The comparison of dextranomer/hyaluronic acid and polyacrylate-polyalcohol copolymers in endoscopic treatment of vesicoureteral reflux

Vantris vs. deflux for treatment of paediatric vesicoureteral reflux: Efficacy and obstruction risk

INTRODUCTION

The aim was to compare the efficacy of polyacrylate polyalcohol copolymer (PPC) injections and dextranomer/hyaluronic acid (Dx/Ha) injections for the endoscopic treatment of vesicoureteral reflux in children.

MATERIAL

This retrospective cohort study included 189 young patients who had endoscopic treatment for vesicoureteral reflux from January 2012 to December 2019 in our center. Among them, 101 had PCC injections and 88 had Dx/Ha injections. Indications for treatment were vesicoureteral reflux with breakthrough urinary tract infection or vesicoureteral reflux with renal scarring on dimercaptosuccinic acid (DMSA) renal scan. Endoscopic injection was performed under the ureteral meatus. Early complications, recurrence of febrile urinary tract infection and vesicoureteral reflux after endoscopic injection, ureteral obstruction and reintervention were evaluated and compared between groups.

RESULTS

Endoscopic treatment was successful in 90.1% of patients who had PPC injection and in 82% of patients who had Dx/Ha injection. Four patients presented a chronic ureteral obstruction after PPC injection, one with a complete loss of function of the dilated kidney. One patient in the Dx/Ha group presented a postoperative ureteral dilatation after 2 injections.

CONCLUSION

Despite a similar success rate after PPC and Dx/Ha injections for endoscopic treatment of VUR, there may be a greater risk of postoperative ureteral obstruction after PPC injections. The benefit of using PPC to prevent febrile UTI and renal scarring in children with low-grade VUR does not seem to outweigh the risk of chronic ureteral obstruction.

LEVEL OF EVIDENCE: 4

Long-term outcome of randomized clinical trial between polyacrylate-polyalcohol copolymer (PPC) and dextranomer-hyaluronic acid copolymer (Dx/HA) as bulking agents for endoscopic treatment of primary vesicoureteral reflux (VUR)

OBJECTIVE

The aim of our study is to compare long-term outcome of endoscopic treatment of VUR using PPC or Dx/HA.

PATIENTS AND METHODS

From October 2014 to April 2017 patients with VUR grades from 3 to 5 that needed endoscopic treatment were eligible for this RCT. Patients were randomized in two groups: PPC and Dx/HA. A VCUG was performed at 6 months; if VUR > 3 was still present a second ET was performed. We included for this long-term follow-up study those patients that were successfully treated at short-term follow-up. At 36 months postoperative VCUG was performed to assess outcome. Success was considered if postoperative VUR grade was 0 at 36 months, and there was no ureteral obstruction.

RESULTS

In the previous study, 60/73 ureters were successfully treated in 36/44 patients, and then we have analyzed 60 ureters in 36 patients. Three patients were lost in long-term follow-up, and then we analyzed 57 ureters in 33 patients divided. PPC group 18 patients (28 ureters); and Dx/HA group 15 patients (29 ureters). After 3 years of follow-up the VCUG showed a success rate of 26/28 of RU in PPC and 26/29 of DX/HA. Two RU in PPC group had ureteral obstruction, and then the successful rate for PPC group dropped to 24/28. The overall successful rate at long-term was 72.7% of the RU in PPC group and 70.3% in Dx/HA group.

CONCLUSION

PPC and Dx/HA has similar long-term outcome in VUR resolution, but ureteral obstruction could be present at long-term follow-up in PPC group.

Successful rescue pneumovesicoscopic surgery for post-Deflux® vesicoureteral junction obstruction

BACKGROUND

Vesicoureteral junction (VUJ) obstruction after Deflux® subureteral injection for vesicoureteral reflux (VUR) is rare and minimally invasive management has not been reported. This work investigated the patients who underwent Deflux® injection for VUR and identified those with subsequent VUJ obstruction.

METHODS

Medical records of matched patients from October 2003 to March 2022 were reviewed, and parameters were retrospectively studied. All patients underwent Deflux® injection. The injection was performed under general anesthesia using the same manner. For patients complicated with VUJ obstruction, the symptoms, signs, management, images, renal ultrasounds, Tc-99m dimercaptosuccinic acid renal scintigraphy, histology of VUJ region, and outcomes were documented and reported. VUJ stenosis was diagnosed by performing renal ultrasound and magnetic resonance imaging.

RESULTS

Totally 407 patients (554 ureterorenal units) received Dx/HA injections for VUR. VUJ obstruction was found in three patients (four ureterorenal units). Originally, three were grade V VUR, and one was grade IV. The repeated injection was not a risk factor for VUJ obstruction. The overall incidence of VUJ obstruction post-Dx/HA injection was 0.7% by ureter. The incidences were 0%, 0.75%, and 2.25% for grade I-III, IV, and V VUR, respectively. After the initial conversion case of pneumovesicoscopic ureteral reimplantation, the procedure was performed smoothly and successfully in the two following cases.

CONCLUSIONS

Pneumovesicoscopic ureteral reimplantation offers an alternative for VUJ obstruction following Dx/HA injection for VUR. Fibrosis and foreign-body reaction may influence the feasibility. High-grade VUR and young age of injection were related to VUJ obstruction.

Endoscopic injection of bulking agents in pediatric vesicoureteral reflux: a narrative review of the literature

In the last 20 years, endoscopic injection (EI) has affirmed as a valid alternative to open surgery for management of pediatric vesicoureteral reflux (VUR). This study aimed to investigate and discuss some debated aspects such as indications, bulking agents and comparison, techniques of injection and comparison, predictive factors of success, use in specific situations. EI is minimally invasive, well accepted by patients and families, with short learning curve and low-morbidity profile. It provides reflux resolution rates approaching those of open reimplantation, ranging from 69 to 100%. Obviously, the success rate may be influenced by several factors. Recently, it is adopted as first-line therapy also in high grade reflux or complex anatomy such as duplex, bladder diverticula, ectopic ureters. The two most used materials for injection are Deflux and Vantris. The first is absorbable, easier to inject, has lower risk of obstruction, but can lose efficacy over time. The second is non-absorbable, more difficult to inject, has higher risk of obstruction, but it is potentially more durable. The two main techniques are STING and HIT. To date, the ideal material and technique of injection has not yet clearly established, but the choice remains dependent on surgeon's preference and experience.

A systematic review & meta-analysis comparing outcomes of endoscopic treatment of primary vesico ureteric reflux in children with polyacrylate poly alcohol copolymer versus dextranomer hyaluranic acid

BACKGROUND & AIMS

There are conflicting reports on the efficacy of bulking agents for vesico ureteric reflux (VUR). In this meta-analysis we have compared the outcomes of endoscopic treatment with polyacrylate polyalcohol copolymer (PPC) and dextranomer hyaluronic acid (DxHA).

METHODS

A systematic review of publications between 2010 and 2020 was conducted covering databases like PUBMED, MEDLINE etc. for (endoscopic treatment) AND (VUR) AND (PPC OR DxHA) AND (recurrence OR complications). PRISMA guidelines were followed and only comparative studies were included. Outcomes were early success defined as absence of VUR in voiding cystourethrogram at 3-months followup, urinary tract infections (UTI) and occurrence of vesico-ureteric-junction obstruction (VUJO). Risk of bias was analysed with Robvis tool and odds-ratios were compared with Revman-3.0.

RESULTS

Among nine studies (heterogeneity; I 2 69-79%) all cleared the risk of bias assessment. There was no significant difference in high grade VUR (p = 0.94) between PPC (40%) and DxHA (43%). Success rate after single injection was significantly higher (p = 0.0001) at 86% (477/555) for PPC vs 69% (474/685) for DxHA. UTI rate between PPC (12%) and DxHA (14.6%) was not statistically significant (p = 0.54). VUJO rate between PPC (3.9%) and DxHA (0.8%) was also not significantly different (p = 0.47). Significantly lesser volume (p = 0.02) was used for PPC (0.7 ml) compared to DxHA (0.9 ml).

CONCLUSION

Reflux resolution was significantly higher with PPC than DxHA. Postinjection UTI/VUJO incidence was not significantly different between them. Limitation of this meta-analysis was heterogeneity & small number of articles. Further studies should focus on long-term outcomes and cost-effectiveness.

Comparison of polyacrylate polyalcohol copolymer (PPC) and dextranomer/hyaluronic acid (Dx/HA) for treatment of vesicoureteral reflux. A systematic review and meta-analysis

PURPOSE

Our study aimed to compare the efficacy of polyacrylate polyalcohol copolymer and Dextranomer-Hyaluronic Acid for endoscopic treatment of vesicoureteral reflux.

MATERIAL AND METHODS

MEDLINE, EMBASE, Scopus, Web of science, Ovid, Cochrane databases, Google scholar have been searched for studies published until January 2022 in any language. Studies that compared the success rate for endoscopic treatment of vesicoureteral reflux in children with two bulking agents, namely, "polyacrylate polyalcohol copolymer." and "Dextranomer-Hyaluronic Acid" were included for this analysis.

RESULTS

Nine studies were included in data synthesis for this meta-analysis. Pooled data with a total of 763 ureters in PPC group and 718 ureters in Dx/HA group indicated that ureters in PPC group were more likely to undergo complete reflux resolution than Dx/HA (OR 3.80, 95% CI: 2.71; 5.31). Among subgroup of patients with high grade reflux, PPC injection had more resolution rate compared to Dx/HA patients (OR: 2.92, 95% CI: 1.19-7.16). In total, 95.81% of the PPC group and 86.52% of the Dx/HA group experienced success after the third injection. However a concerning complication of endoscopic treatment which is ureterovesical junction obstruction (UVJO) was more prevalent in PPC group. So the possible benefits arising from endoscopic treatment with PPC could be offset by the costs of re-implantation surgery or stenting in the case of UVJO.

CONCLUSION

These data indicate that PPC injection for vesicoureteral reflux treatment was associated with a higher success rate, but concerningly, UVJO incidence was higher in the PPC group which might negate the possible benefits of PPC injection However, due to the lack of studies with long-term follow-up, we couldn't reach a definitive conclusion about the superiority of one of the bulking agents over the other.

Endoscopic treatment of primary vesicoureteral reflux in children with two different bulking agents, high success and low complication rates: Comparison of Dexell and Vantris

INTRODUCTION AND OBJECTIVES

To compare the results in terms of efficacy and safety of the endoscopic management for vesicoureteral reflux (VUR) in two different standardized primary VUR cohorts treated with Dexell and Vantris.

PATIENTS

128 refluxing renal units (RRU) in 87 patients with primary VUR (64 females, 23 males). Patients with secondary VUR and severe bladder and bowel dysfunction were excluded. A total of 22 continent children with mild bladder-bowel dysfunction underwent bladder-bowel training before the implantation. All procedures were performed in the presence of sterile urine using a conventional subureteral transurethral injection technique.

RESULTS

There were no statistically significant differences between groups in terms of mean age, sex, RRU side, ^99mTc-DMSA uptake, and reflux grade. The overall resolution rates based on the number of RRUs for up to three endoscopic treatments were 80% (56/70) in Dexell group and 94.8% (55/58) in Vantris group (P = .012). No postoperative recurrences or vesicoureteral junction obstructions were seen in any group.

CONCLUSIONS

Dexell and Vantris provided an effective and safe endoscopic VUR treatment in the early and mid-term follow up of children with primary VUR. The effectiveness of these substances, which can produce different mass effects with different particle sizes, in safe VUR resolution, needs further investigations.

Endoscopic treatment of primary vesicoureteral reflux in children with two different bulking agents, high success and low complication rates: comparison of Dexell and Vantris

INTRODUCTION AND OBJECTIVES

To compare the results in terms of efficacy and safety of the endoscopic management for vesicoureteral reflux (VUR) in two different standardized primary VUR cohorts treated with Dexell and Vantris.

PATIENTS

128 refluxing renal units (RRU) in 87 patients with primary VUR (64 females, 23 males). Patients with secondary VUR and severe bladder and bowel dysfunction were excluded. A total of 22 continent children with mild bladder-bowel dysfunction underwent bladder-bowel training before the implantation. All procedures were performed in the presence of sterile urine using a conventional subureteral transurethral injection technique.

RESULTS

There were no statistically significant differences between groups in terms of mean age, sex, RRU side, 99mTc-DMSA uptake, and reflux grade. The overall resolution rates based on the number of RRUs for up to three endoscopic treatments were 80% (56/70) in Dexell group and 94.8% (55/58) in Vantris group (p = 0.012). No postoperative recurrences or vesicoureteral junction obstructions were seen in any group.

CONCLUSIONS

Dexell and Vantris provided an effective and safe endoscopic VUR treatment in the early and mid-term follow up of children with primary VUR. The effectiveness of these substances, which can produce different mass effects with different particle sizes, in safe VUR resolution, needs further investigations.

Comparison of Subureteral Endoscopic Injection of Dextranomer/Hyaluronic Acid and Lich-Gregoir Ureteral Reimplantation in the Treatment of Pediatric Primary Vesicoureteral Reflux: A Prospective Randomized Study

Background: The gold standard of surgical intervention of vesicoureteral reflux (VUR) is open ureteral reimplantation with high success and low complication rates. However, in recent years, endoscopic injection, dextranomer/hyaluronic acid (Dx/HA), has become an effective therapy for VUR. It is noted that limited prospective randomized trials compare the different surgical techniques of especially endoscopic injection versus open procedures. We aimed to compare the outcomes of endoscopic injection of Dx/HA and Lich-Gregoir open technique of ureteral reimplantation for grades III and IV primary VUR in pediatric patients. Materials and Methods: Between January 2016 and December 2018, 60 pediatric patients with grades III and IV primary VUR were included in a prospective randomized trial. Thirty cases with 45 refluxing ureters managed by endoscopic injection of Dx/HA comprised group A. Open Lich-Gregoir technique used in the other 30 cases with 48 refluxing ureters composed of group B. Renal ultrasound, voiding cystourethrography, and renal scintigraphy were used for follow-up. The surgical success rate, cost-effectiveness, and occurrence of complications were evaluated and compared in both groups. Results: Sixty pediatric patients with 93 refluxing ureters (41 females and 19 males) were included in the trial. The mean follow-up for all patients was 17.7 ± 7.1 months. Overall reflux resolution was 80% (36/45) of the ureters in group A after a single injection and 93.75% (45/48) of the ureters in group B. The difference between the two groups was not statistically significant concerning clinical or anatomical preoperative factors and surgical success rate. There was a statistically significant difference between the two groups in terms of operative time and hospital stay. Conclusion: This comparative study demonstrated a high success rate of open ureteral reimplantation (Lich-Gregoir) procedure over the endoscopic injection of Dx/HA therapy to manage primary VUR grades III-IV. Clinical Trial Number: NCT04798443.

Endoscopic Injection Treatment of Vesicoureteral Reflux in Children: Meeting with the Factors Involved in the Success Rate

The challenges and controversies in vesicoureteral reflux intervention guidelines resulted in a more individualized treatment planning. Endoscopic injection therapy is now widely used and is considered preferable, but still remains less successful than ureteral reimplantation. Τhe endoscopic vesicoureteral reflux approach should be risk-adapted to current knowledge, so more experience and longer-term follow-up are needed. The precise of preoperative, intraoperative, and postoperative factors that affecting endoscopic injection therapy success rates and outcome have not yet been clearly determined. The aim of this study was to investigate these associated factors. Although the reflux grade is the most well-known factor that can affect the success of the procedure, there is no agreement on which factors are the most influential for the efficacy of endoscopic reflux treatment. So, we carried out a broad review of published papers on this topic, and we presented all the potential predictive variables of endoscopic reflux resolution in children.

Brazilian consensus on vesicoureteral reflux-recommendations for clinical practice

Introduction

Vesicoureteral Reflux (VUR) is characterized by a retrograde flow of urine from the bladder into the ureters and kidneys. It is one of the most common urinary tract anomalies and the major cause of urinary tract infection (UTI) in the first years of life. If not properly diagnosed and treated can lead to recurrent UTI, renal scar and, in severe cases, to end stage renal disease. Despite recent advances in scientific and technological knowledge, evaluation and treatment of VUR is still controversial and there is still considerable heterogeneity in evaluation methods and therapeutic approaches. The aim of the present consensus is to give a practical orientation on how to evaluate and treat VUR.

Methods

The board of Pediatric Urology of the Brazilian Society of Urology joined a group of experts and reviewed all important issues on Vesicoureteral Reflux evaluation and treatment and elaborated a draft of the document. On November 2017 the panel met to review, discuss and write a consensus document.

Results and Discussion

Vesicoureteral Reflux is a common and challenging problem in children. Children presenting with Vesicoureteral Reflux require careful evaluation and treatment to avoid future urinary tract infections and kidney scars. The panel addressed recommendations on up to date choice of diagnosis evaluation and therapies.

Risk factors for obstructive complications after endoscopic correction of vesico-ureteral reflux using polyacrylate polyalcohol copolymer

Use of polyacrylate-polyalcohol copolymer (PPC) after endoscopic correction (EC) of vesico-ureteral reflux (VUR) is highly effective but is associated with a higher risk of obstructive complications (OC) compared with other implants. We undertook a STROBE compliant retrospective investigation and studied the OC risk factors to increase the practical safety of PPC.Overall, 798 patients (464 [58.1%] girls and 334 [41.9%]) boys) from 5 hospitals in whom PPC was routinely used were evaluated retrospectively. The patients were subdivided into 2 groups. Group I consisted of 754 (94.5%) children (449 [59.5%] girls and 305 [40.5%] boys) without OC. Median age was 41 months [Q1: 18.0; Q3: 81.0]. Group II comprised 44 (5.5%) patients (29 [65.9%] boys and 15 [34.1%] girls) experiencing OC, and their median age was 21.5 months [Q1: 12.0; Q3: 43.0]. Clinical and renal ultrasound examinations were carried out 1 day and 1 month after EC, and then every 6 months after EC. At the follow-up examination approximately 6 months after EC, voiding cysto-urethrography (VCUG) was performed. All patients with OC underwent diuretic renography.OC occurred in 44 (5.5%) of 798 children, in some cases as late as 60 months after endoscopic injection of the bulking agent PPC for correction of VUR. Univariate analysis revealed that younger age (P < .001), higher grade of VUR (P < .001), male gender (P < .001), second injection (P = .003), and EC injection using hydrodistension implantation technique (HIT; P < .001) represented significant risk factors. At multivariate analysis, only male gender (P = .0078), younger age (P = .0044), HIT technique (P < .0001), and second injection (P = .04) represented significant risk factors for the occurrence of OC.We identified young age, male gender, high reflux grade, HIT technique, and second endoscopic injections as factors associated with the risk of OC after EC of VUR using PPC as a bulking agent. Thus, patients who have undergone EC with PPC must be monitored sonographically for occurrence of OC for at least 60 months after the intervention.

A review of novel STING bulking agents

OBJECTIVE

The objective of this study was to review the literature to compare the efficacy and complications of polyacrylate-polyalcohol copolymer (PPC) and polyacrylamide hydrogel (PAHG) with the current standard of care, dextranomer/hyaluronic acid (Dx/HA), when used to treat VUR in the paediatric population.

METHODS

PubMed, Embase and Cochrane databases were searched. Keywords included Vesicoureteral reflux (VUR), endoscopic; endoscopic injection, endoscopic treatment, dulking material, dextranomer/hyaluronic acid copolymer, polyacrylate-polyalcohol copolymer, Deflux, Dexell, Vantris, Bulkamid, outcome, treatment and children. Prospective or retrospective studies comparing PAHG/PPC directly with Dx/HA were included for review.

RESULTS

Four studies were identified comparing PPC with Dx/HA. All studies showed superior efficacy (on micturating cystourethrogram (MCUG) at 3 months) of PPC over Dx/HA. However, 1 study identified a significantly higher rate of vesicoureteric junction obstruction (VUJO) in the PPC group. One study was identified comparing PAHG with Dx/HA which showed similar efficacy on 3-month MCUG.

CONCLUSIONS

Current data suggest PPC confers a higher resolution rate of VUR and PAHG confers comparable resolution rates for VUR compared with Dx/HA in the paediatric population. However, the incidence of late-onset VUJO in one study is concerning, and high-quality randomised controlled trials with long-term follow-up are needed before making further recommendations.

New bulking agent for the treatment of vesicoureteral reflux: Polymethylmethacrylate/dextranomer

Purpose

The aim of this study was to report preliminary results of endoscopic treatment of vesicoureteral reflux in children with a single injection of a new bulking agent, cross-linked dextran and polymethylmethacrylate mixture.

Materials and Methods

We performed a single-center, single surgeon, prospective, off-label study using polymethylmethacrylate/dextranomer to treat vesicoureteral reflux. All patients underwent endoscopic injection, followed by renal ultrasound and voiding cystourethrogram at 3 months postoperatively to identify de novo or worsening hydronephrosis and vesicoureteral reflux correction (to Grade 0 or I).

Results

Eighteen patients underwent injection of polymethylmethacrylate/dextranomer at our institution between April 2013 and December 2013. Ten were males and eight were females, with a median age of 58 months (range, 6 months to 5 years). Vesicoureteral reflux was unilateral in three patients and bilateral in 15, for a total of 33 renal refluxing units. Vesicoureteral reflux was Grade I in one renal refluxing unit, Grade II in 12, Grade III in 16, and Grade IV in four. Mean injected volume was 0.86 mL. Reflux was corrected in 23 renal refluxing units (69.7%) according to the 3-month voiding cystourethrogram. Complications included urinary retention in one patient. Mild pyelectasis was noted in one patient at 3 months, which spontaneously resolved 3 months later.

Conclusions

Our short-term data show that polymethylmethacrylate/dextranomer injection can be used to treat vesicoureteral reflux with comparable efficacy to other substances currently used and a low rate of complications. Long-term follow-up is required to confirm the usefulness of this material in treating vesicoureteral reflux.

Endoscopic correction of vesicoureteral reflux in children using polyacrylate-polyalcohol copolymer (Vantris): 5-years of prospective follow-up

Introduction

The endoscopic correction of vesicoureteral reflux (VUR) in children is a currently well accepted therapy in many pediatric urology centers. Polyacrylate-polyalcohol copolymer (PPC), namely Vantris^®, is one of the tissue-augmenting substances used for endoscopic reflux therapy. The aim of this study was to evaluate the results with PPC in children.

Material and methods

From 2012 to 2016, 125 children (73 girls and 52 boys) aged 0.6–17.9 years (mean 4.9 ±3.58) were treated with PPC. VUR was unilateral in 64 and bilateral in 61 patients, comprising 197 renal refluxing units (RRUs) grades: II in 72, III in 50, IV in 33 and V in 42. Of these primary reflux was present in 132 RRUs and 65 were complex cases. Voiding cystourethrogram (VCUG) was done 3 months after procedure.

Results

Follow-up was completed in 89.6% of patients (112 children), and 89.8% of RRUs (177 out of 197). Reflux resolved in 86.4% of RRUs after single injection, in 99.4% after second and in 100% after the third. The only significant, but serious complication observed was late ureteral obstruction after PPC injection correcting high grade reflux, which required ureteral re-implantation. This complication was found in 9 out of 112 children (8%), and in 11 out of 177 RRUs (6.2%), 1.1 -2.9 years (mean 2 ±0.7) after the PPC injection. The longest follow-up reaches 4.5 years.

Conclusions

Our data show that the PPC injection is an effective procedure for treating all grades of VUR with high success rate. However, because of the possibility of late ureteral obstruction, which requires ureteroneocystostomy, long-term follow-up is mandatory.

Endoscopic injection therapy

Since the U.S. Food and Drug Administration approved dextranomer/hyaluronic acid copolymer (Deflux) for the treatment of vesicoureteral reflux, endoscopic injection therapy using Deflux has become a popular alternative to open surgery and continuous antibiotic prophylaxis. Endoscopic correction with Deflux is minimally invasive, well tolerated, and provides cure rates approaching those of open surgery (i.e., approximately 80% in several studies). However, in recent years a less stringent approach to evaluating urinary tract infections (UTIs) and concerns about long-term efficacy and complications associated with endoscopic injection have limited the use of this therapy. In addition, there is little evidence supporting the efficacy of endoscopic injection therapy in preventing UTIs and vesicoureteral reflux-related renal scarring. In this report, we reviewed the current literature regarding endoscopic injection therapy and provided an updated overview of this topic.

Application of the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement to publications on endoscopic treatment for vesicoureteral reflux

OBJECTIVE

Following an increasing number of submissions on endoscopic treatment of vesicoureteral reflux (VUR), the Journal of Pediatric Urology sought to establish a quality guideline that would enable reviewers to select the best papers for publication in the journal. The "Strengthening the Reporting of Observational Studies in Epidemiology" (STROBE) Statement, established in 2007, is a 22-item checklist designed to assist with clear reporting of observational studies. This checklist includes a description of methodological items and instructions on how to use them to transparently report observational studies. The aim of the present study was to apply the STROBE principle to observational studies about endoscopic management of VUR, and to establish a "check-list" to assist authors with good-quality submissions.

STUDY DESIGN

The 22 STROBE criteria were listed and applied to publications on endoscopic treatment by utilizing examples from the current literature, with additional suggestions about how future studies could build upon the information already published on the subject.

RESULTS

Based on this strategy, a checklist that is particular to endoscopic treatment studies was produced as a guideline for authors and reviewers.

DISCUSSION

Application of the STROBE statement principles, in combination with key VUR data, will allow better quality submissions and a higher chance of positive reviews and acceptance rates.

Vesicoureteral reflux: From prophylaxis to surgery

Vesicoureteral reflux (VUR) is one of the most common pathologies encountered in pediatric urology. Better understanding of the evolution of VUR and new endoscopic surgical techniques in the last decades have led to major changes in the management of this pathology. However, the treatment algorithm remains complex and is composed of a wide variety of options, from active surveillance to surgical treatment. Herein, we propose to review treatment options for VUR in order to help clinicians make the right treatment decision for the right patient.