Recurrent Vesicoureteral Reflux Research Articles

Repeated ureterocystoneoimplantation in a 13-year child with recurrent vesicoureteral reflux in both segments of a doubled kidney

Introduction. Doubling of the urinary tract is a common developmental anomaly (0.8–1.0%). With complete doubling, vesicoureteral reflux (VUR) is detected in 66-72%, mainly in the lower segment. The aim of the work is to optimize the surgical treatment of VUR with doubling of the urinary tract by endoluminal plasty of the ureteral mouths and reimplantation of the ureter. Materials and methods. In a 13-year child, a laparoscopic longitudinal intravesical ureterocystoneoimplantation technique was used in conditions of ureteral length deficiency and a proximal intervertebral anastomosis was applied. Results. With the doubling of the urinary tract, a number of patients experience a recurrence of VUR, which determines the need for repeated reconstructive surgery. We present a clinical case of successful surgical treatment of recurrent VUR in both segments of a doubled kidney in a 13-year child. In the treatment, the technique of laparoscopic longitudinal intravesical ureterocystoneoimplantation was successfully applied in conditions of ureteral length deficiency and a proximal intervertebral anastomosis was applied. Conclusion. The performed surgical intervention meets the requirements of efficiency and safety and can be used in conditions of ureteral length deficiency in patients with recurrent VUR after previously performed reconstructive operations.

Subureteric injection for the treatment of vesicoureteral reflux in transplant kidneys.

Treatment of de novo vesicoureteral reflux (VUR) into the transplanted kidney constitutes a clinical challenge. Herein, we present our data on patients who underwent endoscopic subureteric injection for the treatment of VUR following renal transplantation (RT) in our center. The patients who underwent endoscopic subureteric injection for VUR into the transplanted kidney after RT in our department between 2008 and 2023 were reviewed retrospectively. Indication for subureteric injection, age, gender, laterality, number of injections, amount of material used, renal failure etiology, auxiliary procedures, and treatment success were noted. All interventions were performed by pediatric urologists who also perform RT. During a median followup of 27.5 (4-160) months, 22 patients (17 women, 77.2%) and 23 transplanted ureters (13 right, eight left, one bilateral) were treated with subureteric injections. In all patients, the indications for subureteric injection were recurrent febrile urinary tract infection (UTI), and the grades of VUR varied between I and IV. Patients received a median of 1.65 cc (0.7-2.7) dextranomer-hyaluronic acid copolymer. In total, 10 RTs (eight from living donors, two from cadaveric donors) were performed in another center, whereas 13 RTs were carried out in our center (eight from cadaveric donors and five from living donors). Among the patients who were transplanted in our center, the rate of subureteric injections due to de novo symptomatic VUR after RT was 2.2% (13/593 patients). After subureteric injections, five patients required a second injection due to the recurrence of VUR. Ureteroureterostomy (to the native ureter) was performed in two patients who had further UTIs after the second endoscopic treatment. Eventually, 19/21 patients (90.4%) benefited clinically from the endoscopic treatment and none of the patients underwent re-do ureteroneocystostomy. It is noteworthy that the etiology of renal failure was VUR nephropathy in seven (31.8%) patients. Subureteric injection provides a high clinical success for the treatment of de novo VUR after RT.

Recurrence of vesico-ureteral reflux in children: is still the endoscopic injection the best option?

Endoscopic injection (EI) is a safe treatment for vesico-ureteral reflux (VUR) in children, but recurrences are not insignificant. This study aims to show if multiple EI is still the best first line management even if in case of recurrences. All patients affected by primary VUR, treated with at least one EI and with at least 5 years follow up were included. All general data were analyzed. Recurrence rate after one, two and three EIs were calculated. One hundred and sixty-one patients (total number =210) were healed after 1 injection, 28 after 2 and 4 after 3 with a global success rate of 91.90%. Recurrence rate is higher in patients older than 3 years old and with IV and V reflux grade. Even if 67.7% of recurrent VUR after one injection was symptomatic, diagnosis of recurrences after multiple EI was mainly radiological. Only 8% of the patients underwent EI need an anti-reflux surgery. Thanks to its low costs and the acceptable recurrence rate, Deflux EI should be proposed as the first therapeutic approach for children affected by VUR, especially in those with low and moderate grades of VUR. Multiple injections could be contraindicated only in older children thank 1 year with high-grade VUR (IV symptomatic and V grade).

A fresh "slant" on modified Mitchell bladder neck reconstruction: A contemporary single-institution experience.

IntroductionPatients with neurogenic urinary incontinence due to an incompetent outlet may be offered bladder neck reconstruction, but the quest for the perfect surgical-outlet procedure continues. Our aim was to characterize continence and complications after modified Mitchell urethral lengthening/bladder neck reconstruction (MMBNR) with sling and to introduce a modification of exposure that facilitates subsequent steps of MMBNR.MethodsA single-institution, retrospective cohort study of patients who underwent primary MMBNR between May 2011 and July 2019 was performed. Data on demographics, urodynamic testing, operative details, unanticipated events, continence, bladder changes, and additional procedures were collected. A 2013 modification that permits identification of the incompetent bladder neck prior to urethral unroofing was applied to the last 17 patients. The trigone and bladder neck are exposed via an oblique low anterolateral incision on the bladder. Ureteral reimplantation is not routinely performed. Focal incision of the endopelvic fascia after posterior plate creation limits breadth of blunt dissection for sling placement. Descriptive statistics were utilized.ResultsA total of 25 patients (13 females) had MMBNR with sling at a median age of 10 years [interquartile range (IQR) 8–11]. Bladder augmentation was performed concurrently in 14/25 (56%) patients. At a median of 5.0 (IQR 3.9–7.5) years follow-up after MMBNR, 9/11 (82%) without bladder augmentation and 13/14 (93%) with bladder augmentation had no leakage per urethra during the day without further continence procedures. Of the three patients with persistent incontinence, two achieved continence with bladder wall Botox injection (overall continence 24/25, 96%). New and recurrent vesicoureteral reflux was noted in five patients and one patient, respectively. Two patients required subsequent bladder augmentation for pressures and one other will likely require it. None have required bladder neck closure or revision.ConclusionMMBNR with sling provides promising continence per urethra in neurogenic bladder with low need for secondary continence procedures. Ongoing modifications may achieve elusive total continence.

Postoperative hydronephrosis following ureteral reimplantation: Clinical significance and importance of surgical technique and experience

BackgroundThough common, postoperative hydronephrosis (POHN) following ureteroneocystostomy raises concern for an underlying obstruction. We aimed to determine the clinical significance of POHN following open (OUR) or robotic (RALUR) ureteral reimplantation. MethodsWe retrospectively reviewed pediatric patients who underwent ureteral reimplantation for vesicoureteral reflux (VUR) from 2008 to 2019 by a single surgeon. Baseline characteristics, operative outcomes, and trends in POHN were assessed. POHN was defined as new onset hydronephrosis or exacerbation of pre existing hydronephrosis. Renal ultrasounds were performed 1, 4, and 12 months postoperatively. Voiding cystourethrograms were performed 4 months postoperatively. Surgical experience for RALUR cases was defined as number of ureters operated over time. ResultsAltogether, 93 patients (127 ureters) underwent RALUR and 19 patients (26 ureters) underwent OUR. POHN was found in 27.6% and 30.8% of ureters after RALUR and OUR, respectively. Rate and time to POHN resolution for RALUR (91.4%, 112 days) and OUR (75%, 211 days) were statistically similar. Odds of POHN after RALUR were directly related with preoperative VUR grade (Range OR: 2.82[2.26–3.52]) and surgical experience (Range OR: 8.88[7.16–11.02]). Surgical experience was inversely related with odds of VUR recurrence (Range OR: 0.41[0.32–0.54]). Rates of VUR resolution were comparable for OUR and RALUR patients. No patient required additional intervention for POHN. ConclusionsIncidence and resolution rate of POHN after OUR and RALUR were similar. Higher VUR grades were associated with increased odds of POHN after RALUR. Increasing RALUR experience improved VUR resolution rate but increased odds of POHN. Surgical success rates were similar for RALUR and OUR. Level of evidenceII

V08-06 REDO ROBOTIC LEFT URETERAL REIMPLANT USING THE EXTRAVESICAL LUAA TECHNIQUE

You have accessJournal of UrologyCME1 May 2022V08-06 REDO ROBOTIC LEFT URETERAL REIMPLANT USING THE EXTRAVESICAL LUAA TECHNIQUE Clark Judge, Anastasia Gliatis, Amrita Mohanty, and Mohan Gundeti Clark JudgeClark Judge More articles by this author , Anastasia GliatisAnastasia Gliatis More articles by this author , Amrita MohantyAmrita Mohanty More articles by this author , and Mohan GundetiMohan Gundeti More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002606.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Recurrence of vesicoureteral reflux (VUR) after reimplantation is a therapeutic challenge. Options include conservative management with surveillance, endoscopic treatment with injection of a Dextranomer-hyaluronic acid bulking agent, and re-operation, either by open or minimally invasive approach. High grade reflux (grade 3-5) recurrence is unlikely to resolve with surveillance or endoscopic treatment. We demonstrate the steps to a redo extravesical robotic-assisted laparoscopic left ureteral reimplant using the LUAA technique (Length of detrusor tunnel (L), use of a U stitch (U) in the proximal detrusorraphy, placement of permanent ureteral alignment suture (A) at the apex of the closure, and inclusion of ureteral adventitia (A) in the detrusorraphy). METHODS: A 12-year-old male presents after a urinary tract infection and a recurrence of grade 3 VUR on the left secondary to volitional urinary holding. He had previously had an extravesical robotic-assisted laparoscopic bilateral ureteral reimplant for bilateral grade 4 VUR seven years prior with resolution of the reflux and urinary tract infections. Pre-operative video urodynamics revealed a smooth, large capacity bladder (740cc) with normal sensation and without detrusor overactivity. After consideration of the options, the patient and his parents elected to undergo a redo extravesical robotic-assisted laparoscopic left ureteral reimplant. RESULTS: Successful completion of the redo extravesical robotic-assisted laparoscopic left ureteral reimplant. There was significant adhesion of the vas deferens to the distal left ureter requiring extensive dissection. CONCLUSIONS: This video demonstrates that an extravesical robotic-assisted laparoscopic left ureteral reimplant is feasible and safe to perform as a re-operation after previous robotic ureteral reimplant. The most significant adhesion encountered was at the distal ureter, with the vas deferens densely adhered. We demonstrate the steps to this advanced procedure. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e715 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Clark Judge More articles by this author Anastasia Gliatis More articles by this author Amrita Mohanty More articles by this author Mohan Gundeti More articles by this author Expand All Advertisement PDF DownloadLoading ...

Vesicoscopic Cross-Trigonal Ureteral Reimplantation for Vesicoureteral Reflux: Intermediate Results.

For the treatment of vesicoureteral reflux, the introduction of vesicoscopic procedures offers new perspectives for improving patient comfort and quality. Our aim was to examine whether minimally invasive vesicoscopic cross-trigonal ureteral reimplantation (VCUR) would meet expectations. Between 2012 and 2021, 99 girls and 35 boys with high-grade vesicoureteral reflux (VUR) underwent VCUR. For two boys, we failed to establish the pneumovesicum, leading to conversion to open surgery. The mean age was 4.5 years, ranging from 10 months to 18 years. VCUR was successfully performed in 132 patients, including 75 patients with bilateral VUR and 12 children with double ureters with unilateral or bilateral VUR, corresponding to a total of 229 operated ureters. The mean time of operation was 151 min for all patients. There were no perioperative complications, with the exception of three cases of pneumoperitoneum without consequences. Postoperatively, we recognized three cases of acute hydronephrosis, two of them required transient drainage. Three patients developed extravasation of urine after the postoperative removal of the transurethral catheter, rapidly resolved by new drainage. In two patients, we combined VCUR with laparoscopic heminephrectomy and opposite laparoscopic nephrectomy, respectively. Overall, mean postoperative hospital stay was 4.2 days. We observed recurrent VUR in seven ureters, resulting in a success rate for VCUR of 96.9%. These results demonstrate the feasibility of VCUR and its potential to displace open surgery with high safety and wide applicability.

Laparoscopic ureteral reimplantation in the recurrent vesicoureteral reflux in a 12-year-old child

Introduction. The antireflux reimplantation of the ureter may be performed using different surgical approaches with the known techniques. Despite the high efficiency of these surgical interventions, there are cases of reflux relapses even after several surgical interventions on the ureterovesical junction (UVJ). The range of ways for laparoscopic reconstruction of the upper urinary tract is increasingly expanding what allows toperform a successful correction of the defect even in technically difficult positions. The main purpose of the present clinical demonstration is to illustrate a successful application of laparoscopic access in the correction of recurrent forms of vesicoureteral reflux (VUR).Material and methods. The authors present a clinical case and management of a patient with Grade 4 VUR on the right (classification by P.E. Heikel et K.V. Parkkulainen, 1966). Previously, a 12-year-old boy had four surgical interventions, both open traditional correction and endovesical implantations of volume-forming drugs. The reflux persisted and was accompanied with constant recurrences of pyelonephritis and progressive deterioration of the kidney function on the right.Results. Despite technical difficulties associated with cicatricial changes in UVJ, an antireflux surgery with laparoscopic access was performed. The follow-up control within one year revealed no recurrences of urinary tract infection. Findings of VUR control examination demonstrated that the renal function was stabilized.Conclusions. A rational approach and justified surgical access have given good outcomes in this patient.

Safety assessment and diagnostic evaluation of patients undergoing contrast-enhanced urosonography in the setting of vesicoureteral reflux confirmation.

Vesicoureteral reflux (VUR) represents a common pediatric anomaly in children with an upper urinary tract infection (UTI) and is defined as a retrograde flow of urine from the bladder into the upper urinary tract. There are many diagnostic options available, including voiding cystourethrography (VCUG) and contrasted-enhanced urosonography (ceVUS). ceVUS combines a diagnostic tool with a high sensitivity and specificity which, according to previous study results, was even shown to be superior to VCUG. Nevertheless, despite the recommendation of the EFSUMB, the ceVUS has not found a widespread use in clinical diagnostics in Europe yet. Between 2016 and 2020, 49 patients with a marked female dominance (n = 37) were included. The youngest patient had an age of 5 months, the oldest patient 60 years. The contrast agent used in ceVUS was SonoVue®, a second-generation blood-pool agent. All examinations were performed and interpreted by a single experienced radiologist (EFSUMB Level 3). The 49 patients included in the study showed no adverse effects. 51% of patients (n = 26) were referred with the initial diagnosis of suspected VUR, while 49% of patients (n = 23) came for follow-up examination or to rule out recurrence of VUR. The vast majority had at least one febrile urinary tract infection in their recent medical history (n = 45; 91,8%). ceVUS is an examination method with a low risk profile which represents with its high sensitivity and specificity an excellent diagnostic tool in the evaluation of vesicoureteral reflux, especially in consideration of a generally very young patient cohort.

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.

The risk factors for recurrence of febrile urinary tract infection and renal scarring in children with functional urinary incontinence.

Functional urinary incontinence is often associated with recurrent urinary tract infection (UTI), vesicoureteral reflux (VUR), and renal scarring. This study aims to evaluate the correlations between urodynamic findings and recurrence of UTI, VUR, and renal scarring in children with functional incontinence. In this retrospective observational study, data on the presence of VUR, urodynamics and 99Tc-dimercaptosuccinic acid scintigraphy findings, and episodes of febrile UTI were obtained from patients' records. The patients had at least 3 years of follow-up. There were significant associations between recurrence of UTI and decreased bladder capacity (hazard ratio: 1.321, P = .028). The receiver operator characteristic curve analysis showed a cutoff value for compliance of 13.25 mL/cmH2 O for renal scarring (P = .000). There was a significant association between bladder wall thickening and VUR (odds ratio: 2.311, P = .008). The compliance had a cutoff value of 14.7 mL/cm H2 O (P = .023) for severe VUR. The frequency of renal scarring was higher in patients with severe VUR and dysfunctional voiding (P = .001 and P = .041, respectively). The independent risk factors for renal scarring were low compliance, severe VUR, and dysfunctional voiding in children with functional incontinence, but recurrence of febrile UTI was not a risk factor for renal scarring. Decreased bladder capacity was a risk factor for recurrence of febrile UTI. The present study suggests that low compliance, severe VUR, and dysfunctional voiding, but not the recurrence of febrile UTI, are the independent risk factors for renal scarring in children with functional incontinence, and decreased bladder capacity is the risk factor for the recurrence of febrile UTI.

Proprietary non-animal stabilized hyaluronic acid/dextranomer gel (NASHA/Dx) for endoscopic treatment of grade IV vesicoureteral reflux: Long-term observational study

Since 1993, children aged >1 year with persistent grade III-V vesicoureteral reflux (VUR) and febrile urinary tract infections (UTIs) attending Uppsala University Hospital have undergone endoscopic injection with proprietary non-animal stabilized hyaluronic acid/dextranomer gel (NASHA/Dx; Deflux®). Investigate long-term incidence of UTI, bladder dysfunction, ureteral reimplantation and overall clinical findings following endoscopic injection of NASHA/Dx. Children with grade IV VUR diagnosed by voiding cystourethrogram (VCUG) and dilating VUR persisting for >1 year were included in this study. 15-25 years after endoscopic treatment, patients' hospital charts were studied. Information on bladder function and UTIs was obtained via questionnaire, 8-18 years after endoscopic treatment. 185 patients (69 boys, 116 girls) were included in the study; 237 grade IV VUR ureters were treated. All study patients were diagnosed with VUR after a febrile UTI (i.e. pyelonephritis). According to the last voiding cystourethrogram, 69% of ureters showed a positive response (VUR grade 0-I), 7% had VUR grade II and 23% had VUR grade≥III. 46 patients (25%) required ureteral reimplantation during follow-up. Among patients treated during the second 5-year period compared with the first (1998-2003 versus 1993-1998), there was a significant decrease in the rate of ureteral reimplantation (31% vs 16%; p=0.0365). This difference may be attributable to developments over time in the injection technique. UTIs occurred in 30 patients (21% of the evaluable population): 28 females and 2 males. Febrile UTIs were reported in 14 patients (10%), all females. Forty-nine patients (34%) had bladder problems (e.g. underactivity, overactivity, incontinence). Five patients underwent ureteral reimplantation 'late', 6-10 years after the last endoscopic injection. In one male patient, calcification around the NASHA/Dx implantation site was observed during routine examination 2 years after endoscopic treatment; no intervention was required. No safety issues were observed in the remaining 97% of the study population. This study represents the longest published follow-up of Grade IV VUR patients undergoing endoscopic treatment. Three-quarters of patients did not need ureteral reimplantation. Optimal injection technique and higher injection volume were associated with a reduced ureteral reimplantation rate. Treatment with NASHA/Dx was durable and well tolerated: long-term risks of UTI, bladder dysfunction and recurrent VUR were low.

Laparoscopic Extravesical Reimplantation in Children with Primary Obstructive Megaureter.

Introduction: Conservative management of primary obstructive megaureter (POM) appears as the best option in patients with adequate ureteral drainage. Nevertheless, surgical intervention is indicated in cases of recurrent urinary tract Infections (UTIs), deterioration of split renal function, and significant obstruction. The gold standard includes: Ureteral reimplantation with or without tapering by open approach. Our objective is to report our results in the treatment of POM by Laparoscopic-Assisted Extracorporeal Ureteral Tapering Repair (EUTR) and Laparoscopic Ureteral Extravesical Reimplantation (LUER) and to evaluate the efficacy and security of this procedure. Materials and Methods: From January 2011 to January 2018 a retrospective study was carried out by reviewing the clinical records of 26 patients diagnosed with POM. All patients underwent laparoscopic ureteral reimplantation following Lich Gregoir technique. In cases of ureteral tapering, an EUTR was performed with Hendren technique. Results: In all patients LUER and EUTR were performed without conversion. No ureteral tapering was necessary in six patients. There were no intraoperative complications. At 3 months in postoperative, 1 patient presented a febrile UTI, and subsequently, a vesicoureteral reflux (VUR) grade III was diagnosed by voiding cystourethrogram. In this case, a redo laparoscopic surgery was performed. After long-term follow-up, all patients were asymptomatic without recurrence of POM or VUR. Conclusion: Laparoscopic-assisted EUTR and LUER following Lich Gregoir technique for POM constitutes a safe and effective option, with a success rate similar to that of open procedure. Nevertheless, larger randomized prospective trials and long-term follow-up are required to validate this technique.

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.

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

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

Endoscopic correction of vesicoureteral reflux in children

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

Preperitoneal Surgical Approach to Treat Vesicoureteral Anastomotic Leakage, Distal Stenosis or Reflux After Kidney Transplantation.

If endourological approaches are not applicable to treat vesicoureteral anastomotic complications after kidney transplantation, the surgical gold standard in many transplant centers is pyeloureterostomy or ureteroureterostomy using the native ureter. We report an original preperitoneal technique that can be used for vesicoureteral reanastomosis in kidney transplant recipients not eligible for endourological treatment. Between January 2011 and December 2015, 18 kidney transplant recipients underwent this new surgical procedure. Of this number, 15 subjects with at least 1year of follow-up were included in the analysis. The indications were vesicoureteral reflux, anastomotic stenosis, and leakage in 8, 5, and 2 patients, respectively. Briefly, a double J stent was preoperatively inserted into the grafted ureter. Surgery was performed through a Pfannenstiel incision. The preperitoneal space surrounding the bladder was dissected and the distal part of the grafted ureter was identified and mobilized. The anastomotic area was resected and another vesicoureteral anastomosis was performed (Lich-Gregoir technique), keeping the JJ stent in place for three weeks. This procedure was performed 213 days (range 17-2608) after kidney transplantation. Median surgical duration was 179 minutes (range 112-314) and median hospital stay 8 days (range 4-14). The success rate was 86.7% (13/15), with a median follow-up of 1148 days (range 517-1808). In two patients, symptomatic recurrence of vesicoureteral reflux required a pyeloureterostomy using the native ureter. The authors describe a simple technique that avoids transperitoneal dissection, potentially yielding more esthetic results thanks to easy access, as well as excellent outcomes.

Recurrent vesicoureteral reflux during pregnancy

Recurrent vesicoureteral reflux during pregnancy

Ureteric patency after Deflux® injection for the treatment of vesicoureteric reflux in children confirmed by a novel epidural catheter-assisted endoscopic technique.

We present EDCAT (epidural catheter-assisted Deflux(®) treatment) for treating vesicoureteral reflux (VUR) and confirming ureteric patency after Deflux(®) treatment. We treated 147 ureters in 101 children (M:F 62:39; VUR ≤ grade III: n = 72; VUR ≥ grade IV: n = 75) using EDCAT between 2011 and 2014. EDCAT involves injecting 1-3 mL of diluted indigo carmine solution through an epidural anesthesia catheter inserted into the Deflux(®)-treated ureter and observing for up to 15 min to confirm patency. For EDCAT, mean age was 4.9 years and mean operative time was 30.1 ± 12.1 min; overall cure of VUR after initial treatment was 87.7 % for VUR grades I-V, 88.9 % for VUR ≤ grade III, and 86.6 % for VUR ≥ grade IV; VUR was cured in 129/147 after 1 treatment, 7/18 after 2 treatments, 7/11 after 3 treatments, and persistent in 4/4. We experienced 1 case of obstruction after an EDCAT catheter was removed before confirming patency. EDCAT catheters were left overnight in 2 ureters in 2 cases when patency could not be confirmed after 15 min to prevent obstruction. Both did not develop obstruction. Four ureters with recurrence of VUR (all grade ≤ II) are being observed. EDCAT allows ureteric patency to be confirmed immediately and prevents obstruction.

Technique of Tubularized Bladder Mucosa Method for Treating Recurrent Vesicoureteral Reflux.

Technique of Tubularized Bladder Mucosa Method for Treating Recurrent Vesicoureteral Reflux.