prevent recurrence of UTI and acquired renal damage. Approximately 15% of children develop renal scarring after a first episode of febrile UTI. Vesico-ureteric reflux (VUR) is diagnosed in 30-40% of children imaged after first febrile UTI. The 'top-down' approach involving ultrasound and dimercaptosuccinic acid scan (DMSA) first after an appropriate interval following UTI, can help in avoiding voiding cystourethrogram (VCUG), an invasive test with higher radiation exposure. The majority view remains that VCUG should be done after the second attack of UTI in girls and first attack of UTI in boys. Although the evidence in favour of antibiotic prophylaxis remains doubtful in preventing renal scars associated with VUR, it remains the first line treatment for high-grade reflux (grade 3-5) with an aim to prevent UTI and allow spontaneous resolution of VUR. Early identification and appropriate treatment of associated bowel bladder dysfunction is an essential part of successful medical management of VUR. Endoscopic treatment of VUR, using a bulking agent, is useful in grade 3 VUR. The main controversy regarding intervention (endoscopic/open surgical intervention) involves absence of strong evidence for these interventions in reducing renal scarring on randomized controlled trials. However, several recent trials have found the surgical interventions to be effective in reducing recurrent pyelonephritis and repeated hospital admissions.

Intraoperative ultrasound-assisted approach for endoscopic treatment of vesicoureteral reflux in children

PurposeDespite minimal invasiveness and high success rate, guidelines still prescribe voiding Cystourethrogram (VCUG) after endoscopic treatment for vesicoureteral reflux (VUR) in children.The aim of this paper was to analyze whether intraoperative ultrasound (IO-US) could improve surgical accuracy and perioperative counseling, thus potentially decreasing the need for postoperative VCUG. MethodsWe selected children treated for moderate to high grade VUR, renal scarring or repeated infections under antibiotic prophylaxis from January to December 2015. Endoscopic injection was combined with IO-US to detect optimal needle placement and to guide mound formation. IO-US findings were compared to surgeon opinion and postoperative VCUG, performed 3months after surgery. All patients were followed-up for 1year. ResultsA significant relationship was found between IO-US mound height (p=0.003) or localization (p<0.0005) and VCUG. Success of endoscopic treatment vs persistence of reflux groups had a mean mound height of 10.62±1.36mm and 8.39±1.08mm respectively (p<0.0005).Height maintained a significant correlation with success in simple and multivariable regression analysis. ROC curve determined ≥9.8mm as predictor of reflux resolution (95% CI 0.825 to 0.998; p<0.0001). ConclusionsIO-US facilitates pediatric urologists to find an optimal location, to reach a volcano mound morphology and height, thus increasing intraoperative accuracy. IO-US also helps evaluating high-risk recurrence and guiding prognostic counseling. Type of studyTreatment study. Level of evidenceII.

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.

Late-onset Uretero-vesical Junction Obstruction Following Endoscopic Injection of Bulking Material for the Treatment of Vesico-ureteral Reflux

To characterize patients who develop late obstruction after subureteral injection of bulking agent for the treatment of pediatric vesicoureteral reflux (VUR). We retrospectively evaluated the medical records of all patients who underwent endoscopic injection for the correction of VUR during 2008-2015 in 2 centers in Israel: Bnai-Zion Medical Center, Haifa, and Schneider Children's Medical Center, Petah Tikva. Nine patients who developed late-onset obstruction were included in the study, and their data were reviewed and analyzed. Three boys and 6 girls with mean age of 3 years were included in the study. All patients had moderate-to-high grade VUR. Following injection, all children had a radiographic evidence showing resolution of the reflux. During follow-up, patients were diagnosed with late obstruction in a mean time of 13.4 months. All patients underwent open re-implantation. Late-onset obstruction may develop in patients treated with subureteral injection for VUR. Patients with high grade reflux and dilated ureters are at risk of late obstruction. Long-term follow-up with ultrasound is mandatory following endoscopic treatment of VUR.

Routine delayed voiding cystourethography after initial successful endoscopic treatment with dextranomer/hyaluronic acid copolymer (Dx/HA) of vesicoureteral reflux (VUR). Is it necessary?

IntroductionSome guidelines recommend an early voiding cystourethrography (VCUG) after endoscopic treatment of vesicoureteral reflux (VUR), but there is no consensus if it is necessary a long-term follow-up in these patients. The aim of our study is analyze if it is necessary a delayed VCUG after initial successful treatment with Dx/HA. Material and methodWe have reviewed all medical charts of patients that underwent Dx/HA treatment from 2006 to 2010. We have selected patients with initial successful treatment and more than 3 years of radiological and clinical follow-up. We have analyzed late clinical and radiological outcomes. ResultsOne hundred and sixty children with 228 refluxing ureters underwent Dx/HA endoscopic treatment with a mean follow-up of 52.13 months. Early VCUG was performed in 215 ureters with an initial successful rate of 84.1%. The group of study was 94/215 ureters with more than 3 years of follow-up with a delayed VCUG. VUR was still resolved in 79.8% of the ureters. Clinical success rate was 91.7%. The incidence of febrile urinary tract infection in those patients with cured VUR and those with a relapsed VUR was 8 and 15%, respectively; but there were no significant differences. We have not found any variable related with relapsed VUR except those ureters that initially received 2 injections (p<.05). ConclusionIf our objective in the treatment of VUR is to reduce the incidence of febrile urinary tract infection it is not necessary to perform a delayed VCUG even though the long-term radiological outcomes is worse than clinical outcome.

STING versus HIT technique of endoscopic treatment for vesicoureteral reflux: A systematic review and meta-analysis

AimOur study aimed to compare the efficacy of two endoscopic techniques used for the correction of vesicoureteral reflux (VUR): subureteral transurethral injection (STING) and hydrodistension implantation technique (HIT). MethodsA systematic review was conducted using MEDLINE, Google scholar, and Cochrane databases from 1984 to 2015. Meta-analysis of the selected studies was performed to compare the extent of reflux resolution following both techniques. ResultsSix observational studies met the inclusion criteria for content. These comprised 632 ureters treated by STING and 895 ureters treated by HIT procedure. All included studies utilized dextranomer/hyaluronic acid (Deflux) as the bulking agent. The overall resolution of VUR was significantly higher in HIT (82.5%) compared to STING (71.4%) [pooled odds ratio (OR)=0.54; 95% confidence interval (CI) 0.42–0.69; P<0.0001; I2=8%]. A subgroup analysis showed that HIT had better outcomes than STING for both lower grade (I–III) [OR=0.43; 95% CI 0.23–0.82; P=0.01; I2=0%] and high-grade VUR (IV–V) [OR=0.43; 95% CI 0.20–0.91; P=0.03; I2=0%]. However, there was no statistical difference in the requirement of additional injections between STING and HIT groups. ConclusionHIT is superior to STING technique for resolution of VUR after Deflux injection. However, more randomized trials with longer follow-up are necessary to demonstrate the benefit of HIT compared to STING procedure. Level of evidenceRetrospective comparative studies – level III.

Polyacrylamide Hydrogel as a Bulking Agent for the Endoscopic Treatment of Vesicoureteral Reflux: Long-Term Results and Safety

Polyacrylamide hydrogel has been shown to offer good short-term success for the endoscopic treatment of vesicoureteral reflux. Our objective was to provide long-term results of its efficacy and safety. We performed a prospective study using polyacrylamide hydrogel to treat all grades of vesicoureteral reflux. Every patient underwent endoscopic injection of polyacrylamide hydrogel followed by 3-month postoperative renal ultrasound and voiding cystourethrogram. Renal ultrasound was repeated at 12 and 36 months. Treatment success was defined as the absence of de novo or worsening hydronephrosis and the absence of reflux. Safety elements included new or worsening hydronephrosis, calcifications of the injected material and urinary tract infections. A total of 76 patients (123 refluxing renal units) were assessed. Median age at surgery was 45 months and median followup was 36 months. Median injected volume of hydrogel per refluxing renal unit was 1.0 ml. The overall success rate 3 months after a single injection was 71%. During long-term followup 68 of 70 eligible patients underwent 12-month ultrasound and 40 of 46 underwent 36-month ultrasound. No upper tract deterioration or bulking agent calcifications were reported. Nine (12%) and 2 patients (3%) presented with nonfebrile and febrile urinary tract infections, respectively. The success rate of polyacrylamide hydrogel for endoscopic treatment of vesicoureteral reflux is comparable to published results of dextranomer hyaluronic acid. The long-term safety data and potential lower cost of polyacrylamide hydrogel provide further support for the use of this nonparticulate bulking agent to treat reflux.

Delayed upper tract drainage on voiding cystourethrogram may not be associated with increased risk of urinary tract infection in children with vesicoureteral reflux

Urinary stasis in the setting of obstruction provides an opportunistic environment for bacterial multiplication and is a well-established risk factor for UTI. Vesicoureteral reflux (VUR) with delayed upper tract drainage (UTD) on VCUG has been reported to correlate with increased UTI risk. We sought to determine whether delayed UTD can be reliably classified, and whether it correlates with UTI incidence, VCUG, or endoscopic findings. Children undergoing endoscopic surgery for primary VUR (2009-2012) were identified. VUR grade, timing, and laterality were abstracted. Demographics, hydrodistention (HD) grade, reported febrile and culture-proven UTI were assessed. UTD on VCUG was graded on post-void images as 1=partial/complete UTD or 2=no/increased UTD. Inter-observer agreement was calculated. Patients were excluded for incomplete imaging or inability to void during VCUG. The cohort included 128 patients (10M, 118F), mean age 4.1 ± 2.1 years. Mean age at diagnosis was 2.8±2.8 years. Mean maximum VUR grade was 3±0.9: 1 (7.8%), 2 (20.3%), 3 (43%), 4 (25.8%), 5 (3.1%). UTD occurred in45(35%), and no drainage in 83 (65%) patients. Agreement coefficient between graders was 0.596 (p<0.0001). Cultures were available in 100 patients (70 positive). Patients experienced a mean of 2±1.2 parent-reported fUTIs and 1.2±1.2 culture-proven UTIs from birth to surgery. UTI rate did not differ by UTD status for parent or culture-proven UTI (Table). On multivariate analysis, no patient characteristic was a significant predictor of UTI based on drainage status. Children diagnosed with VUR before 1 year of age had a higher verified UTI rate (p<0.001). However, drainage was not a significant predictor of UTI rate and when testing the interaction of drainage and age. We sought to determine whether UTD was an accurate predictor of UTI risk to maximize available prognostic information from a single VCUG. Delayed UTD was not a predictor of infection in our patients, nor was it associated with previously described UTI risk factors, such as VUR timing or grade, and voiding dysfunction. Limitations included the retrospective nature of the study in patients undergoing endoscopic VUR treatment, and possible inaccurate UTI reports from parents and pediatricians. UTD can be reliably scored using a binary system with high inter-observer correlation. Our data call into question the previous finding that children with poor UTD are at increased risk of recurrent UTI. Delayed UTD is also not associated with higher HD, or VUR grade compared with those with more prompt UTD.

Comparison of results of endoscopic correction of vesicoureteral reflux in children using two bulking substances: Dextranomer/hyaluronic acid copolymer (Deflux) versus polyacrylate-polyalcohol copolymer (Vantris)

Endoscopic correction of vesicoureteral reflux (VUR) in children offers minimally invasive management and is widely used as a first-line procedure for all grades of reflux. However, there is debate about which tissue-augmenting substance is the best to use. The aim of this study was to evaluate the efficacy of two bulking substances, Deflux (Dx/HA) and Vantris (PPC), for endoscopic treatment of VUR in children. From 2009 to 2012, 65 children (50 girls and 15 boys) aged 1.45-9.9 years (mean 4.85±2.52) underwent endoscopic correction of VUR using Deflux. VUR was unilateral in 31 patients and bilateral in 34 patients, comprising 108 renal refluxing units (RRUs) grades: II in 52, III in 47, IV in 7, and V in 2. From 2012, 68 children (43 girls and 25 boys) aged 0.6-17.9 years (mean 4.89±3.46) were treated with Vantris. VUR was unilateral in 33 and bilateral in 35 patients, comprising 109 RRUs grades: II in 48, III in 29, IV in 13, and V in 19. Voiding cystourethrogram was done 3 months after procedure. All patients completed follow-up (summary Table). With Deflux, reflux resolved in almost 93% of RRUs after two procedures (in 63% after first injection), with Vantris, VUR was corrected in the same percentage after one procedure. The success rate with Deflux ranges between 68% and 92% (only 50-70% after single injection). The reported possibility of reflux recurrence after successful Deflux treatment, and the need for repeated injection led to introduction of the new substance Vantris. The results of a multi-centre survey published in 2014 showed that reflux is corrected in more than 90% of cases after single PPC injection. Our results with PPC confirm a high level of reflux resolution. Our data show that Vantris injection is a safe and effective procedure for treating all grades of VUR with good clinical outcome, and provides a higher and almost complete level of reflux resolution after first injection compared with Deflux.

¿Es necesario realizar una cistouretrografía miccional seriada (CUMS) tardía tras el tratamiento endoscópico exitoso inicial con copolímero de dextranómreo/ácido hialurónico (Dx/HA) para el reflujo vesicoureteral (RVU)?

IntroductionSome guidelines recommend an early voiding cystourethrography (VCUG) after endoscopic treatment of vesicoureteral reflux (VUR), but there's no consensus if it's necessary a long-term follow-up in these patients. The aim of our study is analyze if it's necessary a delayed VCUG after initial successful treatment with Dx/HA. Material and methodWe have reviewed all medical charts of patients that underwent Dx/HA treatment from 2006 to 2010. We have selected patients with initial successful treatment and more than 3 years of radiological and clinical follow-up. We have analyzed late clinical and radiological outcomes. ResultsOne hundred and sixty children with 228 refluxing ureters underwent Dx/HA endoscopic treatment with a mean follow-up of 52.13 months. Early VCUG was performed in 215 ureters with an initial successful rate of 84.1%. The group of study was 94/215 ureters with more than 3 years of follow-up with a delayed VCUG. VUR was still resolved in 79,8% of the ureters. Clinical success rate was 91.7%. The incidence of febrile urinary tract infection in those patients with cured VUR and those with a relapsed VUR was 8 and 15%, respectively; but there were no significant differences. We have not found any variable related with relapsed VUR except those ureters that initially received 2 injections (P<.05). ConclusionIf our objective in the treatment of VUR is to reduce the incidence of febrile urinary tract infection it is not necessary to perform a delayed VCUG even though the long-term radiological outcomes is worse than clinical outcome

MP55-07 HISTOPATHOLOGICAL CHANGES ASSOCIATED WITH POLYACRYLATE POLYALCOHOL BULKING COPOLYMER (PPC, VANTRIS) INJECTION FOR PAEDIATRIC VESICOURETERAL REFLUX (VUR)

You have accessJournal of UrologyPediatrics: Urinary Tract Infection and Vesicoureteral Reflux1 Apr 2016MP55-07 HISTOPATHOLOGICAL CHANGES ASSOCIATED WITH POLYACRYLATE POLYALCOHOL BULKING COPOLYMER (PPC, VANTRIS) INJECTION FOR PAEDIATRIC VESICOURETERAL REFLUX (VUR) Boris Chertin, Stanislav Kocherov, Ermelinda Mele, Simona Gerocarni Nappo, and Nicola Capozza Boris ChertinBoris Chertin More articles by this author , Stanislav KocherovStanislav Kocherov More articles by this author , Ermelinda MeleErmelinda Mele More articles by this author , Simona Gerocarni NappoSimona Gerocarni Nappo More articles by this author , and Nicola CapozzaNicola Capozza More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.598AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Endoscopic correction of VUR utilizing Vantris has demonstrated high efficacy not only during a short term period, but also during a long term follow up without VUR recurrence. We have hypothesized that the obstruction following endoscopic correction of VUR is related to the anatomical features of the UVJ rather than the type of material used for endoscopic correction. Therefore, we have retrospectively evaluated all cases of obstruction following endoscopic treatment of VUR in both departments over the last 5 years and have performed clinical and histological review of these patients. METHODS Study population comprised 2470 patients who underwent endoscopic correction of VUR utilizing Deflux (1790 children) and Vantris (680 patients). 9(0.5%) children (3 F and 6 M) in Deflux group and 8(1.2%) (4 F and 4 M) in Vantris group developed UVJ obstruction and required ureteral re-implantation. 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. RESULTS All children developed obstruction during the period ranging from 2 to 49 months (average 16 months) following endoscopic correction. The primary reflux grade was III in 7, IV in 6 and V in 4 children respectively. The review of pretreatment VCUG demonstrated the presence of refluxing/obstructive ureter in 10(58.8%) out of 17 obstructive ureters showing true obstruction in 7 ureters (1 from Deflux and 6 from Vantris group). Histopathological analysis revealed a pseudocapsule composed of fibrous tissue and foreign body-type 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, Vantris injection and also of primary obstructive megaureter. No significant difference was found in the tissue response between Deflux, Vantris patients and controls. CONCLUSIONS Our data show that Vantris injection does not lead to ureteral fibrosis or inflammatory changes and therefore does not seem to increase the incidence of UVJ obstruction. However, patients with high grade VUR and an initial underlying ureteral pathology should receive appropriate counseling upon surgery concerning the possibility of UVJ obstruction and the need in subsequent ureteral re-implantation. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e738 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Boris Chertin More articles by this author Stanislav Kocherov More articles by this author Ermelinda Mele More articles by this author Simona Gerocarni Nappo More articles by this author Nicola Capozza More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Long-Term Results of Dexell Endoscopic Treatment of Vesicoureteral Reflux: An Option for the Management of Recurrent Urinary Tract Infection

Background: Recurrent urinary tract infection (UTI) due to vesicoureteral reflux (VUR) is common in Iraq. Endoscopic treatment of VUR is used with advantages over antibiotic prophylaxis and ureteral reimplantation. Objectives: This study was performed to assess the efficacy of a new agent, Dexell, for treating patients with VUR and its ability to manage recurrent UTI. Materials and Methods: This research was a prospective study recruiting 156 patients with VUR treated by endoscopic subureteric injection of Dexell. Results: VUR were unilateral in 87 cases and bilateral in 69 cases. VUR grades II-V were 18.7%, 28%, 32%, and 21.3%, respectively. The success rates were 64% after the first injection, 82.7% after second injection, and 93.3% after third injection. All patients with grades II and III were resolved completely while the success rates in higher grades were 91.7% for grade IV and 87.5% for grade V. No significant difference was noted between males and females regarding the success rate of endoscopic treatment (92% vs 91.6%, P > 0.05). Recurrent UTI did not occur throughout the study period after the operation. Conclusions: Cystoscopic injection of Dexell is an effective method for treating patients with VUR. It is a safe day case procedure that can prevent recurrent UTI in patients with VUR.

The comparison of dextranomer/hyaluronic acid and polyacrylate-polyalcohol copolymers in endoscopic treatment of vesicoureteral reflux

BackgroundDextranomer/hyaluronic acid (Dx/Ha;Dexell®) and polyacrylate-polyalcohol copolymer (PPC;Vantris®) are the popular tissue-augmenting substances using for the endoscopic injections of vesicoureteral reflux (VUR). The aim of the study is to evaluate and compare Dx/Ha and PPC in terms of effectiveness, injection techniques and complications with special emphasis on vesicoureteral junction obstruction (VUJO). MethodsA total of 95 patients who underwent endoscopic VUR treatment between 2009 and 2015 were retrospectively reviewed. The patients were divided into two groups: group 1: Patients underwent endoscopic treatment with PPC (n=50 patients, 70 renal refluxing units) group 2: Patients underwent endoscopic treatment with Dx/Ha (n=45 patients, 74 renal refluxing units). ResultsThe overall resolution rates based on the number of renal refluxing units studied was 88.6% and 70.3% in group 1 and group 2, respectively. Resolution rates were significantly better in group 1 compared to group 2. VUJO requiring ureteral reimplantation or stent insertion developed in 7 patients in group 1. No VUJO was observed in group 2. VUJO in group 1 was markedly higher than that in group 2. ConclusionsEndoscopic treatment of VUR with PPC promises better resolution rates but higher VUJO rates compared to Dx/Ha.