Investigation of histopathologic changes in the ureter walls in vesicoureteral reflux

Modified unilateral periureteral injection technique in the treatment of patients with high-grade vesicoureteral reflux: A study of primary findings

Objective

Although endoscopic treatment has been used by many pediatric urologists for the treatment of vesicoureteral reflux (VUR), it has no considerable success in high-grade VUR. We aimed to describe the primary outcomes of unilateral periureteral injection technique (PIT), as well as bilateral PIT in high-grade VUR.

Methods

In this prospective study, we examined 92 ureters in 45 boys and 40 girls from February 2010 to May 2018. Bilateral PIT and unilateral PIT were applied in 67 and 25 refluxing units, respectively. In the unilateral PIT, the subureteral injection site was only at the 5- or 7-o'clock position. However, in the bilateral PIT, the subureteral injection sites were at 5- and 7-o'clock position. Pre- and post-operative reflux grades were evaluated by voiding cystourethrography 6 months after surgery.

Results

Seven patients had bilateral reflux. Overall, 75 (81.5%) ureters showed Grade IV VUR, while 17 (18.5%) had primary Grade V VUR. The mean age of the subjects was 39.2 months. In unilateral PIT ureters, VUR was resolved in 23 (92.0%) refluxing units. It was downgraded to Grade III in one ureter (4.0%) and to Grade II in another ureter (4.0%). In addition, in bilateral PIT cases, VUR was resolved in 60 (89.6%) ureters; it downgraded to Grades II and III in 3 (4.5%) and 4 (6.0%) refluxing units, respectively.

Conclusion

Unilateral PIT can be highly effective in the treatment of selected ureters of high-grade VUR. However, further studies are needed to confirm our results.

Efficacy of hydrodistention implantation technique in treating high-grade vesicoureteral reflux

Purpose

In the endoscopic treatment of vesicoureteral reflux, the relatively high rate of success, the simplicity of the procedure, high patient compliance, and a lack of complications has led to the increased development of injection materials and techniques. We report a method of identifying and maintaining a clear visual field during ureteral and bladder submucosal wall injection of a dextranomer/hyaluronic acid copolymer (Deflux, Oceana, Therapeutics Inc.) by use of the hydrodistention implantation technique (HIT) with the aid of temporary ureteral catheter insertion.

Materials and Methods

We prospectively reviewed patients with grade IV or V reflux who received an endoscopic injection of Deflux. Reflux grade was evaluated before and after treatment (3 months) by use of voiding cystourethrograms. Conventional sub-trigonal injection (STING) was performed with injection of Deflux underneath the bladder mucosa at the 6 o'clock position. HIT was performed either with hydrodistention or with guidewire insertion. These techniques increase visualization of the intramural portion of the distal ureteral wall. Patients with treatment failures were offered reinjection up to three times.

Results

Sixty-three patients completed endoscopic injection and follow-up of 3 months. The overall resolution rate for conventional STING was 58%, i.e., 67% for grade IV and 43% for grade V. The overall resolution rate for HIT was 80%, i.e., 93% for grade IV and 66% for grade V. The modified methods showed higher resolution rates for overall cure owing to the success in patients with grade IV reflux (p=0.026). Although the success of grade V treatment was higher with the modified method, the success rate was not statistically significant (p=0.27).

Conclusions

HIT with the use of either hydrodistention or a guidewire to aid in visualization of the intramural portion of the distal ureter is an effective treatment for high-grade vesico-ureteral reflux.

Is joint hypermobility associated with vesico-ureteral reflux? An assessment of 50 patients

OBJECTIVE

To assess whether there is an increased prevalence of joint hypermobility in patients with vesico-ureteric reflux (VUR).

MATERIALS AND METHODS

We studied 50 patients with primary VUR and matched controls drawn from a reference population. Joint mobility was assessed using the Bulbena hypermobility score.

RESULTS

We identified significantly more patients with VUR with generalized joint hypermobility than controls (24% vs 6.7%, P= 0.007).

CONCLUSION

Our findings confirm our clinical observation of an increased rate of joint hypermobility in patients with VUR. We speculate that an altered composition of the connective tissue may contribute to the severity of the (pre-existing) VUR phenotype.

Investigation of histopathologic changes in pelviureteral junction obstruction

OBJECTIVES

This study aimed to determine histopathologic changes in the pelviureteral junction in children with pelviureteral junction obstruction.

MATERIAL AND METHODS

Seventeen pelviureteral junction specimens obtained from children were divided into two groups: pelviureteral junction obstruction (n = 7) and control (n = 10). Wall thickness of the pelviureteral junction, tunica muscularis of the pelviureteral junction, uroepithelium thickness of the pelviureteral junction, and collagen thickness of the pelviureteral junction were evaluated in resected pelviureteral junctions in children with pelviureteral junction obstruction.

MAIN FINDINGS

The mean wall thickness of the pelviureteral junction, mean tunica muscularis of the pelviureteral junction, and uroepithelium thickness of the pelviureteral junction were not significantly higher than those in the control group. Collagen thickness values in the pelviureteral junction obstruction group were significantly higher than those in the control group.

CONCLUSIONS

Our data suggest that wall thickness (tunica muscularis and uroepithelium) was not significantly increased, but collagen thickness of the ureter was increased in the pelviureteral junctions of children with pelviureteral junction obstruction.