Treatment Of Vesicoureteral Reflux Research Articles

Outcome of salvage ureteral reimplantation after endoscopic treatment failure for high-grade vesicoureteral reflux compared to primary ureteral reimplantation.

Introduction:Surgical treatment of vesicoureteral reflux is required after conservative treatment has failed. However, there is a controversy if fibrosis related to previous attempts of dextranomer/hyaluronic acid (Dx/Ha) injection increases the risk of surgical difficulty and postoperative complications. Therefore, the purpose of our study was to compare the outcome of salvage ureteral reimplantation (SUR), after failed endoscopic therapy, to that of primary ureteral reimplantation in patients with high-grade primary vesicoureteral reflux (VUR).Materials and Methods:We conducted a retrospective analysis of children, <14 years old, treated for Grade IV or V VUR, between 1998 and 2014. Cases were classified into the SUR or the PUR group. Cases of secondary VUR were excluded. All patients were treated using a cross-trigonal ureteral reimplantation technique by two surgeons. The following demographic and clinical variables were included in the analysis: presentation, reflux severity, scarring on imaging, age at endoscopic injection, total amount of Dx/Ha injected, operative time, postoperative hospital stay, operative complications, incidence of febrile urinary tract infections (UTIs) after surgery, and persistent VUR. Between the groups, differences were evaluated using Fisher's exact test.Results:Twenty-six patients were included, 19 in the SUR and 7 in the primary ureteral reimplantation (PUR) group. In the SUR group, 12 cases had a bilateral VUR and 7 had a unilateral VUR, with 4 bilateral and 3 unilateral VUR cases in the PUR group. In the SUR group, 13 patients had received one Dx/Ha injections, with the other 6 receiving two injections, of 0.5 ml of Dx/Ha (range, 0.5–2.0 ml). A bilateral reimplantation was performed in 14/19 patients in the SUR group and 4/7 in the PUR group. The median age at surgery was 4 years in the SUR group and 3 years in the PUR group (P < 0.02). The median operative time was comparable between the groups (120 and 140 min for the SUR and PUR groups, respectively, P = 0.73), with a comparable length of hospital stay (5 and 6 days, respectively, P = 0.061). Blood loss was generally <10 ml, except in three cases in the SUR group, due to difficult dissection. Over the median follow-up of 1 year, persistent Grade III SUR was identified in only one patient in the SUR group, with no occurrence of febrile UTIs postoperatively.Conclusion:SUR for high-grade primary VUR after failed Dx/Ha injection has the same success rate as PUR, with no significant complication rate, although the necessary dissection may be more difficult.

The fate of implant after endoscopic injection of dextranomer/hyaluronic acid in vesicoureteral reflux: time to partial reabsorption and stabilization

Vesicoureteral reflux (VUR) potentially leads to renal damage, scarring, and eventually end-stage renal disease. Endoscopic treatment is well tolerated in children, it has reduced costs, and it effectively prevents urinary tract infections (UTIs), while avoiding long term antibiotics use. With the aim to investigate the time needed to reach the stabilization of the dextranomer/hyaluronic acid (Dx/HA) implants and to identify cut-off heights to ensure the success of the procedure, the authors analyzed ultrasonographic (US) intra-operative appearance of the mounds following endoscopic treatment for VUR and repeated the measurements during serial postoperative evaluations. The final clinical goal would be to obtain an alternative parameter that might reduce the need for postoperative voiding cystourethrogram (VCUG). The authors selected all children treated for moderate-high grade VUR with renal scarring or repeated UTI under antibiotic prophylaxis and followed with regular time points for at least 1 year (time points 1, 3, 6, and 9 months). Endoscopic injection performed with double-HIT/STING technique was combined with US to determine the intra-operative mound height and to calculate reabsorption rate. Mound height was measured as the maximal vertical diameter of the mound visualized at the ureteral orifice. Based on postoperative VCUG findings, patients were divided in group A (success of the endoscopic treatment) and group B (persistence of reflux). Thirty patients aged 1-7 years, counting for 47 ureters, completed the protocol and were included in the analysis. Mounds height had a significant difference between A and B at all time points (P<0.005). However, height did not differ between 6 and 9 months in both groups. Percentage of reduction in A was significant from 1 to 6 months (P<0.005) but not onward, while in B, it was never significant. Ultimately, both groups had a comparable trend of reabsorption, with a complete stabilization achieved in 6 months and an overall reduction of approximately 22%. Following the endoscopic injection of Dx/HA, US mounds height was found to strongly correlate with VCUG, both intra-operatively and for months following the procedure. Compared with the available literature, the authors firstreport a fixed reabsorption rate, consistent with the results in animal modelsand a timeframe to achieve stabilization. The possibility to measure those parameters with US renders this approach useful in the clinical setting, and it justifies the reduced use of VCUG in the follow-up of endoscopic injection for VUR.

Surgical treatment of vesicoureteral reflux in the first year of life?

Surgical intervention in children with VUR is rarely indicated in the first year of life. Early surgical intervention is primarily required for male infants with a high-grade reflux, renal impairment due to reflux nephropathy, infravesical obstruction and breakthrough infections like pyelonephritis or urosepsis. Besides the recommended circumcision, this is usually limited to endoscopic infravesical disobstruction of posterior urethral valves, prolapsing ureteroceles or secondary bladder neck obstructions. Concomitant endoscopic reflux therapy with bulking agents such as hyaluronic acid/dextranomer should be regarded as a downstaging of the VUR; the decision should be made on an individual basis. Urinary diversion, e. g. vesicostomy or ureterocutaneostomy, is only required in exceptional cases.

Endoscopic treatment of vesico-ureteric reflux in children of early age

The purpose of the study was to study the long-term results of endoscopic treatment of infants and young children with vesicoureteral reflux (VUR). Materials and methods . The analysis of the long-term results of endoscopic correction of reflux in infants and young children operated in the hospital from January 2015 to December 2018. Of these, up to 3 years there were 115 patients (67%), up to a year – 56 children (33%). The duration of follow-up was from 2 to 4 years. Polyacrylamide gel DAM+was used as an implant in 70% of cases (191 ureters). Endoscopic treatment with DAM+ was performed in 77 (70%) children from one to 3 years, as well as 23 patients (41%) of infancy. In other cases, used collagen, uradex. Introduction was carried out by methods of STING, HIT 1 and HIT 2. Results and discussion . Evaluation of the effectiveness of the use of drugs: collagen, DAM+, urodex. The type, degree of reflux, kidney function, presence of concomitant pathology were taken into account in the analysis of the correction results, and the effectiveness was evaluated by changing the degree of reflux and the course of the inflammatory process after 6 months – year after endoscopic correction. The disappearance of reflux after a single application of DAM+ took place in 86% of cases. Re-introduction of the implant was performed in 55 children, 3-fold – 20 at 3–4th degree of reflux. Neoimplantation of the ureter was performed in 9 patients with 4–5th degree of reflux, concomitant pathology of the upper urinary tract and signs of reflux nephropathy. Conclusion. The analysis of long-term results showed that the use of endoscopic techniques of reflux correction with the use of the domestic drug DAM+, including in infants, allows to completely cure reflux or reduce its degree to 1–2, providing optimal conditions for the maturation of the uretero-vesical segment.

Long-Term Clinical Outcomes and Parental Satisfaction After Dextranomer/Hyaluronic Acid (Dx/HA) Injection for Primary Vesicoureteral Reflux.

Purpose: Endoscopic dextranomer/hyaluronic acid (Dx/HA) injection is a common treatment for vesicoureteral reflux (VUR) with excellent reported short-term clinical success rates. Long-term outcomes are less well-defined. We assessed long-term outcomes and parental satisfaction after Dx/HA injection for primary VUR with >5-year follow-up.Materials and Methods: Families of all patients who underwent Dx/HA injection for primary VUR at our institution between 2008 and 2012 were contacted for telephone interview. Data collected by phone included parental satisfaction and presence and severity of UTIs pre-operatively and post-operatively. Patient demographics, radiographic VUR data, need for secondary surgery, and surgical indications were obtained through chart review.Results: Five hundred and seventy-five patients underwent Dx/HA injection for primary VUR between 2008 and 2012. Ninety-nine (17.2%) of these patients' parents were successfully contacted and interviewed. Median follow-up time from surgery to survey was 8.4 (IQR 6.8–9.6) years. Secondary surgery was performed in 13/99 (13.1%), most commonly repeat Dx/HA injection. Seven patients (7.1%) underwent secondary Dx/HA injection for persistent VUR without UTIs at a median of 0.35 (IQR 0.33–0.77) years post-operatively. Five patients (5.1%) underwent Dx/HA injection (n = 3) or ureteral reimplantation (n = 2) for VUR with febrile UTIs (fUTIs) at a median of 2.2 (IQR 1.3–5.1) years. One patient had ureteral reimplantation for symptomatic obstruction 2.8 years after initial surgery. Only 3/99 (3.0%) required open or laparoscopic surgery after Dx/HA injection. Eighty-three families (84.7%) reported ≥1 fUTIs pre-operatively. Of these, only 9/83 (10.8%) reported fUTIs post-operatively, for an overall clinical success rate of 89.2%. Clinical success was 93.1% in patients whose pre-operative fUTIs were treated outpatient and 80.0% in those hospitalized at least once for fUTI treatment pre-operatively. Ninety-four percent of parents were highly satisfied, 2.4% partially satisfied, and 3.5% dissatisfied.Conclusions: Endoscopic injection with Dx/HA for primary VUR appears to have good long-term clinical success rates and high parental satisfaction, mirroring our previously reported short-term results. Post-operative ureteral obstruction is rare but may occur years post-operatively, justifying initial sonographic surveillance, and repeat imaging in symptomatic patients.

Single Center Experience with Endoscopic Management of Vesicoureteral Reflux in Children

Objective - The aim of this study was to examine the results of endoscopic treatment for vesicoureteral reflux at our institution. Patients and Methods - The study was of prospective character and included 63 patients with diagnosed vesicoureteral reflux (VUR) in a total of 87 ureters. All patients underwent endoscopic treatment using the hydrodistension implantation technique (HIT) or the subureteral transurethral injection technique (STING). Patients were observed for recurrent UTI after treatment. Fifty (79.4%) patients had no recurrent UTI and 8 (12.7%) patients underwent a second endoscopic treatment and they are now free of UTI. One patient out of the 8 required a third injection. Results - The study included 63 patients with a total of 87 ureters, treated with Dx/HA copolymer. The mean age of the patients was 5.5 years (from 1 to 14 years). Fifty – one patients were female (80.1%) and 12 male (19.9%). Unilateral VUR was found in 39 and bilateral in 24 patients. Fifty-three patients (60.1%) were treated with a combination of HIT and STING procedures and 34 (39.9%) patients were treated with the STING procedure only. No more than 1 ml Dx/HA copolymer was injected into one ureteral orifice. No major complications were observed. Conclusion – The advantages of endoscopic treatment are short stay in hospital, no major complications and short operating time, in comparison to open surgery and it should be the first choice of treatment for patients with vesicoureteral reflux.

Use of Polyacrylamide Hydrogel for Vesicoureteral Reflux Treatment, a Review

Purpose of the review: Vesicoureteral reflux (VUR) is a common pathology encountered in pediatric urology. If left untreated, this condition can lead to infectious complications, hypertension and loss of renal function by scars. There is a trend for minimally invasive procedures to minimise treatment-related complications. Endoscopic subureteral injection of bulking agent in the treatment of VUR is an example of minimally invasive options. Several bulking agents have been studied and the perfect agent has not yet been discovered. Polyacrylamide hydrogel is a relatively new agent used to treat VUR and its use will be reviewed. Recent findings: Three modern studies from a Canadian group have evaluated the use of polyacrylamide hydrogel for endoscopic injection to treat VUR. The first study reported a cure rate of 81.2% without major complication. In the second study, injection of polyacrylamide hydrogel was compared to dextranomer hyaluronic acid and no significant difference was observed, with overall success rate of 73.1% and 77.5% respectively. The third trial evaluated the long-term efficacy and safety of polyacrylamide hydrogel with a 36-month follow-up. Overall success at 3 months was 70.7% and no patient had de novo hydronephrosis or calcification of the agent at 36 months. Conclusion: Polyacrylamide hydrogel seems to be a safe and effective alternative bulking agent in the treatment of VUR. The contribution from other centers to validate those data would be valuable.

Факторы риска формирования обструктивных осложнений эндоскопического лечения ПМР с использованием кополимера полиалкоголя полиакрилата: мультицентровое исследование

Факторы риска формирования обструктивных осложнений эндоскопического лечения ПМР с использованием кополимера полиалкоголя полиакрилата: мультицентровое исследование

Technical challenges of endoscopic treatment for vesicoureteral reflux after Cohen reimplantation

IntroductionThe range of indications for endoscopic treatment of vesicoureteral reflux opens more and more until including correction of secondary reflux (VUR) after ureteral reimplantation. However these cases suppose a technical challenge due to postoperative changes.The aim of this work is to present our experience on endoscopic treatment for VUR in ureteral units with Cohen reimplantation surgery, with special interest in the technical peculiarities of the procedure. Material and methodsA retrospective study of cases of secondary VUR after reimplantation surgery treated by subureteral injection. TechniqueWe put the needle perpendicular to submucous tunnel and inject medially to hole forming a wheal on the anterior face that occludes the meatus. ResultsDuring the 1993–2016 period 21 injections were performed in 15 ureteral units. The ureteral pathology included primary VUR (4), duplex system with lower pole reflux (4), megaureter (3) and ureterocele (2). Average patient age was 5.7 years old (2–12). Successful outcome had been got in 10 ureteral units (66.67%), a decrease of VUR grade in 4 (26.67%) and perseverance/no resolution of grade IV VUR in 1 (6.67%). DiscussionThe anti-reflux mechanism of reimplantation depends on optimizing the submucosous tunnel. This subgroup of patients is small and there are few studies, hindering the agreement on the most appropriate technique. ConclusionEndoscopic treatment of secondary reflux after reimplantation surgery is a procedure with certain technical feature, but safe and effective offering an alternative prior to surgical reoperation.

Ureteral Obstruction After Endoscopic Treatment of Vesicoureteral Reflux: Does the Type of Injected Bulking Agent Matter?

Endoscopic injection of bulking agents for the treatment of vesicoureteral reflux (VUR) has become a therapeutic alternative to antibiotic prophylaxis and ureteral reimplantation. Although considered as a safe and efficient procedure, several studies have reported cases of ureteral obstruction (UO) after endoscopic correction of VUR. This review article evaluates the present VUR literature to estimate the incidence of UO following endoscopic injection of different substances, while also discussing the impact of injection technique and implant volume. Twenty-five publications were identified that provided detailed information on 64 females and 32 males (age range, 7months-48years) that developed UO after endoscopic treatment of VUR using dextranomer/hyaluronic acid (Dx/HA), polyacrylate polyalcohol (PP), polydimethylsiloxane (PDMS), calcium hydroxyapatite (CaHA), polytetrafluoroethylene (PTFE), or collagen. There was some variation in the reported incidence of UO among these materials: Dx/HA (0.5-6.1%), PP (1.1-1.6%), PDMS (2.5-10.0%), CaHA (1.0%), and PTFE (0.3%). Postoperative UO was described following subureteric transurethral injection (STING), intraureteric hydrodistension implantation technique (HIT), combined HIT/STING and double HIT. The injected volume ranged widely, also depending on the type of bulking agent: Dx/HA (0.3-3.0mL), PP (0.3-1.2mL), PDMS (1.0-2.2mL), CaHA (0.4-0.6mL), and PTFE (1.5-2.0mL). The timing of UO varied from immediately after the procedure to 63months. Over half of patients showed asymptomatic hydroureteronephrosis on follow-up imaging, whereas the remaining presented with symptoms of acute UO or fever. UO remains a rare complication after endoscopic correction of VUR, generally reported in less than 1% of treated cases, which appears to be independent of the injected substance, volume, and technique. However, long-term follow-up is recommended as asymptomatic or delayed UO can occur, potentially leading to deterioration of renal function.

Evaluation of the Intravesical Ureters after Failed Endoscopic Treatment of Vesicoureteral Reflux with Dextranomer/hyaluronic Acid in Children via Light and Transmission Electron Microscopic Analysis. A Matched Case-Control Study.

The cytokine profile and the ultrastructural changes of refluxing ureterovesical junctions(UVJs) of children treated with failed dextranomer/hyaluronic-acid (Dx/HA) injections were investigated using immunohis-tochemical methods and transmission electron microscopy(TEM). Eighteen children who had undergone injection for reflux were included the study. The smooth muscle arrangement of the ureteral wall, transforming growth factor-? (TGF-?1),vascular-endotheli-al-growth factor (VEGF) and CD34 were evaluated immunohistochemically, and the results were compared with 10 age-matched autopsy specimens as controls. The ultrastructural evaluation and morphological description was made semi-quantitatively and compared with published data. Four of the patients (22%) were male, and 14 (78%) were female. The mean age of the patients was 105.4 ± 44.5(48-184) months. There was no correlation between the vesicoureteral reflux (VUR) grade and age (P = 0.85). The mean VEGF and CD34 scores were 16.2 ± 9.6 (0-90) cells per HPF and 10.2 ± 3.5 (4-16) vessels per HPF in ureters with reflux; these values were 60.6±16.4 (32-84) cells per HPF and 17.8 ± 4.1 (12-24) vessels per HPF in the control group. The amount of VEGF and CD34 were significantly decreased in patients compared with the control group (P < 0.001, P < 0.001).The TGF-?1 levels were significantly higher in patients with VUR compared with the control group (34.2 ± 19.9 vs 5.0±1.9; P=0.001).The amount of VEGF, CD34, and TGF-?1 were not correlated with the grade of reflux (P = 0.26, P = 0.94, and P = 0.42, respectively). Ultrastructural changes in the muscle cells were observed in all the VUR specimens (Grade II-IV). Refluxing ureters exhibited immune-histopathological abnormalities and ultrastructural changes of the muscle cells in all VUR specimens in the ureterovesical junctions of children treated with failed Dx/HA injec-tions for reflux.

Consideraciones técnicas en el tratamiento endoscópico del reflujo vesicoureteral tras reimplante tipo Cohen

IntroductionThe range of indications for endoscopic treatment of vesicoureteral reflux opens more and more until including correction of secondary reflux (VUR) after ureteral reimplantation. However these cases suppose a technical challenge due to postoperative changes.The aim of this work is to present our experience on endoscopic treatment for VUR in ureteral units with Cohen reimplantation surgery, with special interest in the technical peculiarities of the procedure. Material and methodsA retrospective study of cases of secondary VUR after reimplantation surgery treated by subureteral injection. TechniqueWe put the needle perpendicular to submucous tunnel and inject medially to hole forming a wheal on the anterior face that occludes the meatus ResultsDuring the 1993-2016 period 21 injections were performed in 15 ureteral units. The ureteral pathology included primary VUR (4), duplex system with lower pole reflux (4), megaureter (3) and ureterocele (2). Average patient age was 5.7 years old (2-12). Succesful outcome had been got in 10 ureteral units (66.67%), a decrease of VUR grade in 4 (26.67%) and perseverance/no resolution of grade IV VUR in 1 (6.67%) DiscussionThe anti-reflux mechanism of reimplantation depends on optimizing the submucosous tunnel. This subgroup of pacients is small and there are few studies, hindering the agreement on the most appropiate technique. ConclusionEndoscopic treatment of secondary reflux after reimplantation surgery is a procedure with certain technical feature, but safe and effective offering an alternative prior to surgical reoperation.

Usefulness of the classification of urinary dysfunction for the prognosis of the first endoscopic treatment of vesicoureteral reflux in children over the age of 3

ObjectivesTo assess the diagnostic performance of urinary dysfunction patterns associated with vesicoureteral reflux (VUR) in children over the age of 3 according to the result of the first endoscopic treatment (ENDT1), grouped into a classification designed by our group (CMD.URI-La Fe). Comparison with other current classifications such as that of Van Batavia et al. Material and methodsAmbispective cross-cutting study of a sample of 50 children. Exclusion criteria: previous ENDT, age≤3 years, anatomical or neurological anomalies and a history of ureteral or abdominopelvic surgery. Prior to the ENDT1, a bladder voiding function assessment by uroflowmetry+electromyography (UF-EMG) and post-mictional residue (ultrasound). Other variables from the bladder diary, pre-mictional bladder wall thickness and other clinical variables. The correction of VUR was assessed by isotope cystography 3 months after the treatment. Urinary patterns were classified according to the significant variables (URI-La Fe), and the diagnostic performance of this classification was assessed, comparing it to the classification of patients as proposed by Van Batavia et al. ResultsMean age: 6.8±2.28 years. Males/females (44%/56%). Grades of VUR (mild/moderate/severe). ENDT1 VUR correction rate: 77% (n=38). Diagnostic performance (Van Batavia; URI-La Fe): correct prediction (37.5%; 75%), sensitivity (32.4%; 87.8%), specificity (54.5%; 46.6%), positive predictive value (70.6; 78.3%) and negative predictive value (19.4%; 63.6%). ConclusionsOur results show the usefulness of the non-invasive test and the classification of urinary dysfunction in children aged over 3 years prior to the first endoscopic treatment of VUR.

Retrospective Analysis to Determine the Optimal Timing to Discontinue Continuous Antibiotic Prophylaxis in Patients with Primary Vesicoureteral Reflux

Background: The management of febrile urinary tract infection (fUTI) in patients with vesicoureteral reflux (VUR) is crucial to prevent renal scarring. Continuous antibiotic prophylaxis (CAP) is the most widely used initial treatment for VUR. However, the optimal duration of CAP is still unclear. We aimed to clarify an appropriate patient population and the optimal timing to discontinue CAP. Methods: We reviewed the records of 247 patients with primary VUR between January 2000 and December 2015. Seventy-two patients who discontinued CAP despite persistent VUR were enrolled. Kaplan-Meier method and Cox proportional hazard model was used in statistical analysis. Results: Following the discontinuation of CAP, fUTI developed in 25 patients after a median of 9 months (range 0–81). VUR resolved spontaneously in 9 out of 47 patients without recurrence during follow-up. Multivariate analysis showed bilateral VUR and duration of CAP of less than 1 year after the last fUTI were significant risk factors for recurrence. Conclusion: Among the risk factors examined, patients administered CAP for less than 1 year after the last fUTI and those with bilateral VUR had significantly more frequent recurrence. Our study suggests that the administration of CAP for more than 1 year after the last fUTI is beneficial in avoiding recurrent fUTI.

Utilidad de la clasificación de los patrones de disfunción miccional en el pronóstico del primer tratamiento endoscópico del reflujo vesicoureteral en niños mayores de 3 años

ObjectivesTo assess the diagnostic performance of urinary dysfunction patterns associated with vesicoureteral reflux (VUR) in children over the age of 3 according to the result of the first endoscopic treatment (ENDT1), grouped into a classification designed by our group (CMD.URI-La Fe). Comparison with other current classifications such as that of Van Batavia et al. Material and methodsAmbispective cross-cutting study of a sample of 50 children. Exclusion criteria: previous ENDT, age ≤ 3 years, anatomical or neurological anomalies and a history of ureteral or abdominopelvic surgery. Prior to the ENDT1, a bladder voiding function assessment by uroflowmetry+electromyography (UF-EMG) and post-mictional residue (ultrasound). Other variables from the bladder diary, pre-mictional bladder wall thickness and other clinical variables. The correction of VUR was assessed by isotope cystography 3 months after the treatment. Urinary patterns were classified according to the significant variables (URI-La Fe), and the diagnostic performance of this classification was assessed, comparing it to the classification of patients as proposed by Van Batavia et al. ResultsMean age: 6.8±2.28 years. Males/females (44%/56%). Grades of VUR (mild/moderate/severe). ENDT1 VUR correction rate: 77% (n=38). Diagnostic performance (Van Batavia; URI-La Fe): correct prediction (37.5%; 75%), sensitivity (32.4%; 87.8%), specificity (54.5%; 46.6%), positive predictive value (70.6; 78.3%) and negative predictive value (19.4%; 63.6%). ConclusionsOur results show the usefulness of the non-invasive test and the classification of urinary dysfunction in children aged over 3 years prior to the first endoscopic treatment of VUR.

Interventions for primary vesicoureteric reflux.

Interventions for primary vesicoureteric reflux.

Managing vesicoureteral reflux in children: making sense of all the data.

Current management of vesicoureteral reflux (VUR) in children is the result of a steady albeit controversial evolution of data and thinking related to the clinical impact of VUR and urinary tract infection (UTI) in children, the value of clinical screening, and the relative impact of testing and interventions for VUR. While controversy continues, there is consensus on the importance of bladder dysfunction on VUR outcomes, the likelihood of VUR resolution, and the fact that not all children with VUR require active treatment. Early efforts to define risk stratification hold the most promise to provide more patient-specific treatment of UTI and VUR in children.

Reflux Timing Is a Predictor of Successful Endoscopic Treatment of Vesicoureteral Reflux

ObjectiveTo determine whether vesicoureteral reflux (VUR) that occurs during either the filling or voiding phase on voiding cystourethrogram (VCUG) has prognostic significance on successful endoscopic treatment. Materials and MethodsA retrospective review was performed of 299 patients (438 ureters) with VUR who underwent endoscopic treatment with dextranomer/hyaluronic acid copolymer (Deflux) at a single institution from 2010 to 2013. Success was defined as absence of VUR on 3-month follow-up VCUG. Preoperative VCUGs were analyzed to determine whether the onset of VUR occurred during the filling or voiding phase. Predictor variables to determine success were analyzed, with a specific focus on VUR timing. ResultsSuccess rate was 319/438 (72.8%) by ureter and 202/299 (67.6%) by patient. Reflux was seen during the filling and voiding phases in 290 and 148 ureters, respectively. Success rate was 203/290 (78%) for filling VUR and 116/148 (70%) for voiding VUR. Univariable analysis revealed voiding VUR had significantly increased odds of success (odds ratio [OR] 3.2, P = .049), while high-grade reflux (OR 0.53, P = .005) had significantly decreased odds of success. Multivariable analysis showed that voiding VUR (OR 3.2, P = .005) had significantly higher odds of success while those with high grade reflux (OR 0.42, P = .017) had significantly decreased odds of success. ConclusionThe timing of VUR on preoperative VCUG appears to be an important independent predictor of successful endoscopic treatment of VUR. This has important clinical considerations when selecting VUR patients who would be best candidates for endoscopic treatment.

Unilateral open extravesical ureteral reimplanation with contralateral dextronomer/hyaluronic acid injection performed as an outpatient therapy

Historically, patients with unilateral high-grade vesicoureteral reflux (VUR) and contralateral low-grade or resolved VUR have been treated with bilateral intravesical ureteral reimplantation, which requires postoperative admission. If the high-grade VUR side is treated alone, then the contralateral side is at risk of developing recurrent or worsening VUR. Bilateral subureteric injection of dextronomer/hyaluronic acid (DHA) is another option that can be performed as an outpatient therapy, but a single injection is less effective for high-grade VUR. The safety and efficacy of an outpatient combination of open extravesical ureteral reimplantation (EVUR) and contralateral DHA injection were investigated. A retrospective review of children who had concomitant EVUR and subureteric injection of DHA between January 2005 and December 2015 was performed. Exclusion criteria were diagnosis other than VUR, repeat procedures, and patients with no follow-up. Patient characteristics, postsurgical complications, and follow-up imaging were evaluated. Febrile urinary tract infection (fUTI) was defined as ≥50,000Colony Forming Units (CFU) of an organism from clean-catch or catheterized urine and temperature ≥101.5F. Clinical success is defined as no fUTI for 1 year after the initial operation. Univariate analyses were used to identify risk factors for treatment failure. A total of 117 patients met inclusion criteria. Mean age at surgery was 6.0 years, and 85% were female. The mean pre-operative grade of VUR was 3.3 on the EVUR side and 0.6 on the contralateral side (42% resolved before treatment). Median follow-up was 12.2 months (interquartile range, 3.1-25.4). Sixteen patients (14%) had documented fUTI within 1 year, with a clinical success rate of 86%. Of these, five had a postoperative imaging showing resolution of VUR, increasing overall success to 91%. Postoperative fUTI was more common in patients with pre-operative bowel and bladder dysfunction (BBD) (P=0.003), but this was not associated with a higher reoperation rate (P=0.168). There were 11 total complications, with three grade 3 complications. This study is the first to report safety and outcomes of EVUR and contralateral DHA injection for patients with high-grade VUR with contralateral low-grade or resolved VUR. It was shown that it is an effective and safe treatment that can be performed as an outpatient therapy. Limitations to this study include the retrospective designand the clinical definition of success that is used in a cohort of patients from across the mountain west region without routine postoperative voiding cystourethrogram. Extravesical ureteral reimplantation and contralateral DHA injection can safely be performed as an outpatient therapy and are effective in the treatment of higher grade VUR with contralateral low-grade or resolved VUR. Treatment failure is more likely in patients with BBD.

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

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