Subureteral Injection Research Articles

Single Injection Results of Endoscopic Treatment of Vesicoureteric Reflux with Different Tissue-Bulking Substances in Patients with End Stage Renal Failure

To evaluate the outcome of subureteral injections by using calcium hydroxyapatite (CaHa), dextranomer/hyaluronic acid copolymer (Dx/HA), and polydimethylsiloxane (PDS) in patients with end-stage renal failure (ESRF) who have vesicoureteral reflux (VUR). One hundred-one patients (166 renal units) with ESRF secondary to VUR were included in this retrospective study. The reflux was bilateral in 65 of the cases. CaHa, Dx/HA and PDS were used in 57, 26, and 18 patients, respectively. All patients were reviewed with regard to age, sex, reflux grade, type of injected materials, injectable agent volume, and outcome. The reflux resolved completely in 30 patients (50/96 renal units, 52.1%), in 17 patients (27/44 renal units, 61.4%), and in 4 patients (5/26 renal units, 19.2%) with CaHa, Dx/HA, and PDS, respectively. Regression rates of reflux to grade I with these agents in the same order were 3.1% (2 patients, 3/96 renal units), 4.5% (1 patient, 2/44 renal units), and 11.5% (2 patients, 3/26 renal units). Thus, the overall success rate were noted as 55.2%, 65.9%, and 30.7%, respectively. There was no difference among these three injectables with regard to overall success rates (P = 0.062). No significant correlation with age, reflux grade, agent volume, and significant difference with sex were observed (P > 0.05). In this group of patients, the success rate of the subureteral injection treatment does not appear to be affected by the type of the injectable agent. In addition, the cure rates were independent from the individual factors, reflux grades, and injected volumes.

Transurethral injection therapy with carbon-coated beads (Durasphere®) for treatment of recurrent pyelonephritis in kidney transplant patients with vesico-ureteral reflux to the allograft

Recurrent transplant pyelonephritis (RTP) secondary to vesico-ureteral reflux (VUR) to the transplant kidney (KTx) remains a significant cause of infectious complications with impact on patient and graft outcomes. Our objective was to verify the safety and efficacy of transurethral injection of Durasphere(®) to relieve RTP secondary to VUR after renal transplantation. Between June 2004 and July 2008, eight patients with RTP (defined as two or more episodes of pyelonephritis after transplantation) and VUR to the KTx were treated with subureteral injections of Durasphere(®). The mean age at surgery was 38.8 ± 13.8 yr (23-65). The patients were followed regularly every six months. The mean interval between the KTx and the treatment was 76 ± 74.1 (10-238 months). The mean follow-up was 22.3 ± 16.1 months (8-57 months). Six patients (75%) were free of pyelonephritis during a mean period of follow-up of 23.2 ± 17.1 months (8-57 months). Two of them had no VUR and four cases presented with G II VUR (pre-operative G IV three cases and one case G III). In one case, symptomatic recurrent cystitis made a second treatment necessary. This patient remained free of infections for three yr after the first treatment and for 18 months after the second treatment. Of the remaining two patients, one had six episodes of RTP before treatment in a period of three yr and only two episodes after treatment in two yr of follow-up. The last case had a new episode of pyelonephritis five months after treatment. Transurethral injection therapy with Durasphere(®) is a safe and effective minimally invasive treatment option for KTx patients with recurrent RTP. A second treatment seems to be necessary in some cases.

PEDIATRIC UROLOGY Long-term results after endoscopic VUR-treatment using dextranomer / hyaluronic acid copolymer – 5-year experience in a single-center

BackgroundA number of bulking agents have been used for the endoscopic correction of vesicoureteral reflux in children. We present our long-term results of endoscopic use of dextranomer/hyaluronic acid copolymer (Deflux®) for VUR treatment in children.Patients and methodsBetween 2004 and 2008, 21 children underwent endoscopic subureteral injection of Deflux® in 30 ureters as an outpatient procedure. Twelve children had unilateral reflux (2 duplicated systems) and nine had bilateral reflux. Median age was 5-years (6-months to 14.9-years). Six weeks postoperatively, a voiding cystourethrogram was performed. This study examined the disappearance of VUR and urinary tract infection (UTI) in the long-term follow-up as well as QoL (questionnaire of the parents).ResultsNo intra- or postoperative complications had been noticed. In 25 ureters (83%), VCUG showed no VUR 6-weeks postoperatively. Three children received a 2nd injection (two successful). After a median follow-up of 2.5 years, 27 ureters in 17 children (90%) had no urinary tract infection and VUR. The questionnaire results in regard to quality of life (QoL) were very good in the successfully treated children and the parents would choose the same treatment option again.ConclusionSubureteral injection of Deflux® for children with VUR is an effective treatment option with a low complication rate.

Dextranomer/Hyaluronic Acid Copolymer (Dx/HA) Has no Effect on Bacterial Growth in Culture Media With or Without Antibiotic Discs

Introduction: Endoscopic treatment of vesicoureteral refl ux (VUR) by subureteral injection of biocompatible polymers is an established treatment option for refl ux. Dextranomer/hyaluronic acid copolymer(Dx/HA) has gained wide popularity for treating VUR. We decided to investigate the antibacterial activity of Dx/HA and its interaction with antibiotics in in-vitro conditions. Materials and Methods: Escherichia coli, Pseudomonas aeruginosa, Klebsiella pneumoniae and Proteus mirabilis suspensions were inoculated into Mueller-Hinton agar media and 30 μl of Dx/HA was inoculated in 5 mm diameter pits and the plates were incubated at 37°C for 24 hours. At the end of the incubation period, inhibition zones around the discs were measured. Expansion of the inhibition zones towards the pits which contained Dx/HA was considered as synergism. Dx/ HA was inoculated into pits made in Mueller-Hinton agar medium without antibiotic discs but containing suspensions of bacteria. These media were incubated under the same circumstances and same measurements were done. All experimental procedures were performed twice. Increase in bacterial zone diameters for ≥ 5 mm was inoculated was regarded as signifi cant for each agent. Results: Dx/HA caused no difference in bacterial growth either with or without antibiotic discs as determined by inhibition zones in the culture media. Conclusion : Dx/ha will not contribute to UTI if it is used for the treatment of VUR in cases either with or without infection.

Genitourinary involvement in epidermolysis bullosa: clinical presentations and therapeutic challenges

To present our experience of children with epidermolysis bullosa (EB; a rare bullous disorder of the skin) with genitourinary involvement. The medical records of eight children diagnosed with EB (six junctional and two dystrophic type) with genitourinary involvement were reviewed retrospectively. The data collected included age, clinical presentation, ultrasonographic findings, voiding cystourethrography, urodynamic and uroflowmetry studies, and the treatment challenges. The outcomes of the interventions were evaluated every 6 months. The mean age was 2.3 years (range 1 day to 7 years). The most common clinical presentations were urinary retention and voiding difficulty. Meatomy was performed in two of three boys followed by diminution of urological complaints. In children with vesico-ureteric reflux, subureteric injections of bulking agent and ureteric stenting were satisfactory. Detrusor instability and bladder compliance improved after α-blocker therapy. The mean (range) follow-up was 62.6 (11-120) months except for two who died in early infancy. Considering the potential urological involvement in every child with EB it is essential to provide patients with early appropriate treatment. Management of urological problems should preferably be in a way to entail minimal interventions and if required be performed using small sized instruments. Medical therapy seems promising for voiding dysfunction in this subset of patients.

Distal Ureteral Calcification Secondary to Deflux Injection: A Reality or Myth?

Dextranomer/hyaluronic acid (Dx/HA) copolymer (Deflux) subureteral injection has become a widely accepted form of treatment for vesicoureteral reflux. Long-term histologic studies, both experimental and clinical, have supported and proven the occurrence of calcification at the site of previous injection. These calcifications in clinical settings may be perceived as ureteral stones. We report a case of an adolescent female with unresolved right-sided abdominal pain with a past surgical history of Deflux injection, who presented with a distal ureteral calcification. Upon further investigation the calcification was found to be confined to the submural portion rather than the intraluminal ureter.

Endoscopic Vesicoureteral Reflux Correction in Transplanted Kidneys: Does Injection Technique Matter?

Posttransplant vesicoureteral reflux (VUR) is a common urologic complication after renal transplantation, although its management is controversial. The treatment of choice is open surgical revision ureteral reimplantation with significant morbidity. Recently, endoscopic correction by using nonanimal dextranomer/hyaluronic acid copolymer (NA Dx/HA) injection has been reported to be effective in the treatment of VUR of transplanted kidneys. Herein, we present our 3-year endoscopic correction results in transplanted kidneys where we used two different injection techniques, subureteral and intraureteral. We retrospectively reviewed all patients who underwent endoscopic VUR correction of posttransplant VUR by NA Dx/HA injection between July 2005 and March 2009. We excluded patients with underlying urologic abnormalities. A total of 26 patients (14 women and 12 men) with a mean age of 32.2 years (range: 15–55) were studied. The VUR was also graded as nondilating reflux in 10 (grade I–II) and dilating reflux in 16 (grade III–IV). Seventeen ureters (5 nondilating and 12 dilating VUR) were injected NA Dx/HA intraureterally, and 9 ureters (5 nondilating and 4 dilating VUR) were injected NA Dx/HA subureterally. Overall success rate was 53.8% (14 out of 26). Intraureteral injection technique was successful in nine cases (52.9%), and subureteral injection technique was successful in five cases (55.5%). In nondilating VUR, injection corrected 90% (9 out of 10) of posttransplant patients, whereas in dilating VUR group injection corrected only 31.25% (5 out of 16). We found no statistical significance of injection technique on the success rate. Endoscopic correction by using NA Dx/HA with any injection technique seems to be a plausible alternative to correction of refluxing posttransplant ureters, particularly in nondilating VUR.

Endoscopic treatment of primary grade V vesicoureteral reflux using hyaluronic acid copolymer (DX/HA)

Since DX/HA was approved by the Food and Drug Administration in 2001 as an acceptable tissue-augmenting substance for subureteral injection, endoscopic treatment has become increasingly popular for treating vesicoureteral reflux (VUR). However, most paediatric urologists still continue to recommend ureteral reimplantation as the treatment of choice in the management of grade V VUR. The purpose of this study was to prospectively evaluate the effectiveness of endoscopic subureteral injection of DX/HA in the treatment of grade V reflux. During 2001-2009, 56 children (35 males, 21 females) with primary grade V VUR underwent endoscopic treatment using DX/HA. Their ages ranged from 4 months to 11 years. Forty-nine patients had unilateral grade V VUR, and seven had bilateral grade V (63 refluxing ureters including 17 duplex systems). Renal scarring on dimercaptosuccinic acid was observed in 39 kidneys (mild scarring 13, moderate scarring 14 and severe scarring 12). In all patients, endoscopic injection was made after inserting the needle within the wide ureteral orifice. Renal ultrasound and voiding cystourethrogram was performed 3 months after the endoscopic treatment. If VUR had not resolved, the patient was considered for further endoscopic treatment. After the VUR was resolved, children were followed with renal ultrasound at 1 year and every 2 years thereafter. The VUR completely resolved after first injection of DX/HA in 33 (52.4%) ureters and downgraded to grade I VUR in 7 (11.1%) ureters. 19 (30.2%) ureters required a second injection, and 4 (6.3%) ureters required a third injection to resolve VUR. No children in this series needed reimplantation of ureters or presented with ureteral obstruction during follow-up. Endoscopic treatment with DX/HA is effective in eradicating grade V primary reflux. This simple and minimally invasive treatment should be offered to all parents of children with grade V VUR as an alternative to ureteral reimplantation.

Efficacy of endoscopic subureteral injection for vesicoureteral reflux in adults with decreased bladder compliance

To evaluate the outcome of endoscopic subureteral injection (ESI) in adults with vesicoureteral reflux (VUR) associated with decreased bladder compliance (D-BC). We retrospectively reviewed the medical records of 46 consecutive patients who underwent ESI for VUR at a single tertiary academic center. Fourteen patients (17 ureter units) who had underlying neurological disease with decreased bladder compliance, as determined by filling cystometry, were grouped as D-BC. Thirty-two patients (47 units) who had no signs or symptoms that suggested neurogenic lower urinary tract dysfunctions were grouped as normal bladder compliance (N-BC). We compared the cure rates for ESI between groups, defining cure as complete resolution of reflux on voiding cystourethrogram. In 70.6% of the D-BC group and 70.2% of the N-BC group, VUR resolved completely after the first injection (P = 0.977). One failed unit of D-BC was cured after second ESI, and seven failed units of N-BC were cured after additional treatments (second ESI, two patients; ureteroneocystostomy, five patients). No additional treatments were applied to three units of D-BC or seven units of N-BC without symptoms. No complications related to the ESI were observed. The ESI was found to be effective in adults with VUR regardless of the bladder compliance. As a minimally invasive procedure with a favorable outcome, ESI may represent the first choice for treatment of VUR even in adults with D-BC.

Editorial Comment to Efficacy of endoscopic subureteral injection for vesicoureteral reflux in adults with decreased bladder compliance

Editorial Comment to Efficacy of endoscopic subureteral injection for vesicoureteral reflux in adults with decreased bladder compliance

Severe complications after endoscopic injection of polydimethylsiloxane for the treatment of vesicoureteral reflux in early childhood

Endoscopic subureteral injection of bulking agents has become a widespread treatment for vesicoureteral reflux (VUR) in children. Various biological and plastic materials have been introduced for this purpose with different success and complication rates. Evaluations of this method in previous studies have focused on the success rate of eliminating VUR, whereas complications have been less frequently reported in detail. This report describes four children with VUR grade I to IV-V who experienced severe complications after endoscopic treatment with polydimethylsiloxane at the age of 5 months to 7 years. Three children developed urosepsis and two patients obstructive acute renal failure. These complications required repeated hospitalizations with extensive diagnostic and therapeutic procedures. Percutaneous nephrostomy was necessary in three patients and ureteroneocystostomy was eventually performed in all. These observations suggest that endoscopic treatment of VUR in childhood with polydimethylsiloxane can lead to severe postoperative complications and that a standardized follow-up should be an integral part of endoscopic procedures.

250 Consecutive Unilateral Extravesical Ureteral Reimplantations in an Outpatient Setting

Unilateral extravesical ureteral reimplantation is comparable to intravesical procedures and more effective than subureteral injection to resolve vesicoureteral reflux. Initial reports showed that the procedure could be feasibly done on an outpatient basis. We present further data on a large series of consecutive, planned, outpatient unilateral extravesical ureteral reimplantations. A total of 250 consecutive patients underwent scheduled outpatient unilateral extravesical ureteral reimplantation. We retrospectively reviewed their records. Patient data were collected on reflux laterality and grade, operative time, hospital stay, complications, need for rehospitalization and resolution rate on radiography 1 month postoperatively. A total of 209 females (84%) and 41 males (16%) underwent planned outpatient extravesical ureteral reimplantation, including on the left side in 158 (63%) and on the right side in 92 (37%). Mean reflux grade was 3.2 with grades II to V in 64 (26%), 96 (38%), 74 (30%) and 16 cases (7%), respectively. Average operative time was 63 minutes and average length of stay, defined as time from initial admission in to discharge home, was 6.2 hours (range 3 to 10 hours). Short-term and late complications occurred in 9 (3.6%) and 8 patients (3.2%), respectively. Extravesical ureteral reimplantation for unilateral vesicoureteral reflux may be consistently done on an outpatient basis with a reasonable complication rate and a low postoperative hospital admission rate.

Development of Macroplastique® Bolus Calcification Detected During Long Term Follow-Up After Injection for Vesico-Ureteral Reflux

Purpose Macroplastique® gained acceptance in many parts of the world as an injectable bulking agent for correction of vesico-ureteral reflux. As with other substances, the long-term consequences of such intervention remain largely unknown. Herein we present one important complication detected during follow-up in a single institution series. Material and Methods A total of 232 children underwent subureteric injection between 1998 and 2004, being regularly monitored since. Of these, all patients that have presented with submucosal stones in the prior area of injection have been prospectively captured. Clinical features and data on patient characteristics were obtained by chart review. Results Three patients ages 10, 13 and 15 developed submucosal bladder calcifications 5, 7 and 9 years following the initial injection for vesicoureteral reflux. In all the intervention was uneventful and no clinical or sonographic abnormalities were detected after the procedure. Patients subsequently presented with worsening hydronephrosis, hematuria and irritative lower urinary tract symptoms. On ultrasound and pelvis X-ray we encountered calcifications at the site of prior injection. At time of surgery the calcified material was extracted after unroofing the overlying eroded mucosa. To date no recurrences have been detected and none of the patients have undergone ureteral reimplantation. Conclusions This experience calls attention to a potentially important complication that can be encountered following endoscopic injection with Macroplastique®. Monitoring of these patients appears warranted as long-term issues with new injectable materials remains largely unknown.

Endoscopic Management of Obstructive Refluxing Megaureter: a Novel Approach

Purpose Endoscopic management of primary obstructive refluxing megaureter (PORM) is not addressed in literature. The previous report on ednoureterotomy for PORM was promising. In this study we present our experience with combined endoureterotomy and endoscopic Deflux injection for the treatment of PORM. Material and Methods Between November 2000 and November 2008, from 856 children with VUR were referred for surgical intervention, 18 children (12 female, 6 male) with mean age of 14 months had PORM. Reflux was unilateral in 15 and bilateral in 9 children. All patients underwent ureteroscopic endoureterotomy at 6-o'clock position with insertion of a 3Fr Double-J ureteral stent to the obstructed segment of ureter and subureteric injection of Defluxa at 5-o'clock and 7-o'clock position. The Double-J stent was left in place and removed after 1 week. VCUG was performed at 6 months, and ultrasound was performed at 1 week and 3 months postoperatively. Endoscopic management of primary obstructive refluxing megaureter (PORM) is not addressed in literature. The previous report on ednoureterotomy for PORM was promising. In this study we present our experience with combined endoureterotomy and endoscopic Deflux injection for the treatment of PORM. Results The procedure was uneventful in all patients. Follow up VCUG showed no evidence of reflux in 13 children (72.2%), significant decrease in reflux grade in 2 (11.1%) and no change in 3 (16.7%). Ultrasound revealed no obstruction. The upper tract dilation disappeared in 6 month (7 children) or 12 month (8 children) after surgery. Tailoring and reimplantation was performed in one chil. Conclusions The results of this study demonstrate that combined endoureterotomy and subureteric injection of bulking agents is safe and effective in the treatment of PORM. Less surgical complications and lower rates of hospitalization in comparison with open surgery is remarkable in this procedure.

Predictors of Surgical Outcome in Children With Vesicoureteral Reflux Associated With Paraureteral Diverticula

To retrospectively evaluate success rates of different surgical approaches in the treatment of paraureteral (Hutch) diverticula (PUD) associated with vesicoureteral reflux (VUR) and also to define preoperative objective criteria to predict the surgical outcome. Records of 51 patients who underwent surgical treatment for PUD were reviewed. Intravesical ureteroneocystostomy (UNC), subureteral injection, and extravesical UNC were performed in 23, 28, and 10 renal units, respectively. Records of patients were evaluated with particular emphasis on predictors of treatment outcome. Mean follow-up was 22.1 months (range, 3-46). Statistical significance was set at P <.05. Overall success rates were 91%, 79%, and 80% for intravesical UNC, subureteral injection, and extravesical UNC, respectively (P >.05). The mean PUD index for patients who underwent endoscopic treatment was significantly lower (P <.05). In the endoscopic group, reflux was detected at the late-filling or voiding phase of voiding cystourethrography (P <.005). In patients, who were diagnosed with video urodynamics, reflux began at higher bladder pressures and volumes in the injection group (P <.005). UNC was more frequently used in patients with the orifice at the neck or dome (P <.005). For injection in the lower PUD index, onset of reflux at late-filling or voiding phase on voiding cystourethrography, higher pressure and volume on video urodynamics, and C position orifice are positive predictive parameters for success. Bilateral reflux with high PUD index and grade 5 VUR are associated with failure of intravesical reimplantation. Presence of grade 5 VUR and an early onset of reflux outstand as negative predictive factors for unilateral extravesical UNC.

Injection volumes of dextranomer/hyaluronic acid are increasing in the endoscopic management of vesicoureteral reflux

Dextranomer/hyaluronic acid (Deflux) has been increasingly used for the treatment of vesicoureteral reflux (VUR). Experience has shown that injecting more volume of material is necessary to achieve greater success. We evaluate trends in the number of vials being used to treat VUR using a multi-institutional database and data from patients treated at our own institution. Children of age 0-19 years in the Pediatric Health Information System (PHIS) database from 2003 to 2008 were extracted with a VUR diagnosis (ICD-9 593.7x) and subureteric injection procedure code (CPT 52327). We identified children with reflux treated with endoscopic injection at Seattle Children's Hospital from 2005 to 2008. Hospital trends of the number of vials used were evaluated using multivariate linear regression. From 2003 to 2008, we identified 4,078 endoscopic injection procedures in PHIS. There was a 33% increase in the average number of vials used per patient (p < 0.0001) with more than a threefold increase in the number of patients receiving three or more vials per procedure. All institutions increased the average vials used per patient with the most pronounced increase at the highest-volume centers. These trends were also present in the 186 children treated at our own institution. Over the study period there was an increase in the number of vials of dextranomer/hyaluronic acid being used per patient to treat children with VUR. This practice may improve success rates but will increase the cost of treatment due to the inherent expense of the material.

Endoscopic Subureteral Injection for the Treatment of Vesicoureteral Reflux in Children: Polydimethylsiloxane (Macroplastique®) versus Dextranomer/Hyaluronic Acid Copolymer (Deflux®)

PurposeThe aim of this study was to compare cure rates and complications of polydimethylsiloxane (Macroplastique®) and dextranomer/hyaluronic acid copolymer (Deflux®) in the treatment of vesicoureteral reflux (VUR).Materials and MethodsFrom April 2001 to March 2008, 29 boys and 42 girls (total of 115 ureters) with a mean age of 6 years who had undergone endoscopic subureteral transurethral injection for VUR were enrolled. A single subureteral injection of Macroplastique was performed in 31 ureters in 23 children (group I; grade II: 4; grade III: 12; grade IV: 9; grade V: 6), and a single subureteral injection of Deflux was performed in 84 ureters in 48 children (group II; grade II: 24; grade III: 14; grade IV: 25; grade V: 21). Renal ultrasound was done 1 day after injection, and voiding cystourethrography (VCUG) was done at 3 months. Successful reflux correction was defined as absent or grade I reflux on follow-up VCUG.ResultsNo significant difference in success rates was observed between group I and group II [80.6% (25/31) vs. 78.6% (66/84), respectively, p>0.05]. The following postoperative complications developed: ureteral obstruction in 2 ureters of group I and 3 ureters of group II, asymptomatic urinary tract infection in 3 patients of group I and 2 patients of group II, and bladder calcification by erosion or mucosal necrosis in 2 patients of group I.ConclusionsDespite differences in material properties, both Macroplastique and Deflux were safe for the treatment of children with VUR. Because of the risk of bladder mucosal necrosis and substantial decreases in volume after implantation, long-term follow-up is required.

New Tissue Bulking Agent (Polyacrylate Polyalcohol) for Treating Vesicoureteral Reflux: Preliminary Results in Children

We report the preliminary results of endoscopic treatment of vesicoureteral reflux in children using polyacrylate polyalcohol copolymer. We performed a prospective multicenter review of pediatric patients treated with subureteral injection of a new nonabsorbable substance. Only patients with 1 year of followup were included. A total of 83 patients underwent injection of polyacrylate polyalcohol copolymer at our institutions between 2005 and 2006. Among this group 18 males and 43 females with a median age of 58 months (range 9 months to 18 years) completed 1 year of followup. Reflux was bilateral in 27 patients (44.3%) and unilateral in 34 (55.7%). Number of injected ureters was 88. Reflux grade was V in 3 ureters (3.4%), IV in 12 (13.6%), III in 41 (46.6%) and II in 32 (36.4%). Mean +/- SD injected volume per unit was 0.76 +/- 0.43 ml. Median followup was 20 months (range 16 to 24). Complications after injection included dysuria in 6 patients (9.8%), fever in 3 (4.9%) and lumbar pain in 4 (6.6%). Reflux was eliminated in 78 renal units (88.6%), decreased to grade I in 6 (6.8%) and persisted in 4 (4.5%). Ureteral obstruction developed in 1 patient and was treated operatively. Overall success rate was 83.6%. Polyacrylate polyalcohol copolymer can be used to treat vesicoureteral reflux with comparable efficacy to other substances currently used, with a low rate of complications.

Lich-Gregoir Ureteral Reimplantation with Fixation of Ureter during Detrusorraphy as a Reliable Outpatient Anti-reflux Procedure

We report our experience with a Lich-Gregoir reimplantation (LGR) technique that included fixation of the ureter during detrusorraphy to preserve the integrity of the newly created submucosal tunnel, performed as an outpatient anti-reflux procedure. Ninety-seven children (mean age: 7.9 years) with primary VUR underwent LGR between 1995 and 2008. Twenty-one had bilateral VUR, 8 had ureteral duplication, 9 had megaureter, and 13 had previous subureteric injections. Through a Pfannenstiel incision the ipsilateral ureter was mobilized up to the ureterovesical junction without disturbing ureterotrigonal integrity. A 3-5 cm detrusorotomy was extended from the ureterovesical junction towards the umbilicus, the ureter was placed on the mucosa, and detrusorraphy was performed with a loosely running 3/4-0 polyglactin suture that passed through the detrusor on one side of the incision, taking a 1-2 mm "bite" of the ureteral adventitia, and detrusor on the other side. Postoperative ultrasonograms and voiding cystograms (VCUG) were obtained at 1 and 3 months, respectively. Children were then followed up for clinical symptoms of urinary tract infection with annual ultrasonograms. The mean operative time was 56 min. Eighty-one percent of the children were treated as outpatients. Transient voiding difficulties occurred in 2 children with a bilateral procedure. Reflux was cured in 116 ureters (98%) with a mean follow-up of 58 months (range: 6-128). Ipsilateral obstruction was not evident during ultrasound surveillance. LGR is an outpatient procedure with a high success rate and a low morbidity. Integrity of the newly created submucosal tunnel is important for long-term success, which may be facilitated by our modified detrusorraphy technique.

Is there a learning curve for subureteric injection of dextranomer/hyaluronic acid in the treatment of vesicoureteral reflux?

To answer the question: 'Is there a learning curve associated with a subureteric injection of Deflux(®)?' We retrospectively reviewed charts of patients who received subureteric injection of dextranomer/hyaluronic acid (Deflux(®){AQ2}) (225 procedures) for treatment of vesicoureteral reflux (VUR) by four surgeons. The study included 55 patients, 82 ureters, who had postoperative follow-up with a voiding cystogram or nuclear medicine cystogram. Exclusion criteria were prior anti-refluxing procedures, duplicated collecting systems, and non-achievement of a negative intraoperative cystogram. Patients were divided into two groups based on whether or not they received an intraoperative cystogram after the injection. The two groups were compared for VUR resolution rates on follow-up imaging. Twenty patients underwent an intraoperative cystogram (Group 1, 33 ureters) and 35 did not (Group 2, 49 ureters). The two groups were similar in age, preoperative reflux grade, amount of Deflux injected into each ureter, and time to postoperative studies. In Group 1, 11 ureters (33.3%) and also, in Group 2, 11 ureters (22.4%) had reflux on follow-up imaging. There was no improvement in VUR resolution rate following subureteric injection of Deflux(®) when an intraoperative cystogram demonstrated no reflux to be present immediately after injection. Of ureters that did not reflux on intraoperative cystograms, one-third displayed return of reflux on follow-up imaging, which suggests no learning curve and that failures are not likely to be caused by poor surgical technique.