Resolution Of Reflux Research Articles

Endoscopic treatment of vesicoureteric reflux with dextranomer/hyaluronic acid copolymer (Deflux): Single-surgeon experience with 48 ureters

Purpose:VUR is a common urologic problem in children. Cystoscopic injection of bulking agents (most commonly Deflux) has gained popularity as the first line treatment in the west. However, primarily due to cost factors, it has not gained much popularity in our country. We present our initial experience with cystoscopic Deflux injection for VUR.Materials and Methods:We reviewed our 3-yr experience with the use of Dx/HA (Deflux) for correction of VUR in children and adolescents. All children were evaluated with Ultrasound, MCUG and DMSA renal cortical scan. The indications for surgical correction of VUR included breakthrough infections while on antibiotic prophylaxis, persistent high-grade VUR beyond 3 yrs of age, and presence of significant renal damage on DMSA at diagnosis (in those children presenting with UTI). All children underwent cystoscopic Deflux injection using the standard technique of subureteral injection (0.4-1 ml per ureter). All children received antibiotic prophylaxis for 3-6 months after the injection. USG was done at 1 month and MCUG at 3-6 months after the injection.Results:33 patients (48 ureters) underwent cystoscopic Deflux injection for correction of VUR. Mean age was 4.5 yrs (1-17 yrs); there were 12 boys and 21 girls. Thirteen children had antenatally diagnosed HDN, while 20 children presented with febrile UTI. All children had primary VUR except one child with persistent VUR 4 yrs after PUV fulguration. The VUR was grade 1-2 in 8, grade 3-4 in 37, and grade 5 in 3 ureters. Every child had at least one ureter with dilating reflux (grades 3,4 or 5). When present, low grade VUR (grade 1or 2) was always on the contralateral side. Only one child received a 2nd injection after 6 months. Follow-up MCUG was done in 28 children (41 ureters). Complete reflux resolution was achieved in 27 ureters (65%), and the reflux was downgraded in 2 (5%). There were no complications of Deflux injection.Conclusions:Endoscopic correction of VUR in children is a safe and effective minimally invasive treatment for VUR. It stops or downgrades VUR in 70% of ureters. At present, we recommend it as a first-line treatment for grades 1-4 VUR requiring surgical management. Cost is the major factor limiting its use in our country.

Is the Appearance of the Dextranomer/Hyaluronic Acid Mound Predictive of Reflux Resolution?

Is the Appearance of the Dextranomer/Hyaluronic Acid Mound Predictive of Reflux Resolution?

Spontaneous vesicoureteral reflux resolution in children: A ten-year single-centre experience

To evaluate the spontaneous resolution rate in infants and young children with vesicoureteral reflux (VUR). Paediatric patients with VUR treated in our hospital from January 2000 to December 2010 were retrospectively analyzed. Only patients with pretreatment and follow-up voiding cystourethrogram were included into the study. Treatment success was defined as complete VUR resolution. The resolution rate for infants less than 1 year of age was 38.6% (17 of 44 renal units). Renal units with mild-moderate VUR (I-III) had a resolution rate of 40% (12 of 30 renal units) compared to 35.7% (5 of 14 renal units) with severe grade (IV-V) VUR. The resolution rate for children over 1 year of age was 39,1% (9 of 23 renal units). Renal units with mild-moderate VUR (I-III) had a resolution rate of 42.9% (9 of 21 renal units) compared to 0% (0 of 2 renal units) with severe grade (IV-V) VUR. Infants less than 1 year of age with nonsymptomatic, mild, moderate or severe VUR have a spontaneous resolution rate of more than 35% and therefore should receive a primary conservative therapy. Children over 1 year of age with nonsymptomatic mild-moderate VUR (I-III) have a spontaneous resolution rate of about 40% and should receive primary conservative treatment as well.

Is the Appearance of the Dextranomer/Hyaluronic Acid Mound Predictive of Reflux Resolution?

After endoscopic correction of vesicoureteral reflux, we correlated the appearance of the Deflux® mound with the outcome. We created an online survey based on 11 primary vesicoureteral reflux cases, including 6 failed and 9 successful procedures in a total of 15 renal units. Cases were selected randomly from our video library. All cases were performed by a single surgeon using the double hydrodistention implantation technique until a satisfactory mound was achieved and corrected. An online survey questionnaire was e-mailed to 234 members of the Society for Pediatric Urology. Each survey question contained a preoperative voiding cystourethrogram image as well as images of the ureteral orifice before and after injection. Respondents were asked to predict whether they thought that the appearance of the Deflux mound would be associated with successful reflux resolution on voiding cystourethrogram 3 months postoperatively. We analyzed the percent of correctly answered questions as well as the sensitivity, specificity and predictive value of the ability of experts to predict the outcome. A total of 104 pediatric urologists responded to the survey. Overall, 66.4% of respondents predicted reflux resolution based on mound appearance, including 66% and 67% who correctly predicted success and failure, respectively. Mean outcome predictability per respondent was 66% (range 26% to 86%). The appearance of the Deflux mound and lack of hydrodistention at the completion of the procedure are not reliable predictors of outcome. Based on this experience, postoperative voiding cystourethrogram is still required to truly determine reflux resolution.

Intrarenal reflux in primary vesicoureteral reflux

To elucidate the significance of intrarenal reflux. We retrospectively analyzed 276 patients (age <5 years) with grade III to V vesicoureteral reflux. They were divided into two groups: 55 patients with intrarenal reflux and 221 patients without intrarenal reflux (control group). All patients received low-dose antibiotic prophylaxis. The most common initial presentation in both groups was febrile urinary tract infection. On dimercaptosuccinic acid scan, the rate of decreased differential renal function (<40%) was significantly higher in the intrarenal reflux group than in the control group (51% vs 33%, P < 0.05). Breakthrough urinary tract infections were observed in 26 patients (47%) in the intrarenal reflux group and 61 patients (28%) in the control group (P < 0.01). There was no statistically significant difference regarding spontaneous resolution of reflux, which occurred in nine patients (16%) in the intrarenal reflux group and 32 patients (14%) in the control group. Surgical treatment was selected more often in the intrarenal reflux group (P < 0.05) because of the high incidence of breakthrough urinary tract infection. The rate of spontaneous resolution of high-grade vesicoureteral reflux is similar between patients with and without intrarenal reflux. However, those with intrarenal reflux present are more likely to present a decreased differential renal function and breakthrough urinary tract infections. Consequently, surgical treatment is considered more frequently in cases with intrarenal reflux. Although high-grade vesicoureteral reflux with intrarenal reflux can be treated conservatively, physicians should take into account the higher risk of breakthrough urinary tract infections.

Febrile Urinary Tract Infections After Ureteroneocystostomy and Subureteral Injection of Dextranomer/Hyaluronic Acid for Vesicoureteral Reflux—Do Choice of Procedure and Success Matter?

Despite success rates favoring ureteroneocystostomy over subureteral injection of dextranomer/hyaluronic acid for correction of vesicoureteral reflux, the reported incidence of postoperative febrile urinary tract infection favors the latter. We evaluated contemporary treatment cohorts for an association between correction of vesicoureteral reflux and risk of postoperative febrile urinary tract infection. We retrospectively reviewed the records of 396 consecutive patients who underwent ureteroneocystostomy or subureteral injection of dextranomer/hyaluronic acid between 1994 and 2008. Time to event multivariate analyses included preoperative grade of vesicoureteral reflux and bladder/bowel dysfunction. Of 316 patients meeting study criteria 210 underwent ureteroneocystostomy (356 ureters) and 106 underwent subureteral injection of dextranomer/hyaluronic acid (167). Median patient age was 5.7 years (IQR 3.4 to 8.3). Median followup was 28 months (IQR 8 to 61). Ureteral success was significantly greater after ureteroneocystostomy (88%, 314 of 356 cases) vs subureteral injection of dextranomer/hyaluronic acid (74%, 124 of 167, p = 0.0001). When controlling for preoperative grade of vesicoureteral reflux and bladder/bowel dysfunction, the risk of persistent reflux was 2.8 times greater after subureteral injection of dextranomer/hyaluronic acid (95% CI 1.7-4.7, p <0.0001). The incidence of febrile urinary tract infection did not significantly differ between ureteroneocystostomy (8%, 16 of 210 cases) and subureteral injection of dextranomer/hyaluronic acid (4%, 4 of 106; HR 1.96, 95% CI 0.64-5.9, p = 0.24) even when controlling for preoperative grade of vesicoureteral reflux, a predictor of postoperative febrile urinary tract infection on multivariate analysis (HR 2.2 per increase in grade, 95% CI 1.3-3.6, p = 0.0022). Persistent reflux was not a predictor of postoperative febrile urinary tract infection (HR 0.81, 95% CI 0.22-2.9, p = 0.75 for ureteroneocystostomy vs HR 1.8, 95% CI 0.2-17.3, p = 0.6 for subureteral injection of dextranomer/hyaluronic acid and HR 1.8, 95% CI 0.3-3.3, p = 0.6 for both). The incidence of postoperative febrile urinary tract infection may be independent of radiographic procedural success.

Factors that impact the outcome of endoscopic correction of vesicoureteral reflux: a multivariate analysis

To identify independent factors that may predict vesicoureteral reflux (VUR) resolution after endoscopic treatment using dextranomer/hyaluronic acid copolymer (Deflux) in children free of anatomical anomalies. A retrospective study was conducted in our pediatric referral center from 1998 to 2011 on children with primary VUR who underwent endoscopic injection of Deflux with or without concomitant autologous blood injection (called HABIT or HIT, respectively). Children with secondary VUR or incomplete records were excluded from the study. Potential factors were divided into three categories including preoperative, intraoperative and postoperative. Success was defined as no sign of VUR on postoperative voiding cystourethrogram. Univariate and multivariate logistic regression models were constructed to identify independent factors that may predict success. Odds ratio (OR) and 95 % confidence interval (95 % CI) for prediction of success were estimated for each factor. From 485 children received Deflux injection, a total of 372 with a mean age of 3.10 years (ranged from 6 months to 12 years) were included in the study and endoscopic management was successful in 322 (86.6 %) of them. Of the patients, 185 (49.7 %) underwent HIT and 187 (50.3 %) underwent HABIT technique. On univariate analysis, VUR grade from preoperative category (OR = 4.79, 95 % CI = 2.22-10.30, p = 0.000), operation technique (OR = 0.33, 95 % CI = 0.17-0.64, p = 0.001) and presence of mound on postoperative sonography (OR = 0.06, 95 % CI = 0.02-0.16, p = 0.000) were associated with success. On multivariate analysis, preoperative VUR grade (OR = 4.85, 95 % CI = 2.49-8.96, p = 0.000) and identification of mound on postoperative sonography (OR = 0.07, 95 % CI = 0.01-0.18, p = 0.000) remained as independent success predictors. Based on this study, successful VUR correction after the endoscopic injection of Deflux can be predicted with respect to preoperative VUR grade and presence of mound after operation.

Use of Validated Bladder/Bowel Dysfunction Questionnaire in the Clinical Pediatric Urology Setting

Questionnaires to quantify pediatric bladder/bowel dysfunction have recently been developed as research instruments. We evaluated our use of a bladder/bowel dysfunction questionnaire in a busy clinical setting. We distributed a validated bladder/bowel dysfunction questionnaire to all new pediatric urology outpatients older than age 4 years from May 1 to July 31, 2010. We instructed families to complete the questionnaire without assistance. Physicians were blinded to responses during the study period. We compared total scores between groups of patients with bladder/bowel dysfunction related and bladder/bowel dysfunction unrelated primary diagnoses. We also compared individual item scores pertaining to urinary incontinence, dysuria, nocturnal enuresis and constipation in patients with those specific primary ICD-9 diagnosis codes to those of other bladder/bowel dysfunction related diagnoses. Of 358 questionnaires reviewed 91 (25%) could not be adequately scored. Of the remaining 267 patients 134 had bladder/bowel dysfunction related diagnoses and 133 had bladder/bowel dysfunction unrelated diagnoses. The patients with bladder/bowel dysfunction related diagnoses had a higher score on the validated questionnaire (p <0.001). Patients with primary ICD-9 diagnoses for urinary incontinence (p = 0.0026, p = 0.0164), dysuria (p = 0.008) and nocturnal enuresis (p <0.0001) had higher scores on corresponding items of the questionnaire than those with other bladder/bowel dysfunction related diagnoses. The ICD-9 diagnosis of constipation was not associated with higher scores for constipation related items. A validated bladder/bowel dysfunction questionnaire is a useful tool in the pediatric urology clinical setting that correlates well with physician assessment. The questionnaire can help patients and their families better define their bladder/bowel symptoms before their visit. Some families will not be able to fill out the questionnaire appropriately.

Single Center Experience with Endoscopic Subureteral Dextranomer/Hyaluronic Acid Injection as First Line Treatment in 1,551 Children with Intermediate and High Grade Vesicoureteral Reflux

In recent years the endoscopic injection of dextranomer/hyaluronic acid has become an established alternative to long-term antibiotic prophylaxis and the surgical management of vesicoureteral reflux. We determined the safety and effectiveness of the endoscopic injection of dextranomer/hyaluronic acid as first line treatment for high grade vesicoureteral reflux. Between 2001 and 2010, 1,551 children (496 male, 1,055 female, median age 1.6 years) underwent endoscopic correction of intermediate and high grade vesicoureteral reflux using dextranomer/hyaluronic acid soon after the diagnosis of vesicoureteral reflux on initial voiding cystourethrogram. Vesicoureteral reflux was unilateral in 761 children and bilateral in 790. Renal scarring was detected in 369 (26.7%) of the 1,384 patients who underwent dimercapto-succinic acid imaging. Reflux grade in the 2,341 ureters was II in 98 (4.2%), III in 1,340 (57.3%), IV in 818 (34.9%) and V in 85 (3.6%). Followup ultrasound and voiding cystourethrogram were performed 3 months after the outpatient procedure, and renal ultrasound was performed annually thereafter. Patients were followed for 3 months to 10 years (median 5.6 years). Vesicoureteral reflux resolved after the first, second and third endoscopic injection of dextranomer/hyaluronic acid in 2,039 (87.1%), 264 (11.3%) and 38 (1.6%) ureters, respectively. Febrile urinary tract infections developed during followup in 69 (4.6%) patients. None of the patients in the series needed reimplantation of ureters or experienced any significant complications. Our results confirm the safety and efficacy of the endoscopic injection of dextranomer/hyaluronic acid in the eradication of high grade vesicoureteral reflux. We recommend this 15-minute outpatient procedure as the first line of treatment for high grade vesicoureteral reflux.

Ureteral Advancement in Patients Undergoing Laparoscopic Extravesical Ureteral Reimplantation for Treatment of Vesicoureteral Reflux

Laparoscopic extravesical ureteral reimplantation for vesicoureteral reflux has gained acceptance as a feasible treatment associated with minimal morbidity. However, ureteral advancement with this technique has not been attempted. We examined the usefulness of ureteral advancement via laparoscopy. A total of 30 patients with 51 refluxing ureters underwent laparoscopic extravesical ureteral reimplantation for treatment of vesicoureteral reflux between August 2009 and September 2011. Mean ± SD patient age was 60.8 ± 48.6 months. During the procedure 15 patients underwent ureteral advancement (advancement group), while 15 did not (nonadvancement group). We compared operative times and postoperative rates of urinary tract infections and persistent reflux between the groups. There was no significant difference in operative times in unilateral (mean ± SD 110 ± 25 vs 125 ± 42 minutes) and bilateral cases (mean ± SD 214 ± 52 vs 203 ± 40 minutes) between the nonadvancement vs advancement groups. All patients underwent voiding cystourethrography 3 to 4 months postoperatively. Reflux resolution rate for ureters was significantly higher in the advancement group (100%) than in the nonadvancement group (85%, p <0.05). No patient in the advancement group had postoperative urinary tract infection. Fixation of the ureter with the bladder muscularis at the proximal limit of the detrusor defect and/or a percutaneous hitch stitch placed in the ventral side of the proximal limit of the detrusor defect facilitated ureteral advancement. Ureteral advancement is a simple and feasible procedure in laparoscopic ureteral extravesical reimplantation and may improve the resolution rate of vesicoureteral reflux.

Duplicaciones del tracto urinario

ObjectivesReview the clinical and radiological characteristics of the different kinds of urinary tract duplications, assessing the outcome of the cases and the incidence of renal parenchymal injury. Material and methodsA retrospective study was performed including 301 children diagnosed of renal duplication by urological ultrasound, voiding cystourethrogram (VCUG) and 99-technetium renal scintigraphy (DMSA). ResultsThey were classified in four groups. The first consisted of 166 (55.1%) cases that had complete ureteral duplication without an obstructive component (CD). The cases that had an upper system obstruction due to an ectopic ureter (EU), 19 (6.3%), or an ureterocele (UTC), 35 (11.6%), were divided into two different groups. The fourth group 81 (26.9%) had incomplete ureteral duplication. The nephro-urological study was performed in 181/301 after a urinary tract infection; in 100/301 after a prenatal finding of hydronephrosis. It was a casual diagnosis in 20/301.The percentage upper kidney dilation in the diagnostic ultrasound was significantly higher in those with EU 16/19 (84%) and in those with UTC 33/35 (94%), compared with the upper pole dilations found in the CD 35/166 (21%) and ID 21/81 (25%).Surgery was performed in 96/166 (41%) of the CD, 7/81 of the ID, 16/19 (84%) of the EU, and 34/35 (97%) of the UTC. Three cases with EU and 8 with UTC needed a second surgery, and 3 a third one. No scintigraphy changes were observed in 58% of the patients in the CD group, 87% in the ID group, 29% in the EU group, and 5% in the UTC group.As regards the renal duplications who did not have surgery, it was found that there were 98 refluxing units in the CD, and 74 in the ID. The spontaneous resolution of the vesicoureteral reflux (VUR) was 80% in the CD, and 90% in the ID (McNemar test P<.001). The average healing time ranged from 1 year to 5 years (Mean: 3 years and 3 months). ConclusionThe patients with higher risk of having renal injury are those who presented with a duplication with upper kidney obstruction due to ectopic insertion of the ureter, particularly due to an ureterocele.

614 VUR INDEX (VURX): A NOVEL TOOL TO PREDICT VESICOURETERAL REFLUX (VUR) RESOLUTION BASED ON THE FIRST VCUG IN CHILDREN LESS THAN TWO YEARS OF AGE

You have accessJournal of UrologyPediatrics: Imaging (Genital & Urinary Tract)/Infections and Vesicoureteral Reflux1 Apr 2012614 VUR INDEX (VURX): A NOVEL TOOL TO PREDICT VESICOURETERAL REFLUX (VUR) RESOLUTION BASED ON THE FIRST VCUG IN CHILDREN LESS THAN TWO YEARS OF AGE Arun Srinivasan, Lindsay Herrel, Edwin Smith, Jane Share, David Blews, Hal Scherz, and Andrew Kirsch Arun SrinivasanArun Srinivasan Atlanta, GA More articles by this author , Lindsay HerrelLindsay Herrel Atlanta, GA More articles by this author , Edwin SmithEdwin Smith Atlanta, GA More articles by this author , Jane ShareJane Share Atlanta, GA More articles by this author , David BlewsDavid Blews Atlanta, GA More articles by this author , Hal ScherzHal Scherz Atlanta, GA More articles by this author , and Andrew KirschAndrew Kirsch Atlanta, GA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.692AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The usefulness of International Reflux Grading System is limited by evidence based on small sample sizes, poor inter-observer concordance, and poor predictive values for moderate grade VUR. We aim to provide an indexing tool to more reliably predict resolution rates by improving concordance rates among physicians and improve our ability to predict VUR resolution based on the first VCUG. METHODS We identified all patients aged < 2 years diagnosed with VUR between 2006-2010. We excluded patients with secondary VUR, ureteroceles, and megaureters. Patient age, indication for VCUG, ultrasound and renal scan findings as available, gender, anomalies, follow up data and eventual outcomes were collected. Two blinded radiologists reviewed the VCUGs and recorded the phase of VCUG when reflux (timing of reflux) was first noted. We categorized timing of reflux as early filling, end filling and voiding phase. Univariate and multivariate analysis was performed to identify factors that best predict VUR resolution. A Multilayer Perceptron neural network model was used to construct the VUR index (VURx) with normalized importance for each variable. The VURx was then validated by ROC and Kaplan-Meier curves. RESULTS 229 patients fit our patient criteria. 75% of the VCUGs were performed for UTI at a mean age of 0.42 years. By multivariate logistic regression analysis, absence of high grade reflux (OR 5.53), absence of anomalies (OR3.54) and timing of reflux (OR5.37) were found to be predictors of spontaneous resolution. The neural network model found the same variables to be predictive of reflux resolution with high normalized importance. A VURx was constructed using these three variables with a minimum value of 1 signifying a high resolution rate (92.3%) and maximum value of 5 signifying low rate of resolution (8.3%). This model was tested using resolution graphs (p<0.05), ROC curves (AUC 0.82) and Kaplan-Meier curves (p<0.05) all signifying high correlation. CONCLUSIONS VUR index – a score based on presence of high grade reflux, anomalies and timing of VUR is highly predictive of spontaneous resolution in children aged < 2 years. Patients with a low VURx may not require further studies by virtue of their high resolution rate while those with high VURx may be better served by earlier intervention. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e250 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Arun Srinivasan Atlanta, GA More articles by this author Lindsay Herrel Atlanta, GA More articles by this author Edwin Smith Atlanta, GA More articles by this author Jane Share Atlanta, GA More articles by this author David Blews Atlanta, GA More articles by this author Hal Scherz Atlanta, GA More articles by this author Andrew Kirsch Atlanta, GA More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Abnormal Dimercaptosuccinic Acid Scan May Be Related to Persistence of Vesicoureteral Reflux in Children with Febrile Urinary Tract Infection

PurposeThis study assessed whether 99mtechnetium dimercaptosuccinic acid (DMSA) scintigraphy used for the assessment of renal sequelae after febrile urinary tract infection (UTI) has any prognostic value for outcome measurement of vesicoureteral reflux (VUR) by retrospectively evaluating the correlation between abnormal DMSA scintigraphy results and persistence of VUR in children with febrile UTI.Materials and MethodsThe medical records of 142 children (57 boys, 85 girls) admitted with febrile UTI from January 2004 to December 2006 and who were followed up for more than 1 year were retrospectively reviewed. At the initial and follow-up visits, renal ultrasound and DMSA scans were performed within 7 days from the diagnosis and voiding cystourethrography (VCUG) was performed within 1 month in all case and follow-up evaluations.ResultsThe children's mean age was 4.8±3.6 years (range, 0.3 to 14 years). The mean follow-up was 28.2±4.8 months. At the initial examination, VUR was more often associated with an abnormal DMSA scan result (83.3%) than with a normal DMSA scan result (16.7%, p=0.02). The frequency of VUR with an abnormal DMSA scan during acute UTI was significantly higher than the frequency of VUR with a normal DMSA scan (38.8% vs, 25.8%, respectively, p=0.004). Also, high-grade VUR was associated with an abnormal DMSA scan result (32.5%) more often than with a normal DMSA scan result (0%, p=0.01). Children with an abnormal DMSA scan had a lower resolution rate of VUR (17.5%) than did children with a normal DMSA scan (75.0%) at the follow-up VCUG (p=0.02).ConclusionsAn abnormal result on a DMSA scan during febrile UTI is associated with high-grade and persistent VUR. DMSA scans performed during febrile UTI are useful in reflux resolution in childhood.

Can We Rely on the Presence of Dextranomer-Hyaluronic Acid Copolymer Mounds on Ultrasound to Predict Vesicoureteral Reflux Resolution After Injection Therapy?

Can We Rely on the Presence of Dextranomer-Hyaluronic Acid Copolymer Mounds on Ultrasound to Predict Vesicoureteral Reflux Resolution After Injection Therapy?

Clinical Evolution of Vesicoureteral Reflux Following Endoscopic Puncture in Children With Duplex System Ureteroceles

We studied the clinical evolution of vesicoureteral reflux after endoscopic puncture of ureterocele in pediatric duplex systems. We retrospectively reviewed charts of children with duplex system ureteroceles treated between 1992 and 2007. We analyzed patient age, prenatal diagnosis, urinary tract infection at presentation, differential renal function and preoperative vesicoureteral reflux. The fate of associated vesicoureteral reflux after endoscopic puncture of ureterocele was specifically addressed. We analyzed 60 patients with a mean age of 12 months, of whom 32 (52%) were diagnosed prenatally and 40 (66%) presented with a urinary tract infection. The majority of ureteroceles were ectopic, and pre-puncture vesicoureteral reflux was seen in 40 patients (67%). Postoperative voiding cystourethrogram was performed in 50 cases. New onset of vesicoureteral reflux occurred postoperatively in 24 patients (40%), mainly ipsilateral to the lower pole or contralaterally. Spontaneous vesicoureteral reflux resolution or improvement occurred in 16 of 22 patients (72%) observed after primary endoscopic puncture of ureterocele. Surgical intervention after endoscopic puncture of ureterocele was performed in 25 patients (42%), of whom 9 underwent more than 1 reparative procedure. Vesicoureteral reflux after endoscopic puncture of ureterocele may occur in the ipsilateral upper or lower poles, or in the contralateral renal segments. Therefore, the reflux is not necessarily related to the puncture itself. Vesicoureteral reflux after endoscopic puncture of ureterocele can resolve spontaneously in a significant number of patients. Therefore, initial management by close surveillance is warranted. Considering the simplicity of the procedure, our findings support that endoscopic puncture of ureterocele is an attractive alternative for the initial management of pediatric duplex system ureteroceles.

A simple and safe technique for trocar positioning in vesicoscopic ureteric reimplantation

Anchoring of the urinary bladder to the anterior abdominal wall is essential to prevent perivesical gas leak and dislodgement of trocar. Existing techniques have the risk of going through the peritoneal cavity and injuring the bowel. Our aim was to find a safe technique to anchor the bladder wall to the abdominal wall. Nineteen cases were studied prospectively. A curved urethral dilator was introduced and made to point on the anterior abdominal wall. Abdominal wall was incised over the tip of the dilator till the bladder was seen which was then sutured to the anterior abdominal wall. The bladder was then incised and the trocars were railroaded on the dilator into the bladder. Cohen's reimplantation was then done. Out of the 19 cases, conversion to open was done in two early cases. In one case, the trocar got pulled out, but was easily reintroduced. Mean operating time was 210 min. Mean follow up was 20.9 months. There was a resolution of reflux in 13, reduction in the grade of reflux in 1 and no failures. In five cases, post op MCU is awaited. This technique of fixing the bladder to the anterior abdominal wall is safe and easy to perform. It is recommended while doing vesicoscopic reimplantation.

Robotic-assisted laparoscopic extravesical ureteral reimplantation: An initial experience

ObjectiveThere are many emerging techniques using robotic-assisted laparoscopy (RAL) in pediatrics. We performed a retrospective review of our first patients who underwent RAL extravesical ureteral reimplantation. Materials/MethodsBetween October 2007 and May 2010, a single surgeon performed RAL extravesical ureteral reimplantation in 17 patients. Six patients underwent bilateral reimplantation, resulting in a total of 23 ureters repaired. There were 16 females and 1 male (mean age 6.23 years). Four patients had prior Deflux injection. Postoperative reflux status was assessed by voiding cystourethrogram. Results16 patients (22 ureters) were compliant with follow up. Mean follow up was 11.5 months. Mean anesthetic time was 3 h, 57 min for unilateral and 4 h, 45 min for bilateral repair. Complete vesicoureteral reflux resolution was seen in 20 ureters (90.9%), downgrading in one ureter, and unchanged persistent reflux in one ureter. Average hospital stay was 1.3 days. No patients required postoperative catheterization at discharge. ConclusionsOutcomes for new procedures can be variable and unpredictable as the technique evolves. Given the high success rates of open reimplantation, a minimally invasive technique must show comparable results if it is to play a continuing role. Our initial results are encouraging, but prospective analyses are required to outline the future role of RAL ureteral reimplantation.

Can thoracoscopic Heller’s myotomy give equivalent results to the more usual laparoscopic Heller’s myotomy in the treatment of achalasia?: Table 1

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was 'Can thoracoscopic Heller's myotomy (THM) give equivalent results to the more usual laparoscopic Heller's myotomy (LHM) in the treatment of achalasia?' Altogether, more than 478 papers were found using the reported search, of which eight represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. THM and LHM are two recognised approaches to the performance of a distal oesophageal myotomy in the treatment of achalasia. Of the two meta-analyses on this subject, Campos et al. [Campos GM, Vittinghoff E, Rabl C, Takata M, Gadenstätter M, Lin F, Ciovica R. Endoscopic and surgical treatments for achalasia: a systematic review and meta-analysis. Ann Surg 2009;249:45-57] illustrated improved symptom control in LHM compared with THM. Wang et al. [Wang L, Li Y, Li L, Yu C. A systematic review and meta-analysis of the Chinese literature for the treatment of achalasia. World J Gastroenterol 2008;14:5900-5906], however, observed no difference in remission rates following either approach. Close scrutiny of comparison studies revealed superiority in long-term outcomes and symptoms following LHM in three studies. There were, however, studies that illustrated comparable outcome results for THM in both resolution of dysphagia and reflux. Morbidity rates following THM were noted to be similar to or slightly higher than those following LHM in five studies, but no statistically significant difference was illustrated in these studies. Operating time and length of stay were noted to be significantly shorter in LHM when compared with THM in three studies, although there were exceptions to this, with two studies illustrating shorter or equal operating times for THM. However, LHM operating times have been shown to improve with experience gained. We conclude that there is good evidence demonstrating the effectiveness and safety of LHM, and it has come to be regarded as the gold standard treatment of achalasia. When THM is compared with LHM, the long-term results approach parity on occasion but not consistently. The overall postoperative morbidity of THM is not significantly different from that of LHM. An advantage of LHM over THM that is demonstrated is that LHM offers a shorter hospital stay and reduced operative time.

Nicht neurogene Blasenfunktionsstörungen und vesikoureteraler Reflux bei Kindern

Various types of bladder dysfunction are associated with urinary tract infection, renal damage and vesicoureteral reflux (VUR). In this article the influence of functional bladder disturbances such as detrusor instability (overactive bladder, OAB) and bladder sphincter dyssynergia (dysfunctional voiding), on the resolution of vesicoureteral reflux are reviewed. In summary, it is important to distinguish between children with dysfunctional voiding (increased activity of the pelvic floor during voiding) and those with OAB (detrusor overactivity during filling) because the latter has less effects on VUR.

Can we Rely on the Presence of Dextranomer-Hyaluronic Acid Copolymer Mounds on Ultrasound to Predict Vesicoureteral Reflux Resolution After Injection Therapy?

We determined whether the presence or absence of dextranomer-hyaluronic acid copolymer mounds on bladder ultrasound coincides with voiding cystourethrogram results after injection therapy in children with primary vesicoureteral reflux. We retrospectively reviewed consecutive cases of dextranomer-hyaluronic acid copolymer injection for primary vesicoureteral reflux. The primary outcome investigated was the appearance of dextranomer-hyaluronic acid copolymer mounds on ultrasound and their association with voiding cystourethrogram results postoperatively. An intramural dextranomer-hyaluronic acid copolymer mound on ultrasound was considered a negative test result for vesicoureteral reflux. A total of 187 cases were identified, of which 132 had imaging available for evaluation. Intramural mounds were seen on ultrasound in 86 cases postoperatively, of which 34 (40%) had a positive voiding cystourethrogram. Of 46 cases in which no mound was identified 21 (46%) had a positive voiding cystourethrogram. The sensitivity of ultrasound to determine the presence or absence of vesicoureteral reflux was 38%, specificity was 67%, accuracy was 55%, the positive predictive value was 46% and the negative predictive value was 60%. Our results indicate poor correlation of dextranomer-hyaluronic acid copolymer mound appearance on ultrasound with voiding cystourethrogram results after injection. To adequately evaluate for the resolution of vesicoureteral reflux a voiding cystogram or nuclear medicine cystogram needs to be performed after injection therapy.