Resolution Of Reflux Research Articles

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.

Impact of Bariatric Surgery on Hiatal Hernia Repair Outcomes

Large hiatal hernias are notorious for their high recurrence rates after conventional repair. Recurrence rates have been described to be higher in obese patients due to increased intra-abdominal pressure. We hypothesized that patients who undergo hiatal hernia repair (HHR) with bariatric surgery (BAR) will have a lower hernia recurrence rate when compared to patients who undergo HHR with fundoplication (FP) due to the decrease in intra-abdominal pressure observed with weight loss. This was an Institutional Review Board approved retrospective review. The outcomes of patients who underwent HHR+BAR as well as patients who had HHR+FP only from 2007 to 2014 were reviewed. Patients who had small hiatal hernias (<2 cm), underwent an anterior repair, or had gastropexy only were excluded. The primary outcome was hernia recurrence and reflux resolution. The outcomes of 58 patients who had HHR+BAR were compared with 30 patients with HHR+FP. Hernia recurrence rate for HHR+BAR was 12 per cent, whereas hernia recurrence rate for HHR+FP was 38 per cent (P < 0.01). Reflux resolution for HHR+FP was 78 per cent, whereas reflux improvement rate for HHR+BAR was 84 per cent (P = n.s.). Combining HHR with BAR leads to a lower hernia recurrence rate when compared to patients who undergo HHR with FP.

Augmentation enterocystoplasty without reimplantation for patients with neurogenic bladder and vesicoureteral reflux

The objective of this study was to assess the clinical outcome of vesicoureteral reflux (VUR) after augmentation cystoplasty alone in patients with a hypocompliant neurogenic bladder. Between January 2009 and December 2014, 29 patients with a hypocompliant bladder associated with VUR confirmed by videourodynamics (VUD) preoperatively were recruited in this study. All patients had undergone bladder augmentation with a generous detubularized segment of bowel at our institution. No effort had been made to correct the existing reflux. Preoperative assessment included urinalysis, kidney function tests, ultrasonography, and videourodynamic evaluation. All patients had various degrees of VUR. The status of VUR and bladder function were studied by VUD. The mean follow-up period was 2.2 years (range 0.5–5.5 years). The VUD manifested a significant improvement of bladder capacity, diminution of intravesical pressure, and resolution of reflux after bladder augmentation. After the surgery, 24/29 (83%) no longer had reflux, 3/29 (10%) showed improvement in reflux, and 2/29 (7%) demonstrated no change in reflux. In addition, 16/21 (76%) patients had reflux Grades I-III; 100% patients with reflux Grades IV and V had complete cessation of reflux. Only one patient had symptomatic urinary infection after the surgery. Augmentation enterocystoplasty without ureteral reimplantation is thus effective and adequate for patients with high-pressure and hypocompliant neurogenic bladder. Therefore, ureteral reimplantation is not necessary when augmentation enterocystoplasty is recommended for patients with high-pressure, low-compliant bladder and VUR.

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.

Robot-assisted Laparoscopic Extravesical Ureteral Reimplantation: Technique Modifications Contribute to Optimized Outcomes

BackgroundRobot-assisted laparoscopic extravesical ureteral reimplantation (RALUR-EV) is being adopted at large pediatric urology centers in the United States, but currently there is not consensus on surgical technique to facilitate the best possible outcomes. ObjectiveTo describe technique modifications that may lead to improved radiographic vesicoureteral reflux (VUR) resolution. Design, setting, and participantsBetween December 2008 and February 2015, a single surgeon performed RALUR-EV at an academic medical center. Only children with persistent grade 3–5 VUR at age 5 yr on voiding cystourethrogram (VCUG), those who had breakthrough urinary tract infections, or those with renal scarring were selected to undergo surgical correction of VUR with RALUR-EV. Children undergoing RALUR-EV for obstructive megaureter or ureterovesical junction obstruction were excluded. Fifty-eight patients (83 ureters) fit the inclusion criteria. Surgical procedureWe highlighted adjustments to our technique, called LUAA to represent length of detrusor tunnel (L), use of a U stitch (U), placement of permanent ureteral alignment suture (A), and inclusion of ureteral adventitia (A) in detrusorraphy. Outcome measurements and statistical analysisThe primary end point was resolution of VUR on postoperative VCUG. Results and limitationsBecause technique modifications were made at two distinct time points, we generated three patient groups for comparison. We observed complete resolution of VUR in 82% of ureters, including 8 of 12 ureters (67%), 8 of 11 ureters (73%), and 52 of 60 ureters (87%) for technique modification cohorts 1, 2, and 3, respectively. There were no ureteral complications at median follow-up of 30 mo. Retrospective design and possible confounding from the learning curve limit this study. ConclusionsUsing the standardized LUAA technique, we demonstrated an improvement in outcomes. Given the wide range of published resolution rates following RALUR-EV, there is a need for standardization of technique to facilitate best possible outcomes. We propose the LUAA technique as a new standard for RALUR-EV to achieve this goal. Patient summaryWe examined the safety and efficacy of a minimally invasive surgery in children. We identified several critical adjustments to surgical technique that improve rates of successful outcome.

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 ...

Ultrasonographic mound height as predictor of vesicoureteral reflux resolution after endoscopic treatment in children

PurposeEndoscopic dextranomer/hyaluronic acid copolymer (Dx/HA) injection is a safe and efficacious treatment option for vesicoureteral reflux (VUR) in children. Endoscopic appearance, hydrodistention and amount of injected Dx/HA have been demonstrated not to be reliable predictors of outcome. Aim of this study was to evaluate Dx/HA mounds on ultrasound scans (US) and find out any eventual correlation with reflux resolution. MethodsWe selected patients treated with endoscopic injection for moderate to high VUR, renal scaring or repeated infections under antibiotic prophylaxis. Success was defined by absence of VUR at control 3months after surgery; at 3months we also measured mound height ultrasonographically. ResultsWe considered a total of 32 children (15 male, 17 female; 53 ureters) with a median age of 3years (±24months). Overall success rate was 77% per ureter. Success rate correlates directly with age and inversely with VUR grade. Mound height is the major predictive parameter for reflux resolution (sensitivity 100%, specificity 65.9%); mean mound heights of success-group vs. persistence-of-reflux group were 9.97±1.61mm and 7.29±1.74mm respectively (p<0.0005). ConclusionA mound measuring at least 9.8mm at post-operative US scan is a predictor of reflux resolution. Age and grade also seems to influence success rate.

Complications after bladder augmentation in children.

Bladder augmentation is an effective surgical procedure for increasing bladder capacity and reducing pressure on the urinary system. It is indicated for patients with anomalies such as spina bifida, myelomeningocele, urethral valve and bladder exstrophy, who progress with low tolerance of medication. This was a retrospective study conducted on pediatric patients submitted to bladder augmentation from 2000 to 2011. 34 patients aged 4 to 17 years were submitted to bladder augmentation, 30 of them with an ileal loop and 4 with a ureter.A continent urinary shunt was performed in 16 patients, the Mitrofanoff conduit was associated in 15, and the Macedo technique was used in one. Mean follow-up was 34.35 months (1 to 122 months). Mean creatinine was 1.5 ng/ml (0.4 to 7.5 ng/ml) preoperatively and 1.78 ng/ml postoperatively. Three patients required a renal transplant during follow-up. There was improvement or resolution of vesicoureteral reflux in 83.5% of the kidneys on the right and in 75% on the left. Bladder capacity increased, on average, from 152.5 ml to 410 ml. The main complications were vesical lithiasis in 3 patients and conduit perforation in one. Bladder augmentation showed good results in this series, preserving renal function in most of the patients.

Can morbidly obese patients with reflux be offered laparoscopic sleeve gastrectomy? A case report of 40 patients

BackgroundThe incidence of reflux in obesity can reach greater than 35%. Most surgeons recommend Roux-en-y gastric bypass to patients with pre-existing reflux. One alternative to Roux-en-y gastric bypass is the addition of anterior fundoplication (AF) with posterior crural approximation (pCA) to laparoscopic sleeve gastrectomy (LSG) in patients with documented reflux. MethodsBetween February 2011 and April 2013 we reviewed data from the bariatric registry on weight loss, resolution of symptoms, and quality of life presurgery and postsurgery for all patients who consented to participate in the registry and underwent LSG with AF/pCA. ResultsForty patients met inclusion criteria; 78% (31) were female. The mean initial weight was 298 ± 64 lbs. with mean BMI of 49 ± 8 kg/m2. The mean DeMeester score was 36 ± 27 (normal <14.7). Nine (22.5%) patients had esophagitis. Thirty-six (90%) patients had hiatal hernia. There were no intraoperative complications. The mean operative time was 84 ± 20 minutes and the mean hospital stay was 1.6 ± .9 days. Postoperative complications included 1 fluid collection, 1 narrowing, 4 admissions for nausea and dehydration, 1 for pancreatitis, and 1 for deep vein thrombosis . Thirty-eight (95%) patients had immediate resolution of reflux, whereas 2 (5%) patients complained of worsening symptoms. On short-term follow-up of 24 ± 6 months, 55% of patients responded to the gastroesophageal reflux disease-health related quality of life questionnaire with improvement in their median score from 31/75 interquartile range (IQR 25) preoperatively to 0/75 (IQR 6.5) postoperatively (P < .0001). Their %excess body mass index loss was 69 ± 27%. ConclusionsMorbidly obese patients with documented reflux can be offered LSG with the addition of AF/pCA.

The Biocompatibility of a Cellulose Exopolysaccharide Implant in the Rabbit Bladder When Compared With Dextranomer Microspheres Plus Hyaluronic Acid

To evaluate biocompatibility of a cellulosic exopolysaccharide (CEC) as bulking agent in rabbit urinary bladder. The experimental study was developed at the Nucleus for Experimental Surgery or UFPE. The new agent was injected into the bladder of the adult rabbits using a small abdominal incision. Animals were injected with 0.2 mL of dextranomer microspheres (Dx) plus hyaluronic acid and CEC. The animals were studied after 3 days (G1), 90 days (G2), and 11 months (G3). The biocompatibility was evaluated according to the histologic parameters (presence of blood vessels, inflammatory reaction, and collagen deposition) by a quantitative analysis. The Student paired t test was used for continuous variables, and the scores were compared through the chi-square test. Both materials were structurally homogeneous and free from inflammatory cells or blood vessels (G1). In 3-month samples (G2), CEC areas were densely invaded by fibroblasts and blood vessels. Dx areas were fragmented but still homogeneous and free from cells or blood vessels. Samples from 3 and 11 months showed a significant difference in favor of CEC especially concerning preservation of material in the implant site, as well as the presence of neovascularization. This experimental study represents a positive outcome in terms of reflux resolution in the long term. Further studies may be necessary to confirm its efficacy when in clinical use. The CEC exhibited low inflammatory response and integrated with the host tissue better than Dx in the long-term follow-up.

MP54-02 MULTI-INSTITUTIONAL ANALYSIS AND VALIDATION OF THE VESICOURETERAL REFLUX INDEX (VURX)

You have accessJournal of UrologyPediatrics: Urinary Tract Infections/Vesicoureteral Reflux1 Apr 2015MP54-02 MULTI-INSTITUTIONAL ANALYSIS AND VALIDATION OF THE VESICOURETERAL REFLUX INDEX (VURX) Angela M. Arlen, Aaron D. Weiss, Michael Garcia-Roig, Traci Leong, Christopher S. Cooper, and Andrew J. Kirsch Angela M. ArlenAngela M. Arlen More articles by this author , Aaron D. WeissAaron D. Weiss More articles by this author , Michael Garcia-RoigMichael Garcia-Roig More articles by this author , Traci LeongTraci Leong More articles by this author , Christopher S. CooperChristopher S. Cooper More articles by this author , and Andrew J. KirschAndrew J. Kirsch More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.2025AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Diagnosis and management of vesicoureteral reflux (VUR) in young children remains controversial. VURx is a novel tool designed to predict spontaneous reflux resolution in children less than 2 years of age. We performed a multi-institutional validation study, evaluating improvement and resolution rates of young children with newly diagnosed VUR. METHODS Children diagnosed with primary VUR before 24 months of age with ≥2 VCUGs were identified. A 1-6 point VURx was assigned as previously described [Figure 1A]. Demographics, VUR grade and timing, ureteral anomalies, and radiographic outcomes were evaluated. Time to event analysis was performed to identify predictors of time to spontaneous VUR resolution. Resolution was defined as a negative VCUG and improvement as a ≥2 grade decrease in maximum VUR grade. RESULTS Three hundred and sixty-nine children (219 girls, 150 boys) from participating institutions met all inclusion criteria. Mean age at diagnosis was 4.7 ± 4.9 months. One hundred and one patients (27.4%) had early to mid-filling, 214 (58%) late filling and 54 (14.6%) had voiding only VUR. Mean maximum VUR grade was 2.7 ± 1.1; 87 children (23.6%) had high-grade reflux. Ureteral anomalies, complete duplication or periureteral diverticulum (PUD), were observed in 51 children (13.8%). Mean VURx was 3.1 ± 1 with the following breakdown: 1 (17), 2 (88), 3 (151), 4 (78) and 5-6 (35). VURx 1 to 5-6 had improvement/resolution rates of 88.2%, 77.3%, 62.3%, 32.1% and 14.3%, respectively, consistent with the previously published rates (p=0.818) [Figure 1B]. Children with filling phase VUR (p<0.001), grade 4-5 reflux (p<0.001), and ureteral anomalies (p=0.003) had significantly longer median times to improvement or resolution on time to event analysis. Median time to spontaneous resolution was 12.6, 12.7, 15.1, 25.6 and 31 months for VURx 1 to 5-6, respectively. Sixty-five children (17.6%) underwent surgical intervention during the follow-up period. CONCLUSIONS VURx is a simple, validated tool that reliably predicts significant improvement and spontaneous resolution of primary reflux in children diagnosed prior to 2 years of age. In an era where optimal management of VUR remains debatable, the VURx provides additional prognostic information facilitating individualized patient care. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e664 Peer Review Report Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Angela M. Arlen More articles by this author Aaron D. Weiss More articles by this author Michael Garcia-Roig More articles by this author Traci Leong More articles by this author Christopher S. Cooper More articles by this author Andrew J. Kirsch More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Vesicoureteral Reflux Index: 2-Institution Analysis and Validation

The vesicoureteral reflux index is a novel tool designed to predict spontaneous reflux resolution in infants younger than 2 years. We performed a multi-institutional validation study to confirm the discriminatory power of the vesicoureteral reflux index to predict the vesicoureteral reflux resolution rate in young children. We identified patients diagnosed with primary vesicoureteral reflux before age 24 months who had 2 or more voiding cystourethrograms available. Demographics, vesicoureteral reflux grade and timing, ureteral anomalies and radiographic outcomes were evaluated. The C-index was estimated for time to event model assessment. A total of 219 girls and 150 boys met study inclusion criteria. Mean ± SD age at diagnosis was 4.7 ± 4.9 months. Of the patients 101 (27.4%) had early to mid filling, 214 (58%) had late filling and 54 (14.6%) had voiding only vesicoureteral reflux. High grade reflux was present in 87 patients (23.6%) and ureteral anomalies were observed in 50 (13.6%). A vesicoureteral reflux index of 1, 2, 3, 4 and 5 or greater showed an improvement/resolution rate of 88.2%, 77.3%, 62.3%, 32.1% and 14.3%, respectively. On time to event analysis children with filling phase vesicoureteral reflux (p <0.001), grade 4-5 reflux (p <0.001) and ureteral anomalies (p = 0.003) had significantly longer median time to resolution. Median time to spontaneous resolution was 12.6, 12.7, 15.1, 25.6 and 31 months or greater for a vesicoureteral reflux index of 1, 2, 3, 4 and 5 or greater, respectively (C-index 0.305, 95% CI 0.252-0.357). During the study period 65 patients (17.6%) underwent surgical intervention. The vesicoureteral reflux index is a simple tool that reliably predicts significant improvement and spontaneous resolution of primary reflux in patients diagnosed at younger than 2 years. The index provides valuable prognostic information, facilitating individualized patient care.

Augmentation enterocystoplasty without reimplantation for patients with neurogenic bladder and vesicoureteral reflux

Objective To assess the outcome of vesicoureteral reflux after augmentation cystoplasty in patients with neurogenic bladder. Methods Between January 2008 and January 2014, a total of 25 patients, with a hypocompliant bladder associated with vesicoureteral reflux confirmed by video-urodynamics preoperatively, were recruited in this study. They all had undergone bladder augmentation with a generous detubularized segment of bowel at our institution. No effort had been made to correct existing reflux. Preoperatively assessment included urinalysis, kidney function tests, ultrasonography, video-urodynamic evaluation. All patients had various degrees of vesicoureteral reflux. The status of vesicoureteral reflux and bladder function were studied by video-urodynamic. Results Mean follow-up was 2.2 years (range 0.5 to 5.5 years). The video-urodynamics manifested a significant improvement of bladder capacity, diminution of intravesical pressure and resolution of reflux after bladder augmentation. Of the 25 patients, 20 (80%) no longer had reflux, 3 (12%) had improvement, 2 (8%) had no change. Sixteen of 18 with grades Ⅰ to Ⅲ (89%), all refluxing units with grade Ⅳ to grade Ⅴ (100%) showed complete cessation of reflux. Symptomatic urinary infection was not found after surgery. Conclusions Augmentation enterocystoplasty without ureteral reimplantation is effective and adequate for patients with high pressure and hypocompliant neurogenic bladder. Therefore, ureteral reimplantation is not necessary underwent when augmentation enterocystoplasty is recommended to patients with neurogenic bladder and vesicoureteral reflux. Key words: Urinary bladder, neurogenic; Vesico-ureteral reflux; Augmentation enterocystoplasty; Ureteral reimplantation

Can Distal Ureteral Diameter Predict Reflux Resolution After Endoscopic Injection?

To test the predictive value of distal ureteral diameter (UD) on reflux resolution after endoscopic injection in children with primary vesicoureteral reflux (VUR). This was a retrospective review of patients diagnosed with primary VUR between 2009 and 2012 who were managed by endoscopic injection. Seventy preoperative and postoperative voiding cystourethrograms were reviewed. The largest UD within the false pelvis was measured. The UD was divided by the L1-L3 vertebral body distance to get the UD ratio (UDR). One radiologist interpreted the findings of voiding cystourethrography in all patients. Clinical outcome was defined as reflux resolution. Seventy patients were enrolled in this series (17 boys and 53 girls). Mean age was 5.9 years (1.2-13 years). Grade III presented in 37 patients (53%), and 33 patients (47%) were of grade IV. Mean distal UD was 5.5mm (2.5-13mm). Mean UDR was 37.8% (18%-70%). Macroplastique injection was performed in all. Subureteric injection was performed in 60 patients (86%), whereas intraureteric injection was performed in 10 patients. No postoperative complications were detected. The effect of grade, UD, and UDR on success after endoscopic injection was tested. UD and UDR were significant predictors of reflux resolution on logistic regression analysis (P<.007 and .001, respectively). UDR provides an objective measurement of VUR and appears as a predictive tool of success after endoscopic injection.

Significance of an endoscopically injected nodule detected on ultrasound as a predictive factor for the resolution of vesicoureteral reflux.

Endoscopic treatment of vesicoureteral reflux (VUR) is feasible in pediatric patients. As endoscopic injection has a lower success rate than ureteral reimplantation, a postoperative voiding cystourethrogram (VCUG) is usually performed. The present study evaluated whether the presence of a nodule on noninvasive ultrasound could predict the resolution of VUR and replace invasive VCUG. Patients who received an injection of endoscopic bulking agent for VUR from January 2005 to December 2010 were evaluated retrospectively. It was evaluated whether a nodule, an echogenic mass lesion distinguished from the bladder at the ureteral orifice, was present on the ultrasound one month postoperatively. The success of the injection in the group with nodules was compared with that of the group without nodules by VCUG 3 months postoperatively. A total of 149 patients (220 ureters) met the inclusion criteria. The mean age at surgery was 3.5 years (range, 0.6–18 years). The overall success rate was 73.2%. A nodule was present in 152 cases (69.1%). The group with nodules had a higher success rate than the group without nodules (84.2%, 128/152 vs. 48.5%, 33/68, respectively; P<0.001). According to multivariate analysis, injection nodules were a predictive factor for the success of the endoscopic injection (odds ratio, 6.050; P<0.001). The failure rate increased with increasing injection volume. The sensitivity of sonographic injection nodules for predicting success was 79.5% and the specificity was 59.3%. To conclude, the presence of a postoperative nodule can predict the resolution of VUR.

Supraesophageal Reflux: Correlation of Position and Occurrence of Acid Reflux–Effect of Head-of-Bed Elevation on Supine Reflux

Supraesophageal reflux of gastric contents can contribute to perennial nasopharyngitis, cough, and asthma. However, effective treatment strategies for supraesophageal reflux disease (SERD) remain inadequately defined. The purpose of this study is to assess the prevalence and timing of SERD and to investigate the efficacy of head-of-bed elevation in its treatment. A retrospective chart review of patients seen at Scripps Clinic Division of Allergy, Asthma and Immunology was performed who had undergone overnight nasopharyngeal pH monitoring with a commercially available nasopharyngeal pH-monitoring device, Dx-pH Measurement System from Restech, San Diego, Calif. Subjects with reflux were classified based on the position of reflux as either supine only, upright only, or both supine and upright. In a subset of subjects with supine-only reflux, pH monitoring was compared before and after elevating the head of bed 6 inches. Adequate nasopharyngeal pH-monitoring data were obtained for 235 patients. Reflux was detected in 113 (48%) patients. The pattern of reflux observed was 62 (55%) supine only, 4 (4%) upright only, and 47 (42%) upright and supine. Sequential overnight nasopharyngeal pH monitoring before and after head-of-bed elevation was obtained in 13 individuals with supine-only reflux. Ten subjects demonstrated significant improvement, 8 of whom demonstrated complete resolution of supine reflux with 6 inches of head-of-bed elevation. This study provides new evidence that SERD frequently occurs in the supine position and that 6 inches of head-of-bed elevation is effective in reducing supine SERD.

Novel augmentation ileocystoplasty technique to manage non-compliant bladders in the presence of obstructed megaureters: the "fez procedure".

To show the efficacy and safety of a novel modification of Studer's neobladder, herein defined as the "fez procedure." The medical records of 21 children (mean age 9.4 ± 1.3 years) who underwent the "fez procedure" at King Abdulaziz University Hospital, Jeddah, Saudi Arabia, to manage refractory poorly-compliant bladders and concomitantly obstructed megaureters were retrospectively reviewed. The patients had been previously managed by either preliminary cutaneous ureterostomy (17 patients) or temporary nephrostomy (four patients) to improve and stabilize the renal functions. The "fez procedure" entailed augmentation ileocystoplasty and the use of an afferent tubularized ileal loop for direct ureteroileal anastomosis. The augmented bladder together with the tubularized loop were fashioned as a "fez" with its tassel. The outcome measures were changes in cystometric capacity, bladder compliance, glomerular filtration rate, serum creatinine, technetium 99m-diethylene triamine pentaacetic acid diuretic renography (T1/2), ureteral diameter, vesicoureteral reflux, febrile urinary tract infections, continence and complications. The mean study follow-up period was 52.5 ± 12.8 months. Means of changes of cystometric capacity (273.2 ± 60.9 mL) and bladder compliance (15.6 ± 4.2 mL/cm H2 O) were significant (P < 0.0001). Resolution of ureteral obstruction was documented with improved T1/2 and ureteral diameter (P < 0.0001, each) of all patients. The initially improved renal functions after ureterostomies or nephrostomies were maintained after "fez surgery," with non-significant changes in the improved glomerular filtration rate (P = 0.22) and serum creatinine (P = 0.18). None of the patients experienced ureteral restenosis, vesicoureteral reflux, febrile urinary tract infections, incontinence or significant complications. The "fez procedure" represents a versatile and successful surgical option for these selected patients, as it offers improved bladder capacity/compliance, resolution of ureteral obstruction and vesicoureteral reflux, preservation of the renal function, control of urinary tract infections and urinary continence, and acceptable morbidity.

Early versus delayed presentation of posterior urethral valves in children: Consequences and outcome of vesico-ureteric reflux

Introduction: Delayed presentation of patients with posterior urethral valve (PUV) is common in our country and is usually associated with complications and morbidities. Objective: To determine the pattern of presentation of PUVs and its complications and outcomes in these patients with respect to decrease or resolution of vesico-ureteric reflux (VUR) and/or requirement of additional operative procedures. Materials and Methods: A retrospective study was conducted, and 30 children of PUV were analyzed with respect to the pattern of presentation, duration of symptoms, age at primary fulguration, grade of VUR and its outcome. Results: Patients with early presentation were diagnosed early, had their PUV fulgurated early and had lesser grades and better resolution of their VUR and good outcome. The reverse was seen in those patients who presented late and already had some form of renal impairment such as higher and bilateral grades of VUR and higher serum creatinine levels. Some of them also required additional procedures which added to their morbidity. Discussion: Delayed presentation of PUV is common in our country and is associated with an increased incidence and a higher grade of VUR which does not decrease or resolve on follow-up and usually requires additional operative interventions adding to the morbidity of both the parents and the child. On the other hand, early presentation leads to early diagnosis and early relief of obstruction and is associated with lesser VUR, which resolves over time. Conclusion: With early presentation, diagnosis and treatment, the outcome of patients with PUVs is expected to improve. Efforts at improving awareness and early diagnosis and referral among the health team should be encouraged.

Bladder Volume at Onset of Vesicoureteral Reflux is an Independent Risk Factor for Breakthrough Febrile Urinary Tract Infection

Improved identification of children with vesicoureteral reflux at risk for recurrent febrile urinary tract infection may impact management decisions. We hypothesized that reflux occurring earlier during bladder filling increases the duration of exposure of the kidneys to bacteria, and, therefore, increases the risk of pyelonephritis. Children with vesicoureteral reflux and detailed voiding cystourethrogram data were identified. Bladder volume at onset of reflux was normalized for age. Demographics, reflux grade, laterality, presence/absence of bladder-bowel dysfunction and breakthrough febrile urinary tract infections were assessed. Median followup was 24 months (IQR 12 to 52). A total of 208 girls and 47 boys were analyzed with a mean ± SD age at diagnosis of 3.1 ± 2.6 years. On univariate analysis history of febrile urinary tract infection (HR 2.17, 95% CI 1.33-2.85, p = 0.01), dilating vesicoureteral reflux (HR 1.6, 95% CI 1.05-2.42, p = 0.03) and bladder-bowel dysfunction (HR 1.66, 95% CI 0.99-2.75, p = 0.05) were associated with an increased risk of breakthrough febrile urinary tract infection. Median bladder volume at onset of reflux in children with breakthrough febrile urinary tract infection was significantly less (33.1%) than in those without infection (49.5%, p = 0.003). Reflux onset at 35% predicted bladder capacity or less was associated with a significantly increased risk of breakthrough febrile urinary tract infection on multivariate analysis (HR 1.58, 95% CI 1.05-2.38, p = 0.03). Children with early filling vesicoureteral reflux are at increased risk for breakthrough febrile urinary tract infection independent of reflux grade. Bladder volume at onset of reflux should be recorded during cystograms since it provides additional prognostic information about the risk of pyelonephritis and resolution, and may assist with counseling and clinical decision making.

Outcomes of a minimally invasive surgical approach to manage persistent high-grade vesicoureteric reflux post successful augmentation cystoplasty of patients with non-compliant bladder

Secondary vesicoureteric reflux (VUR) is a common problem associated with non-compliant bladders. Management of this disorder is debatable in literature. Many authors reported high resolution rate of VUR with augmentation cystoplasty (ACP) alone. Others showed significant residual VUR after ACP and recommend ureteric re-implantation (UR) at time of augmentation. Studying efficacy of endoscopic correction of persistent high-grade VUR (ECVUR) post successful ACP. Patients with non-compliant bladders and high-grade VUR are enrolled in the program of our institute, where they are initially managed conservatively. Those not responding are managed endoscopically using intravesical botulinum toxin A and ECVUR. Patients who are not candidates or failed this approach undergo ACP without UR. A total of 82 patients with non-compliant bladder underwent ACP between 2001 and 2011. Of those, 24 patients had high-grade VUR with 44 refluxing units (RU), 20 bilateral and 4 unilateral. The mean age at intervention was 7.62 years with a mean follow-up of 5.6 years. Patients with persistent high-grade VUR and recurrent breakthrough febrile UTI despite antibiotic prophylaxis following ACP were identified and enrolled in our prospective trial of interval ECVUR. Statistical analyses was performed to identify predictors of high-grade VUR resolution after ACP and ECVUR. A p value <0.05 was considered statistically significant (Table 1). Of the 24 patients, 17 underwent ileocystoplasty and 7 underwent ureterocystoplasty. One of the patients that underwent ileocystoplasty found to have a blind ending RU that was excised. Of the 36 remaining RU, 21/36 (58.3%) showed complete resolution in the first follow-up cystogram, and 1 showed complete resolution after 1 year. Two patients, each with single RU, received repeat ACP because of poor compliance and/or inadequate bladder capacity post ureterocystoplasty and showed complete resolution of reflux post-operatively, which increased the resolution rate post ACP to 66.6% (24/36) (Table 2). Of the remaining 12 RU in 7 patients, 10 underwent trial of ECVUR. VUR resolved in 8 RU after the first trial and in another 2 after the second trial (Table 3). Parents of 1 patient with the remaining 2 RU preferred to continue with conservative management (Table 2). VUR in patients with non-compliant bladder is usually secondary to high detrusor pressure, low compliance and small capacity. Whereas some investigators showed high resolution rate of VUR post augmentation without UR, claiming that by successfully augmenting the bladder, compliance will increase, detrusor pressure will decrease, and as a result, VUR will spontaneously resolve. Others showed high incidence of persistent VUR (47-57%) and recommend UR at time of ACP. In our study, the incidence of spontaneous resolution was 66.6% (24/36). In cases where VUR persists, ECVUR was performed. With this approach, VUR resolution increased to 94% (34/36). This study is limited by the small number of patients, lack of randomization and lack of comparison group in which patients undergo ACP with UR. ACP without UR with interval endoscopic management seems to be an effective and adequate treatment for high pressure, non-compliant bladder as well as high-grade VUR when conservative management fails.