Durability of a Single Successful Endoscopic Polytetrafluoroethylene Injection for Primary Vesicoureteral Reflux: 14-Year Followup Results

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.

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.

Current medical diagnosis and management of vesicoureteral reflux in children

Vesico-ureteral reflux (VUR) is presented in approximately %1 of children and is associated with an increased risk of pyelonephritis and renal scarring. Despite its prevalence and morbidity, many aspects of VUR diagnosis and treatment are controversial. We objectively assessed the published data; the data base for many current diagnoses and treatment patterns of VUR is limited. Recent studies have focused on developed determination of VUR-related renal morbidity, improved stratification tools that children would benefit most from which VUR treatment option, and improved reporting of the long-term outcomes of VUR treatments in children who are at risk for VUR. In this review, the advances in the diagnosis and treatment of VUR will be accompanied by the current guidelines.

The influence of ureteral orifice configuration on the success rate of endoscopic treatment of vesicoureteral reflux

Background:

To investigate the effect of polyacrylate polyalcohol copolymer (Vantris) injection for the correction of VUR in children according to ureteral orifice shape and VUR grade.

Materials and Methods:

Forty children (29 girls and 11 boys) with 61 renal refluxing units (RRU) and primary VUR underwent endoscopic correction of their reflux, using Vantris. Under general anesthesia, routine cystoscopy was performed and ureteral orifice configuration and dynamic hydro distention grade were determined. The injection technique was STING, HIT or a combination of them. Ultrasound scan was performed one and 3 months after injection and radionuclide cystography (RNC) was performed 3 months after the operation.

Results:

The mean volume of injected Vantris was 0.62 cc. Reflux was corrected in 52 (85.2%) of the 61 RRU after single injection and this equates reflux correction in 37 of the 40 patients. No significant correlation was observed between ureteral orifice shape and VUR correction rate.

Conclusions:

Our results showed that there was no correlation between the ureteral orifice configuration and the success rate of endoscopic surgery for VUR in short term.

Durability of antireflux effect of ureteral reimplantation for primary vesicoureteral reflux: findings on long-term cystography

OBJECTIVE

To evaluate the long-term durability of successful ureteral reimplantation (UR) for vesicoureteral reflux (VUR) through a review of late cystography (LC) findings.

MATERIALS AND METHODS

We performed a retrospective chart review of all children with primary VUR who underwent successful open UR (grade 0 VUR into the reimplanted ureter[s] on initial cystogram) at our institution from January 1990 to December 2002. We identified successful UR patients who underwent LC ≥ 1 year after UR and reviewed the results for the presence of recurrent VUR into the reimplanted ureter(s).

RESULTS

Seven-hundred ninety-four patients underwent successful open UR for primary VUR, of whom 60 (7.6%) had a subsequent LC. Preoperative VUR grade was ≤ II in 20 (34.5%) and ≥ III in 38 (65.5%). Median age at UR was 3.5 years (IQR 1.3-6.2 years); 51 (85%) were female. UR was intravesical in 45 (75%) and bilateral in 19 (32%). LC was performed at a median of 38.7 months after UR (IQR 19.6-66.1 months). Indication for LC was febrile urinary tract infection (UTI) in 16 (27%), nonfebrile UTIs in 15 (25%), follow-up of contralateral VUR in 16 (27%), and other clinical indications in 13 (21%). The recurrence rate was 0%; of the 79 reimplanted ureters, 100% (95% CI 95.4-100) had no VUR (grade 0).

CONCLUSION

Among children who underwent successful open UR for primary VUR, there was no VUR recurrence on extended follow-up. This suggests that the late durability of open antireflux surgery is excellent.