Deflux Injection Research Articles

Long term evaluation of continence after complete primary bladder exstrophy repair

Continence after bladder exstrophy (BE) repair remains a major debatable challenge to pediatric urologists, together with the lack of standard definitions and long-term results in large series. We assessed the long-term urinary continence in 142 toilet-trained cases after one (1-) stage of complete primary repair of bladder exstrophy (CPRE) and consequent procedures to achieve this goal in a single tertiary referral center. The current retrospective study included 123 boys and 19 girls with BE that were repaired by (1-) stage CPRE. The Mean age at (BE) repair was 9.5±2.6 weeks. Complete penile disassembly (CPD) was used for epispadias repair in 42 (34.1%) and modified Cantwell-Ransley repair (MCR) was used in 81 (65.9%) boys. Bilateral anterior transverse innominate osteotomies (ATIO) were applied in all. Urinary continence was expressed in terms of the dry interval (DI). Continence procedures were afforded if CPRE failed to achieve DI≥3h (hrs.), those were in the form of endoscopic bladder neck injection (BNI), bladder neck reconstruction (BNR), and bladder neck closure (BNC) with catheterizable stoma. The mean age at follow up was 12.1±5.2 years. DI≥3h was gained in 23 (16.2%) after CPRE alone, while complementary post-CPRE continence procedures were required to reach this goal in the remaining patients. Deflux injection was reported in 10 (7%), CIC in 8 (5.6%), BNR in 32 (22.5), and BNC with catheterizable stoma alone in 37 (26.1%), or with Charleston pouch in 32 (22.5%). We think that ≥3h DI with voiding represents an appropriate definition of continence after BE repair. According to the results in the current series, we think that successful anatomical closure of BE is achievable, but the functional outcome in terms of continence and its evaluation is tricky. Results of continence were reported to change with age of the child, and it is difficult to evaluate both before toilet training age and long-term follow up. Long-term follow up of CPRE with bilateral ATIO alone or with BNI results in ≥3h DI in a few cases; BNR after CPRE can provide a good chance for continence; otherwise, BNC with catheterizable stoma is a valid option.

MP70-14 LOW RISK OF SECONDARY TREATMENT AFTER ENDOSCOPIC INJECTION OF VUR USING THE DOUBLE HIT METHOD: ANALYSIS OF 3059 PROCEDURES OVER 19 YEARS

You have accessJournal of UrologyCME1 Apr 2023MP70-14 LOW RISK OF SECONDARY TREATMENT AFTER ENDOSCOPIC INJECTION OF VUR USING THE DOUBLE HIT METHOD: ANALYSIS OF 3059 PROCEDURES OVER 19 YEARS Ricardo Arceo-Olaiz, Shuvro De, and Andrew Kirsch Ricardo Arceo-OlaizRicardo Arceo-Olaiz More articles by this author , Shuvro DeShuvro De More articles by this author , and Andrew KirschAndrew Kirsch More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003338.14AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Individuals with VUR have increased risk of recurrent febrile urinary tract infections, increasing the risk of renal scarring, and end stage renal disease. Endoscopic injection was first proposed in the 1980s as a means of curing VUR as a minimally invasive alternative to open ureteral reimplantation. Despite high success rates with reimplantation, it generally involves an open approach with associated risks and potentially painful recovery. Review of the contemporary double HIT method reaches success rates of 93%; however, the need for secondary procedures has not been evaluated. The objective of our study is to report our experience for additional Deflux (Dx/HA) injections after first injection failure. METHODS: We retrospectively reviewed our database of children who underwent Deflux (Dx/HA) from April 2003 to December 2021. We divided our population in 2 groups: Group A underwent Dx/HA injection from 2003 till 2012 represents historical method of endoscopic injection, and Group B underwent Dx/HA injection from 2013 till 2021 representing the double HIT method. We compared both groups to assess the need of additional injections. RESULTS:: A total of 3059 Dx/HA injections were performed by 8 surgeons. We excluded patients >18 years of age, leaving 3006 injections in this timeframe (2515 girls; 491 boys). In Group A, (from 2003 till 2012) 2168 injections were done and in Group B, (from 2013 till 2021) 838 patients were injected. A total of 285 secondary injections were performed during the whole period, representing only 9% of all procedures. In Group A, 221 additional injections were done (mean 22/year) compared to 64 in Group B (mean 7/year). A statistically significant 71% of decrease in additional injections was seen in Group B, as well as a 32% decrease in mean injections per year. CONCLUSIONS: Endoscopic injection of a bulking agent to correct VUR has a high success rate, comparable to ureteral reimplantation. In our experience, primary injection with the double HIT method has a low chance of secondary treatment and supports its use as a first line option for children with primary VUR. Source of Funding: None. © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1009 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ricardo Arceo-Olaiz More articles by this author Shuvro De More articles by this author Andrew Kirsch More articles by this author Expand All Advertisement PDF downloadLoading ...

V02-12 URETEROCELE EXCISIONAL TECHNIQUE USING THULIUM LASER

You have accessJournal of UrologyCME1 Apr 2023V02-12 URETEROCELE EXCISIONAL TECHNIQUE USING THULIUM LASER Jordan Krieger, Ali Antar, and Margaret Knoedler Jordan KriegerJordan Krieger More articles by this author , Ali AntarAli Antar More articles by this author , and Margaret KnoedlerMargaret Knoedler More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003232.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Ureteroceles are cystic dilations of the distal ureter at its insertion site into the bladder and occur in 1 in 1000 births. Endoscopic intervention is minimally invasive and can alleviate obstruction in >95% of cases. The Thulium laser is a relatively new laser with a 1940 nm wavelength and a four times higher absorption in water than the Holmium laser. This theoretically leads to better tissue ablation and hemostasis. Our objective is to demonstrate the safety and efficacy of Thulium laser use for excision of ureteroceles. METHODS: This is a 22-year-old patient with normal renal function and a complex urologic history including bilateral duplicated collecting systems, vesicoureteral reflux with bilateral deflux injections, a right-sided ureterocele, and recurrent urinary tract infections resulting in hospitalizations for pyelonephritis. She was taken to the operating room for an endoscopic right ureterocele excision using Thulium laser. We used the Soltive SuperPulsed Thulium Fiber Laser (200 micron) with settings of 1 joule (J) for pulse energy and 20 hertz for frequency (20 watts). Total energy used was 2756 J. Tissue ablation and hemostasis were excellent, and no additional time was required at the end of the case to obtain hemostasis from the excised edges. She discharged the same day without issues. RESULTS: Six weeks later the patient followed-up in our clinic with a renal ultrasound demonstrating no hydronephrosis and a decompressed ureterocele. She denied any flank pain or recurrent infections. CONCLUSIONS: Thulium laser excision is a safe and efficacious treatment option for management of symptomatic ureteroceles. It showed excellent tissue ablation and hemostatic properties. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e172 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jordan Krieger More articles by this author Ali Antar More articles by this author Margaret Knoedler More articles by this author Expand All Advertisement PDF downloadLoading ...

A novel endoscopic approach for management of hutch diverticulum concomitant vesicoureteral reflux with dextranomer/hyaluronic acid copolymer injection

There are various treatment options for symptomatic bladder diverticulum, including robotic-assisted laparoscopic bladder diverticulectomy, open and endoscopic techniques. But, to date, the optimal surgical technique remains unclear. To present the preliminary long-term follow-up results of a novel technique of dextranomer/hyaluronic acid copolymer (Deflux) plus autologous blood injection for correction of hutch diverticulum in patients with concomitant vesicoureteral reflux (VUR). We retrospectively reviewed four patients who had hutch diverticulum with concomitant VUR and had undergone submucosal Deflux following autologous blood injection. Patients with neurogenic bladder, posterior urethral valve, or voiding dysfunction were excluded from the study. Success was defined as the resolution of the diverticulum, hydronephrosis, and hydroureter on ultrasonography at a 3-month follow-up and long-term symptom-free period. Four patients with hutch diverticula were included. The median age at the time of surgery was 6.1 (range 3-8) years. Three of them had unilateral VUR, and one had bilateral VUR. During the procedure, a mean of 0.625ml Deflux plus a mean of 1.25ml autologous blood were injected submucosally for correction of VUR. Additionally, a mean of 1.62ml Deflux plus a mean of 1.75ml autologous blood were injected submucosally to occlude the diverticulum. The median follow-up was 4.6 (range 4-8) years. This method had excellent success in all patients in the current study with no postoperative complications such as febrile urinary tract infection, or diverticulum, hydroureter, or hydronephrosis in follow-up ultrasounds. Submucosal injection of Deflux plus autologous blood injection can be a successful endoscopic intervention for treatments of hutch diverticulum in patients with concomitant VUR. Deflux injection can be a simple and cost-effective technique.

Efficacy of Bladder Ultrasound in Prediction of Resolution of Vesicoureteral Reflux After Endoscopic Subureteral Hyaluronic Acid/Dextranomer (Deflux) Injection

ObjectiveTo evaluate the efficacy of bladder ultrasound (US) in predicting the resolution of vesicoureteral reflux (VUR) after subureteral endoscopic Deflux injection in low-grade vs high-grade VUR patients. Materials and MethodsBetween 2014 and 2020, 160 children (220 ureters) were administered subureteral Deflux injection for treatment of primary VUR. The mean age at surgery was 72 months. Low-grade reflux (grades II-III) was observed in 190 ureters and high-grade reflux (grades IV-V) was observed in 30 ureters. Bilateral surgery was performed in 60 patients. All patients had follow-up using bladder US and voiding cystourethrography (VCUG) at 3 months and 12 months. Outcome included identification of Deflux mounds by bladder US and correlation of Deflux mounds identified with radiographic success rates of VUR on VCUG. ResultsSingle Deflux injection showed radiographic success rates in 98% of low grade reflux patients and 26.7% of high grade reflux patients at last follow-up. Bladder US was able to detect Deflux mounds in 89% of low grade reflux and 43.3% of high grade reflux patients at last follow up. Our study demonstrated higher sensitivity, Positive predictive value and accuracy in Deflux detection by bladder US in low grade reflux vs high grade reflux patients. ConclusionBladder-US was highly sensitive for detection of Deflux implants. Bladder-US could be adjusted in follow-up of patients with low-grade reflux treated by Deflux injection, while VCUG could be preserved for follow-up of high-grade reflux, this will lead to reduction of unnecessary radiation exposure during VCUG for children with low grade reflux.

Local tissue reaction and histopathological characteristics of three different bulking agents: a rabbit model.

ABSTRACTPurpose:We assessed the efficacy and safety of a single injection of three bulking agents over the short- and long-term follow-ups in rabbits. Dermal and preputial matrices were compared with Deflux (DxHA) injection.Material and methods:Twenty-four rabbits were divided into three groups. Group I (n=8) underwent the injection of a lyophilized dermal matrix (LDM) beneath the seromuscular layer of the bladder wall. Rabbits in group II (n=8) were injected with lyophilized preputial matrix (LPM). Rabbits of group III (n=8) were injected with DxHA as the control group. They were followed up for 1 and 6 months after the injection. Subcutaneous injection of all bulking agents was also performed in nude mice. Biopsies were stained with LCA (leukocyte common antibody), CD68, CD31, and CD34. Scanning electron microscopy (SEM) and MTT assay were also performed.Results:Immunohistochemistry staining with CD68 and LCA revealed higher inflammation grade in LDM as compared with LPM and DxHA. Fibrosis grade was also higher in LDM both in short- and long-term follow-ups. However, no significant difference was detected in CD31 and CD34 staining between control and experimental groups. SEM analysis showed that the particle size of LPM was more similar to DxHA. MTT assay revealed that cell proliferation was similar in DxHA, LDM, and LPM. In-vivo assay in nude mice model showed more promising results in LPM as compared with LDM.Conclusion:The long-term results demonstrated that LPM was more similar to Deflux with the least local tissue reaction, inflammation, and fibrosis grade.

Diagnosing and treating occult vesicoureteric reflux using PIC cystography: Is it influenced by abnormalities on DMSA?

Positioning the Instillation of Contrast cystography (PICc) is used to identify occult vesicoureteric reflux (VUR) in patients with recurrent urinary tract infections (UTI) despite optimized bladder and bowel function and without VUR demonstrated on conventional imaging. To determine the incidence of finding occult VUR in such patients usingPICc and the benefit, if any, of treating it. We also assessed if this was influenced by abnormalities on the pre-operative DMSA. This was a retrospective review of PICc in our hospital between 2016 and 2018 and involved three paediatric urologists. The primary indication for PICc was two or more culture proven UTIs despite optimized bladder and bowel function and no reflux on voiding cystourethrography (VCUG) or indirect radionuclide cystography (I-RNC). All children had a preoperative DMSA scan to document any abnormalities. PICc was performed in a standardized way to each ureteric orifice. If occult reflux was found, it was treated concomitantly by cystoscopic injection of Deflux®. To assess the influence of the pre-operative DMSA status, the cohort was subdivided into two groups based on the DMSA scan: Group 1-abnormal DMSA, Group 2-normal DMSA. The median follow-up was 26 months (range 3-39 months). PICc was performed in 25 patients [23 females and 2 males; median age: 7 years (range 2-16 years; IQR=4)]; 17 from Group 1 and 8 from Group 2. Occult VUR was identified in 22 patients (88%); 15/17 (88.2%) in Group 1 and 7/8 (87.5%) in Group 2 (p=0.9). After cystoscopic treatment, 21/25 (84%) became infection free and this was not influenced by the preoperative DMSA status (p=0.6). Fig 1. In this challenging group of patients, looking for and treating occult reflux appears to be clinically useful and beneficial. The ability to test and treat at the same sitting is an added advantage of PICc. The DMSA results did not influence the diagnostic or therapeutic aspect of the process. Our results concur with other published literature. There is a high incidence of finding occult reflux using PICc in this cohort of patients. Concomitant cystoscopic treatment led to 84% of children becoming infection free on follow up. Abnormalities on DMSA did not influence either the likelihood of finding occult reflux or the likelihood of successful treatment.

Robot-assisted continent urinary diversion according to the Mitrofanoff principle: results of a bicentric study.

To assess the outcomes of continent urinary diversion according to the Mitrofanoff principle by robot-assisted laparoscopic surgery in terms of continence, catheterization and repeat surgery. All adult patients who underwent procedures for continent urinary diversion via a robot-assisted laparoscopic route between October 2014 and November 2018 were enrolled retrospectively. Abdominal continence and clean intermittent catheterization ability were noted, as well as patient characteristics, details of the technique, intra- and perioperative parameters, and complications. Ten patients were included. Bladder-sphincter disorders were due to neurological causes in nine patients, and one patient had idiopathic bladder sphincter dyssynergia. A continent catheterizable channel was created using the appendix in six cases and the ileum in four cases. The median operative duration was 245min (IQR 228-370). Two patients had a Clavien 3 complication requiring laparoscopy to separately drain a haematoma and a pelvic abscess. The median follow-up was 21months (IQR 17-27). Abdominal continence without further intervention was obtained in 6/10 patients (60%). Two patients needed an open revision of the continent urinary diversion, one required injection of Deflux® and one an intradetrusorian injection of botulinum toxin type A (Botox®). Further surgery was needed for two patients to improve urethral continence. At the end of follow-up, all patients were continent and clean intermittent catheterization was possible. Continent urinary diversion performed according to the Mitrofanoff principle is possible via a robot-assisted laparoscopic route and yields good outcomes on abdominal continence in the short term in patients with clean intermittent catheterization ability.

Development of Late Continence in Bladder Exstrophy and Epispadias Patients

To evaluate to what extend urinary continence develops during puberty in patients with classic bladder exstrophy (CBE) and epispadias. The operative database was reviewed for surgical procedures and urinary continence in all 65 CBE and epispadias patients born in 1976-2005. Excluded were 2 patients who had insufficient data for evaluation. Thirty-five patients with volitional voiding were incontinent at the age of 10 years, 27 had daily incontinence, and 8 had rare incontinence. Sixteen patients (46%) became later fully continent without any major surgery (except Deflux injections in 3 patients) or CIC treatment. Among these 16 fully continent patients there were 7/8 with rare incontinence, 9/23 with daily incontinence (P=.04); 3/9 males with CBE, 10/13 males with epispadias, 3/5 females with CBE, and 0/4 females with epispadias (P=.25 between sex and P=.48 between diagnosis). Of the 15 patients remaining incontinent, 10 had daily and 5 had rare incontinence episodes. The latest control was at the median age of 19 years (interquartile range 17-21 years). Twenty-five patients (40% of the whole material) were fully continent (11/38 (29%) with CBE and 14/25 (56%) with epispadias, P=.04) and 8 (13%) had rare incontinence with volitional voiding (1/38 [3%] with CBE and 7/25 [28%] with epispadias). Almost half of the incontinent CBE and epispadias patients with volitional voiding achieved continence after the age of 10 without major surgery. Prognosis for pubertal development of continence was best in patients with rare incontinence and in males with epispadias.

Outcomes of urinary tract abnormalities diagnosed by the routine third trimester scan

ObjectiveThe aim of this study is to determine the incidence of congenital abnormalities of the kidneys and urinary tract (CAKUT) detected for the first time in an unselected population undergoing a routine third trimester scan between 30–34 week’s gestation. MethodsThis was a retrospective analysis of 8562 routine third trimester ultrasound scans during which the fetal anatomy was evaluated, and, any structural abnormalities detected, recorded onto a fetal database which was subsequently analysed for CAKUT. All postnatal records of antenatally diagnosed CAKUT were obtained and analysed for diagnosis and management. ResultsThere were 26 cases of urological abnormalities detected for the first time in the third trimester. The most frequent abnormality was unilateral renal pelvis dilatation (73%). Postnatal ultrasound confirmed abnormalities in 19 (73%) newborns, with two (8%) resolving antenatally and four (15%) postnatally. The overall incidence of new CAKUT detected by the third trimester scan was 0.22% (19/8562) with a male to female ratio of 1:1.6. Four patients required surgery, two received cystoscopic injection of Deflux with circumcision, one received cystoscopic valve ablation and one patient received a staged hypospadias repair. ConclusionRoutine third trimester scanning is already performed in many countries with proposed benefits primarily directed towards the monitoring of fetal growth and late pregnancy malpresentation. For healthcare systems that still utilize two routine scans, debate is ongoing as to the value of introducing a routine third trimester scan. The ability to detect additional and potentially missed CAKUT is a further benefit, which in isolation is likely of too small an impact to merit implementation. However, the combination of fetal structural assessment, growth velocity monitoring and fetal presentation evaluation presents a strong case for inclusion in an antenatal screening program. The findings of this study highlight the importance of a detailed fetal structural evaluation at each antenatal ultrasound scan.

Ectopic Intravesical Ejaculatory Ducts: Case Report of Bulking Agent Injection for Treatment of Recurrent Epididymitis in a Patient With Anorectal Malformation

As far as we know this is the first report on bulking agent injection into intravesical ectopic ejaculatory orifices reported in the English literature. During a follow-up period of 23 months, the child was free of episodes of epididymo-orchitis. Deflux injection in this rare anomaly of intravesical refluxing ducts had prevented irreversible damage to the testes from recurrent EO. Thus, it may be a better option than vasectomy when antibiotic treatment fails.

Endoscopic Treatment for Post-Transplant Vesicoureteral Reflux

IntroductionVesicoureteral reflux (VUR) is one of the most common ureteric complications after kidney transplantation that might cause symptomatic infections which deteriorate graft function. Surgical reimplantation has been the standard treatment; recently, endoscopic injection has been an alternative approach. We report our endoscopic treatment results and analyze the long-term outcome, even in patients with less optimal graft function. Materials and methodsA total of 16 patients and 19 symptomatic VUR were diagnosed at mean time of 88.3 months after their transplantation. The distribution of VUR grade was 1, 2, 8, 6, and 2 for grade I to V, respectively, with a mean VUR grade of 3.26 according to their voiding cystourethrogram images. Endoscopic Deflux injections were performed by a single urologist via rigid cystoscope with a beveled needle system. They were followed monthly thereafter. ResultThe average number of admissions due to symptomatic urinary tract infection was 2.68/person, and the mean creatinine level before endoscopic treatment was 1.63 mg/dL. The amount of Deflux injection was 0.7 to 1.2 mL per affected ureter; the mean creatinine level after endoscopic treatment was 1.41 mg/dL. The eGFR remained stationary in both eGFR > 60 and eGFR < 60 mL/min groups with a clinical success rate of 75% in both groups. ConclusionEndoscopic dextranomer-hyaluronic acid injection is a safe and feasible treatment option for VUR after kidney transplantation. Our data showed its efficacy in recipients whose eGFR is less than 60 mL/min.

Can transient resting of the bladder with vesicostomy reduce the need for a major surgery in some patients?

Neuropathic bladder, voiding dysfunction, and posterior urethral valves may cause a great challenge in children. Preserving the kidney function is the main aim in all of these patients which can be achieved by cutaneous vesicostomy. The objective of this study is to evaluate the long-term outcomes of patients who have undergone cutaneous vesicostomy in an 11-year period at the study center. In this retrospective study, the authors evaluated the long-term treatment results and complications of cutaneous vesicostomy on children with bilateral severe hydronephrosis, bilateral vesicoureteral reflux (VUR), and urosepsis who were operated at our center from 2007 to 2018. There were 64 (80%) boys and 16 (20%) girls. Their mean of age was 15.27 months old when they underwent vesicostomy. Twenty-three (28.75%) of them had neurogenic bladder and 17 (21.25%) of them had intact neuronal pathway defined as dysfunctional voiding. Twenty-five (31.25%) boys had posterior urethral valves. Fifteen (18.75%) of them were younger than six months old with primary bilateral high-grade VUR and urosepsis. Mean of follow-up time was 65.34±37.82 months (11.5 months-10.5 years). Cure rate was 95% in urinary tract infection, 80.7% in secondary VUR, and 40% in primary VUR. Creatinine level was significantly reduced after vesicostomy and during follow-up (P<0.001). Complications after vesicostomy were stoma stenosis (11.25%), mucosal prolapse (7.5%), dermatitis (3.75%), and febrile urinary tract infection (5%). In primary VUR after vesicostomy, 60% of the patients did not require an intervention to correct the reflux (Table). A number of 29 of 66 patients with closed vesicostomy needed another surgery: three modified Gil-Vernet antireflux surgeries, one ureteral reimplantation, two endoscopic Deflux injections, 13 valve ablations, six ileocystoplasties, and four Botox injections. The 37 (56.06%) remaining patients did not require any other surgery after closure of vesicostomy. Vesicostomy should be considered in children with neuropathic bladder or bladder outlet obstruction in case first-line therapies fail. This simple and reversible procedure can reduce febrile urinary tract infections, protect the upper urinary tract, and reduce the need for a major surgery without decreasing the bladder capacity.

Pathological changes associated with DEFLUX use in vesicoureteric reflux

Vesicouretral reflux (VUR) which is the backflow of urine from the bladder to the kidneys leading to renal dysfunction. It is a common problem that is being encountered. Most of children and infants with UTI turn to be having VUR and patients who left untreated turned to have renal scarring and in turn to have end stage renal disease. For preventing these consequences, an intervention is needed. Previously, surgical intervention was the mainstay treatment and the new practice have endoscopic injection of deflux that is a gel-like material that consist of Dextranomer/Hyaluronic acid copolymer, which had replaced other methods of invasive antireflux surgeries and becoming the preferred method used in practice for solving VUR by building an artificial valve system. In the following case, we will highlight the histologic manifestation of the deflux injection.

Persistence and appearance of vesicoureteral reflux/obstruction following open reimplantation for vesicoureteral reflux

Introduction: Appearance or persistence of vesicoureteral reflux (VUR) and other obstructive complications after open reimplantation of ureters is well known and up to 7.5% of cases require reoperation. In this study, we have assessed children presenting with recurrent urinary tract infection (UTI) following open reimplantation for VUR. Materials and Methods: We retrospectively collected hospital data of 14 children referred to us for management of recurrent UTIs following open ureteric reimplantation for vesicoureteric reflux from January 2006 to December 2015. Results: Fourteen children presented to our center at a mean age of 31.85 ± 10.17 months. The mean serum creatinine was 0.77 ± 0.26 mg% (range 0.5–1.3). Urine culture was positive in all with Escherichia coli being the most common organism grown on culture. Two children had obstruction at the vesicoureteric junction, and the remaining twelve children had 14 ureteral units with VUR. Two children underwent reimplantation into Boari flap, five underwent open reimplantation, and the remaining seven underwent endoscopic Deflux injection. Repeat voiding cystourethrogram done within 1 year of surgery revealed no VUR in any child. Conclusions: Appearance or persistence of VUR and obstructive complications after open reimplantation surgery is a matter of great concern for the parents of these children as well as the treating pediatric urologists. Appropriately selected open/endoscopic treatment can help in resolving these complications.

Comparing treatment modalities for transplant kidney vesicoureteral reflux in the pediatric population

Non-refluxing ureteral reimplantation is favored in pediatric renal transplantation to prevent complications, such as vesicoureteral reflux (VUR) in the transplant ureter. VUR resulting in febrile urinary tract infections remains a problem in this population, leading to repeated hospitalizations and increased morbidity. Revision of the vesicoureteral anastomosis can be a surgical challenge due to scar tissue and tenuous vascularity of the transplant ureter. Therefore, alternative options such as endoscopic injection of Deflux at the neo-orifice and surveillance with prophylactic antibiotics have emerged as potential treatment modalities for transplant ureter VUR. The authors reviewed their experience of the management of VUR in the transplant ureter, comparing outcomes of various modalities. With Institutional Review Board approval, a retrospective chart review of all renal transplant patients from January 2002 to January 2017 was conducted. All patients with VUR on voiding cystourethrogram (VCUG) after surgery were identified. Indications for end-stage renal disease, urologic comorbidities, pretransplant VCUG, and operative details were recorded. After transplantation, febrile urinary tract infections, ultrasound findings, and any further interventions-surveillance, subureteral endoscopic injection of Deflux, or ureteral reimplantation-were documented along with their outcomes. Overall, VUR was identified in 35/285 (12.3%) transplant patients aftera non-refluxing ureteroneocystostomy. VUR was managed with surveillance in 17/35 (49%), intravesical Deflux injection in 11/35 (31%), and immediate redo ureteral reimplantation in 7/35 (20%). Ten out of 11 patients undergoing Deflux injection had a postoperative VCUG. All patients developed VUR recurrence; the majority showed immediate failure and only 1/10 showed late recurrence. Of the immediate failures, 3/9 patients were maintained on prophylactic antibiotics, and 6/9 patients underwent ureteral reimplantation. In these six patients undergoing reimplantation after failed Deflux, 3/6 (50%) patients required additional surgeries: One patient developed recurrence of reflux and two patients developed ureterovesical junction obstruction. In contrast, no complications were seen in patients undergoing primary ureteral reimplantation. The study is limited by low numbers and a retrospective design. However, the results of this study differ significantly from the published Deflux series showing a success rate of more than 50% in the treatment of transplant kidney VUR. In fact, post-Deflux redo ureteral reimplantation was associated with an increased risk of postoperative complication. The use of Deflux in the post-transplant setting has poor results. In the study series, 11/11 patients demonstrated clinical and radiographic failure. Therefore, as an institution the authors do not recommend Deflux as first-line treatment of VUR in the transplant patient.

Ureteric-urethral engraftment as a new surgical technique for management of incontinence in bladder exstrophy complex: A retrospective cohort

ObjectivesTo report the results of a novel surgical technique for achieving urinary continence in patients with bladder exstrophy complex (BEC) by ureteric-urethral engraftment (UUE) technique. Patients and methodsSixteen female patients with BEC and a mean ± SD age of 3.48 ± 1.75 years were referred for primary exstrophy repair from 2009 to 2012. From these, 9 patients were operated by single-stage bladder closure (group I); while 7 patients underwent the novel technique of UUE to compare the continence achievement (group II). In UUE technique, distal ureter was applied for total urethral replacement while the lower part of engraft was fixed in external genitalia. No osteotomy was performed in none of the groups. Continence and upper urinary tract evaluation were performed in the follow-ups with 3 months intervals for the first year and biannually thereafter. The patients were followed-up for a mean ± SD duration of 72 ± 6 months. ResultsAll patients in both groups experienced an uneventful postoperative period. In group II, 5 patients were continent day and night and voided per urethra without need for augmentation or intermittent catheterization technique (71.42%); while 55.55% of patients in group I achieved total continence (n = 5). Partial continence was achieved in 4 (44.44%) and 2 (28.57%) patients in group I and II, respectively. However, 3 patients in UUE group had postoperative vesicoureteral reflux that was successfully managed by Deflux injection. ConclusionThe eventual clinical outcomes of BEC children undergoing the UUE technique were promising. This practicable, safe, and reproducible option will add one complementary stage to the previously used reconstruction techniques. These patients would necessitate further surveillance with upper urinary tract evaluations during the adult life.

Extending indications of micropercutaneous nephrolithotomy: It is not just about cracking stones

ObjectiveTo describe our experience and results of using the MicroPerc™ micropercutaneous nephrolithotomy armamentarium (PolyDiagnost, Germany) for unusual indications unexplored using this modality. Patients and methodsWe used the MicroPerc™ system for stone clearance in three ureteric calculi, two bladder calculi, one case of urethral calculus, for antegrade biopsy in a case of upper tract urothelial carcinoma, for Deflux® (dextranomer/hyaluronic copolymer, Salix Pharmaceuticals, Uppsala, Sweden) injection in three cases of vesico-ureteric reflux (VUR), and three cases of posterior urethral valve (PUV) fulgurations. A 4.85-F ‘All-Seeing Needle®’ (PolyDiagnost) was used in most of the cases. An 8-F mini-micro sheath was used where stability was deemed necessary. Clinical data were collected in a dedicated database. Intraoperative variables, postoperative complications, and outcomes were assessed. ResultsAll patients were successfully treated with complete stone clearance at 1month with no residual fragments. The antegrade biopsy confirmed a high-grade papillary neoplasm. There were no technical difficulties with injection of Deflux or PUV fulgurations. Follow-up at 1year revealed no stone recurrence, resolved reflux in all three cases, and all the children that had had PUVs were voiding well. The small sample and retrospective nature of the analysis are the limitations of this study. ConclusionMicroPerc™, besides its usual use for minimally invasive percutaneous nephrolithotomy, can also be feasibly used for ureteric, bladder and urethral stones, and for treating non-calculus diseases such as PUVs and VUR. True to its name, it may be an ‘All-Seeing Needle’ in reality with much more to offer and harvest from.

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.

MP55-10 DELAYED OBSTRUCTION WITH SILENT LOSS OF RENAL FUNCTION AFTER DEXTRANOMER/HYALURONIC ACID COPOLYMER (DEFLUX) INJECTION FOR VESICOURETERAL REFLUX: A CLOSE LOOK AT A DISTURBING OUTCOME

You have accessJournal of UrologyPediatrics: Urinary Tract Infection and Vesicoureteral Reflux1 Apr 2016MP55-10 DELAYED OBSTRUCTION WITH SILENT LOSS OF RENAL FUNCTION AFTER DEXTRANOMER/HYALURONIC ACID COPOLYMER (DEFLUX) INJECTION FOR VESICOURETERAL REFLUX: A CLOSE LOOK AT A DISTURBING OUTCOME Dimitri Papagiannopoulos, Ilina Rosoklija, Earl Cheng, and Elizabeth Yerkes Dimitri PapagiannopoulosDimitri Papagiannopoulos More articles by this author , Ilina RosoklijaIlina Rosoklija More articles by this author , Earl ChengEarl Cheng More articles by this author , and Elizabeth YerkesElizabeth Yerkes More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.601AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Dextranomer/hyaluronic acid copolymer (Deflux) first received FDA approval in 2001 for endoscopic injection in children with grade II-IV vesicoureteral reflux (VUR). With its minimally invasive nature, high success rates and few reported complications, Deflux has enjoyed widespread popularity. As experience has grown, Deflux implantation has been used in an off-label fashion to included cases of grade V VUR, ureteral duplication, voiding dysfunction, and children less than 12 months old. Post-operative ureteral obstruction has been reported in 1% of cases, and is typically transient in nature, occurring within the first 1-2 weeks of surgery and associated with obstructive symptoms. More recently, documented cases of delayed, silent obstruction and a loss of renal function have surfaced. In hopes of adding awareness to this complication, we present three such cases. METHODS This is an institutional case series of three patients who underwent Deflux injection and developed delayed ureteral obstruction. Pre-operative clinical indications, imaging studies, operative notes, and post-operative course were reviewed. RESULTS Patient ages ranged from 8 months to 7 years at the time of Deflux injection. All three underwent double hydrodistension implantation technique (double-HIT) with 1-2 cc of Deflux per ureter. All three patients underwent off-label use: two had documented voiding dysfunction and one was less than 12 months old. All patients had post-operative imaging with documented resolution of reflux and absence of hydronephrosis followed by a prolonged symptom-free period. Delayed obstruction was identified between 18-52 months post-operatively with evidence of hydronephrosis, parenchymal thinning, and loss of renal function. Two patients were asymptomatic until the time of diagnosis, and one patient had a febrile urinary tract infection that necessitated work-up. All patients required open ureteral remplantation, with observed periureteral rind and pathologically confirmed peri-ureteral inflammation in all cases. CONCLUSIONS In this case series of three patients, delayed obstruction was identified as late as 52 months from Deflux injection, and all were treated in an off-label fashion. We now place increased emphasis on the need for long-term follow-up after Deflux in both routine and complex cases, particularly in situations of off-label use. Unfortunately it appears that silent loss of renal function can occur despite periodic surveillance. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e739 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Dimitri Papagiannopoulos More articles by this author Ilina Rosoklija More articles by this author Earl Cheng More articles by this author Elizabeth Yerkes More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...