Dynamic Hydrodistention of the Ureteral Orifice: A Novel Grading System With High Interobserver Concordance and Correlation With Vesicoureteral Reflux Grade

Advancements in Surgical Management of Megaureters

PURPOSE OF REVIEW

To review and describe the recent evolution of surgery for the various types of pediatric megaureter.

RECENT FINDINGS

Megaureter management first relies on determining the underlying cause, whether by obstruction, reflux, or a combination, and then setting appropriate surgical indications because many cases do not require surgery as shown by observation studies. Endoscopic balloon dilation has been on the rise as a major treatment option for obstructive megaureter, while refluxing megaureters can also be treated by laparoscopic and robotic techniques, whether extravesically or transvesicoscopically. During ureteral reimplantation, tapering is sometimes necessary to address the enlarged ureter, but there are also considerations for not tapering or for tapering alternatives. Endoscopic and minimally invasive surgeries for megaureter have been the predominant focus of recent megaureter literature. These techniques still need collaborative prospective studies to better define which surgeries are best for patients needing megaureter interventions.

The correlation between ureteric orifice morphology and primary vesicoureteral reflux grade and the impact on the effectiveness of endoscopic reflux correction

INTRODUCTION

Early diagnosis and treatment of primary vesicoureteral reflux (VUR) are essential for preserving renal function.

OBJECTIVES

The study explored whether preoperative cystoscopic grading of refluxing ureteric orifices (UO) correlated with their shape in an institution with non-performance of hydrodistention of the UO in the diagnosis and grading of VUR. We also assessed the relationship between the UO shape and VUR grade with the effectiveness of endoscopic correction of primary VUR in children.

METHODS

This retrospective study included consecutive patients ≤15 years treated for primary VUR. The reflux grade was based on the results of preoperative voiding cystourethrography as mild, moderate, or severe.

RESULTS

Fifty-one patients with 77 renal refluxing units (RRU) underwent endoscopic treatment with Deflux®. VUR was bilateral in 51 % of patients. VUR was mild in 13 %, moderate in 53 %, and severe in 34 % of cases. The patients with mild and moderate VUR had stadium-shaped UOs in 60 % and 54 % RRUs, respectively. Horseshoe-shaped UOs constituted 42 % of UOs in patients with severe VUR, followed by 31 % of golf-hole UOs. The reflux resolution rate after the first endoscopic injection was 84 %. The preoperative VUR grade correlated with UOs shape (p < 0.001). No significant correlation between UOs configuration and the outcome of endoscopic treatment was seen (p = 0.452). The preoperative VUR grade negatively correlated with a favorable endoscopic treatment (p = 0.043).

DISCUSSION AND CONCLUSION

Our data indicate ureteral orifice shapes are closely related to preoperative VUR grade. There was no correlation between the UO configuration and the success rate of endoscopic treatment of VUR, in contrast to the significant negative correlation between the VUR grade and the success rate of endoscopic treatment.

Armamentarium to treat primary vesicoureteral reflux in children

Primary vesicoureteral reflux often spontaneously resolves in children. However, in select patients, untreated reflux can contribute to recurrent pyelonephritis leading to irreversible renal damage. Management is therefore based on a given child's likelihood of recurrent urinary tract infections and risk of subsequent renal parenchymal injury. Therapeutic options for urinary reflux are diverse, ranging from observation with or without continuous low-dose antibiotic prophylaxis to a variety of operative interventions.

Do Volume of Injection and Learning Curve Influence the Results of Endoscopic Correction of Vesicoureteric Reflux Using Dextranomer/Hyaluronic Acid? A Single Surgeon Experience

Background: Available reports regarding the technical factors for successful endoscopic treatment (ET) of vesicoureteric reflux (VUR) using dextranomer/hyaluronic acid copolymer are inconclusive. We studied single-surgeon data to evaluate the association of injected volume and surgeon experience with success after ET for VUR. Materials and Methods: Fifty-eight children (87 ureters) with grades 2-4 primary VUR were included. Success was defined as complete resolution of reflux on follow-up imaging. Volume of injection between success and failed groups was analyzed; volume of injection was further studied using receiver operating characteristic curve (ROC) analysis. Patients were then divided into two groups: group 1 (early experience) and group 2 (later experience). Both groups were compared for age, grade of reflux, volume of injection, and success. Results: Overall success of one injection was 76%. The mean volume of injection was significantly larger in successful ureters than failed ureters (P = .008). On ROC analysis, the volume of 0.75 mL (area under curve 0.747, 95% confidence interval 0.60-0.89) had a good discriminative ability to predict success of the injection procedure. Furthermore, a volume cutoff of 0.8 mL demonstrated significant influence on success (success 14/25 ureters for <0.8 mL and 36/42 ureters for 0.8 mL or more volume of injection, P = .0097), whereas no difference in success was observed with a cutoff volume of 0.9 mL (P = .2480). When the patients were divided into two groups based on surgeon experience, group 2 demonstrated better success than group 1 (84% versus 65%, P = .04). Both groups were comparable for age (P = .09), grade of reflux (0.46) and the median volume of injection was similar (0.8 mL) in both the groups. Conclusions: We found that a minimal volume of 0.75 mL dextranomer/hyaluronic acid injection may be required to achieve success of ET in moderate grade primary VUR. Success also improved with increasing surgeon experience.

Evolving surgical management of pediatric vesicoureteral reflux: is open ureteral reimplantation still the 'Gold Standard'?

Vesicoureteral reflux, the retrograde flow of urine from the bladder into the upper urinary tract, is one of the most common urologic diagnoses in the pediatric population. Once detected, therapeutic options for urinary reflux are diverse, ranging from observation with or without continuous low-dose prophylactic antibiotics to a variety of operative interventions. While a standardized algorithm is lacking, it is generally accepted that management be tailored to individual patients based on various factors including age, likelihood of spontaneous resolution, risk of subsequent urinary tract infections with renal parenchymal injury, and parental preference. Anti-reflux surgery may be necessary in children with persistent reflux, renal scarring or recurrent pyelonephritis after optimization of bladder and bowel habits. Open, laparoscopic/robot-assisted and endoscopic approaches are all successful in correcting reflux and have been shown to reduce the incidence of febrile urinary tract infections.

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.

Diagnostic value of hydrodistention of the ureteral orifice

INTRODUCTION/OBJECTIVE

The dynamic hydrodistention (HD) classification is a basic and objective way of rating the ureteral orifice opening. This study evaluated the value of hydrodistention of the ureteral orifice in the diagnosis of vesicoureteral reflux (VUR).

MATERIAL AND METHODS

Between January 2012 and March 2013 the HD grade in 106 ureters was prospectively assigned. A 9.5-Fr rigid cystoscope with a 0-degree lens was used in all procedures. Warm saline was used and the irrigation bag was placed approximately 1 m above the bladder level on full flow. The grading is as follows: H0 denotes absence of ureteral dilation; H1 indicates dilation of the ureteral orifice only; H2 allows visualization of the intramural ureter; and H3 allows visualization of the extramural ureter. Indications for cystoscopy were endoscopic and open surgical treatment of VUR, stent removal, and any other diagnostic reasons. Exclusion criteria were patients with: infravesical obstruction, neuropathic bladder, severe detrusor over activity/dysfunctional voiding, duplex system, paraureteral diverticulum, bladder exstrophy and grade-1 VUR. The 51 refluxing ureters (RUs) were compared with 55 non-refluxing ureters (NRUs). Finally, sensitivity, specificity, positive and negative predictive values, and accuracy rate of HD were evaluated.

RESULTS

A total of 106 ureters in 61 patients with a mean age of 5.3 ± 3.9 years (range 2 months-15 years, median 5 years) were prospectively assigned. The mean HD grade in the RUs was 2.17 ± 0.55. The mean HD grades were 2.0 ± 0.63, 2.07 ± 0.53, 2.38 ± 0.5 and 2.5 ± 0.57 for VUR grades 2-5, respectively. The mean HD grade in the NRUs was 1.60 ± 0.70. The HD grades were H0 to H3 in 7.3%, 30.9%, 56.4% and 5.4% of the NRUs, respectively. The RUs group (2.17 ± 0.55) showed a statistically higher HD grade than the NRUs group (1.60 ± 0.70) (P < 0.005). Sensitivity, specificity, positive and negative predictive values, and accuracy rate of HD grading in the diagnosis of VUR were 92%, 38%, 58%, 84%, and 64%, respectively. The mean HD grade in contralateral ureters of unilateral VUR was 1.55 ± 0.72 and HD grades were H0-H3 in 0%, 55.6%, 33.3% and 11.1% of these nine ureters, respectively. In these nine non-refluxing contralateral ureters, after endoscopic correction of ipsilateral VUR, new contralateral VUR did not occur.

CONCLUSION

Even though HD grade was high in the VUR group and popularity of the HD grading is on the increase, HD grading by itself still has a low diagnostic value.

Persistence and recurrence of vesicoureteric reflux in children after endoscopic therapy - implications of a risk-adapted follow-up

Introduction

There is no well-defined follow-up scheme available to reliably detect persistent or recurrent vesicoureteric reflux (VUR) after endoscopic therapy (ET), but also to reduce postoperative invasive diagnostics in these children.

Our aim was the evaluation of possible predictors of persistence and recurrence of VUR, in order to elaborate and test a risk-adapted follow-up regimen.

Material and methods

92 patients (85/92%f, 7/8%m, age 2.99y) underwent direct isotope cystography (DIC) three months after ET. Persistent or recurrent VUR, scarring on dimercaptosuccinic acid (DMSA) scans and further fUTIs after therapy (follow-up 24.6 m) were documented and analysed.

Results

VUR persistence 3 months after ET was found in 11 (11.9%) patients; recurrent VUR in 4 (4.3%) patients. Scarring on preoperative DMSA and dilating VUR (°III and °IV) were significantly associated with recurrent VUR. If only children with preoperative positive DMSA scan or dilating VUR would have undergone DIC, only 58/92 DICs (64%) would have been necessary. Only 45.5% of otherwise detected VURs would have been identified using this risk-adapted strategy.

Conclusions

Limiting invasive follow-up diagnostics (VCUG) and, therewith, the radiation burden in a predefined group of patients at risk for persistence or recurrence of VUR is not recommended, due to the significant chance of missing persistent or new onset contralateral VUR. Therefore, we recommend a routine follow-up VCUG after ET. Further prospective scientific efforts to evaluate new, alternative factors influencing persistence and recurrence of VUR, in order to establish an effective follow-up strategy, are warranted.

Is routine voiding cystourethrogram necessary following double hit for primary vesicoureteral reflux?

INTRODUCTION AND OBJECTIVE

Current AUA guidelines recommend voiding cystourethrogram (VCUG) following endoscopic treatment of vesicoureteral reflux (VUR). We evaluated the clinical and radiographic outcomes of children undergoing Double HIT (hydrodistention implantation technique) for primary VUR to determine success rates and the necessity of postoperative VCUG.

STUDY DESIGN

Children with a history of febrile urinary tract infection (fUTI) undergoing Double HIT for primary VUR between 2009 and 2012 were identified. Patients were prospectively classified as high or low clinical and radiographic risk. Children were categorized as high clinical risk if they had ≥ 3 fUTIs or documented bladder bowel dysfunction (BBD). High radiographic risk included those <2 years of age or with grade 4-5 VUR. Initially, all children underwent postoperative VCUG ("routine" group), while only those with an indication (high radiographic risk or clinical failure) did so during the latter portion of the study ("indicated" group). Clinical success was defined as no postoperative fUTI and radiographic success as negative postoperative VCUG. Average clinical follow-up was 34.7 ± 17.2 months.

RESULTS

Two hundred and twenty-two children (198 girls, 24 boys) underwent Double HIT at a mean age of 4.1 ± 2.7 years. Mean maximum VUR grade was 3 ± 0.8. Sixty-eight children (30.6%) had documented BBD. Fourteen children (6.3%) experienced postoperative fUTI, for a clinical success rate of 93.7%. One hundred and fourteen patients (51.4%) underwent postoperative VCUG; 76 were "routine" and 38 were "indicated" [Figure]. Of children classified as low clinical/radiographic risk, 96.6% did not have a postoperative fUTI, compared to 91.1% for high risk patients (P = 0.771). Odds of clinical success for routine VCUG group were 9.9 times higher than for the indicated VCUG group (95% CI, 2-50). Odds of radiographic success for the routine cohort were 13 times higher than for the indicated group (95% CI, 4.2-40). Nine children (4.1%) underwent additional procedures.

DISCUSSION

We found no difference in clinical success among the different risk groups; the number of children with postoperative fUTI was relatively few so there was not statistical power to discern any differences between patients who experienced clinical success versus clinical failure. However, children with an "indicated" VCUG (i.e. those less than 2 years of age, grade 4-5 VUR or those with a fUTI) were 13 times more likely to experience a radiographic failure. This cohort of 38 patients had a 50% radiographic cure rate and a 78.9% clinical cure rate, compared to the overall long-term clinical success rate of 93.7%. Our data demonstrates that we can predict failures with relatively high sensitivity, and it may therefore be prudent to selectively obtain postoperative VCUG rather than recommend it for all children undergoing dextranomer hyaluronic acid co-polymer (Dx/HA) injection. Our study has several limitations that warrant consideration. Not all children underwent a postoperative VCUG, so the true radiographic success rate is unknown. Incidence of fUTI may also be artificially low, as some radiographic failures proceeded directly to another injection or reimplantation. While we were able to demonstrate that children undergoing an "indicated" VCUG were more likely to experience radiographic failure, a larger patient cohort is necessary to determine whether age or VUR grade is more predictive of failure. Finally all patients underwent endoscopic Dx/HA injection, therefore the incidence "spontaneous resolution" is unknown.

CONCLUSION

Long-term clinical success following Double HIT for the endoscopic correction of primary VUR is high, and the majority of children avoid additional procedures. Unless indicated by high-grade, young age, clinical failure, or family/surgeon preference, consideration should be given to making postoperative VCUG an option rather than a recommendation in children undergoing endoscopic treatment of primary VUR using the Double HIT method.

Effective endoscopic diagnosis and treatment of pediatric occult vesicoureteral reflux with intermediate to long-term follow-up

PURPOSE

Recurrent febrile urinary tract infections (fUTIs) in children with non-diagnostic voiding cystourethrogram (VCUG) are challenging, as misdiagnosis can lead to renal damage and increased morbidity. We compared fUTI rates before and after endoscopic treatment of patients with suspected occult VUR.

METHODS

Between January 2009 and December 2012, children with history of fUTI and non-diagnostic VCUG(s) underwent endoscopic ureteral hydrodistention (HD) and injection of dextranomer hyaluronic acid co-polymer (Dx/HA). fUTI rates before and after intervention were evaluated. Demographics, imaging and endoscopic findings were assessed.

RESULTS

Thirty-four children (mean age 5.4±2.8 years) underwent bilateral Dx/HA injection for occult VUR. Average follow-up was 28.8 months. Seventeen children had renal scarring. Mean ureteral HD grade was 2.2/3. HD grade for ureters associated with renal scarring was significantly (p<0.05) higher (2.6/3) than those without scarring (2.0/3). Mean injected volume was 1.2 mL. Ureters associated with renal scarring (n=21) required significantly (p<0.05) higher volumes (1.4 mL) than those without scarring (n=47; 1.1 mL). Prior to intervention, the fUTI rate was 0.15/patient/month compared to just 0.02 after treatment (p<0.0001).

CONCLUSIONS

Incidence of fUTIs significantly decreased following treatment, supporting the use of Dx/HA injection in carefully selected children when the suspicion for occult VUR is high.

Intraoperative cystography pre- and post-endoscopic treatment for vesicoureteral reflux: guaranteed success?

OBJECTIVE

This study was designed to investigate whether post-endoscopic treatment (ET) intraoperative cystography is predictive of treatment outcome.

PATIENTS AND METHODS

Patients diagnosed with vesicoureteral reflux (VUR) and treated endoscopically with polyacrylate/polyalcohol copolymer or dextranomer hyaluronic acid were studied prospectively between August 2009 and April 2011. Slow infusion pre-ET cystography was performed under anesthesia. Post-ET cystography was performed only if the intraoperative pre-ET results demonstrated VUR.

RESULTS

Over a period of 20 months, 23 patients were studied (18 girls, five boys), with an average age of 41.9 months (range 13 months-11 years). Thirty-two renal units with reflux were treated: nine bilateral cases, seven right, and seven left. The distribution of reflux grades was as follows: two grade I, 10 grade II, 11 grade III, nine grade IV. All injected ureters demonstrated grade 0 hydrodistention after the procedure. Twelve of 23 of the pre-ET cystography results were negative for VUR, indicating that the sensitivity of this test is 47% compared with the preoperative voiding cystourethrography (VCUG) or nuclear cystogram. There were no procedure complications.

CONCLUSION

Of all patients (n = 23), nearly 60% did not demonstrate pre-ET VUR on intraoperative cystography. If a postoperative VCUG had been performed on all patients, more than half would have received unnecessary radiation. Therefore, this study demonstrates that post-ET cystography does not predict the success of ET of VUR intraoperative. Pre-ET cystography under general anesthesia before ureteral injection, has very low sensitivity, creating false-negatives that may complicate the interpretation of post-ET cystography. We suggest that intraoperative cystography before and after ET fails to show clinical utility and should not be used to predict the outcome of endoscopic VUR treatment.

A comparison of the double hydrodistention implantation technique (HIT) and the HIT with a polyacrylate/polyalcohol copolymer (PPC) for the endoscopic treatment of primary vesicoureteral reflux

OBJECTIVES

We aimed to compare the success rates of the double hydrodistention implantation technique (HIT) and the HIT with a polyacrylate/polyalcohol copolymer (PPC) for the treatment of primary vesicoureteral reflux (VUR) with a new nonbiodegradable tissue-augmenting substance (Vantris, Promedon, Cordoba, Argentina).

METHODS

Between January 2011 and December 2012, fifty-two children who underwent subureteric injection for primary VUR are included. The children were randomly separated into two groups, the HIT and the double HIT groups, according to the type of injection. Success was defined as no reflux on a follow-up voiding cystourethrogram (VCUG) after 6 months. The patients were evaluated according to sex, age, grade of reflux, number of injections, and injected volume, and the radiological success rates were compared.

RESULTS

Fifty-two patients underwent an endoscopic injection for primary grade III-V VUR. The HIT group consisted of 26 patients with 33 ureters, and the double HIT group consisted of 26 patients with 35 ureters. There were no significant differences in terms of the sex, ages, VUR grades, bilaterality between the two groups. The mean injected volumes were ml 1.12 (1.02-1.22) in the HIT group and 1.24 ml (95 % CI 1.10-1.38) in the double HIT group. The reflux was resolved in 21/33 (63.6 %) ureters in the HIT group and in 30/35 (85.7 %) ureters in the double HIT group, (p < 0.05). We had only one complication. This patient in the double HIT group, developed bilateral hydronephrosis and oliguric renal failure requiring open reimplantation at the sixth month.

CONCLUSION

We observed successful results double HIT method with PPC in Grade III-V reflux, but the long-term follow-up of patients is needed for hydronephrosis. As the double HIT treatment leads to a higher success rate, its use is preferable.

Evaluation of new Deflux administration techniques: intraureteric HIT and Double HIT for the endoscopic correction of vesicoureteral reflux

Vesicoureteral reflux (VUR) is one of the most common urologic diagnoses affecting children, and optimal treatment requires an individualized approach that considers potential risks. Management options include observation with or without continuous antibiotic prophylaxis and surgical correction via endoscopic, open or laparoscopic/robotic approaches. Endoscopic correction of VUR is an outpatient procedure associated with decreased morbidity compared with ureteral reimplantation. The concept of ureteral hydrodistention and intraluminal submucosal injection (Hydrodistention Implantation Technique [HIT]) has led to improved success rates in eliminating VUR compared with the subureteral transurethral injection technique. Further modifications now include use of proximal and distal intraluminal injections (Double HIT) that result in coaptation of both the ureteral tunnel and orifice. Endoscopic injection of dextranomer/hyaluronic acid copolymer, via the HIT and Double HIT, has emerged as a highly successful, minimally invasive alternative to open surgical correction, with minimal associated morbidity.

Clinical outcome after endoscopic therapy for occult vesicoureteral reflux in females: preliminary results of a retrospective case series

OBJECTIVE

The aim of this study was to evaluate the clinical outcome after endoscopic therapy by injection of bulking agent in the treatment of occult vesicoureteral reflux (VUR) [no VUR on standard voiding cystourethrography (VCUG), but positive (99m)Tc-2,3-dimercaptosuccinic acid (DMSA) scan] in females who have recurrent febrile urinary tract infections (UTIs).

MATERIAL AND METHODS

A case series was retrospectively identified of 24 females (mean age 15.5 years) with negative VCUG, but renal scars in one (n = 4) or both (n = 20) kidneys on DMSA scan. Endoscopic injection was performed bilaterally in 20 (83.3%) and unilaterally in four patients (16.7%). The incidence of postoperative UTIs was documented with a mean follow-up of 2.5 years (range 1-6 years).

RESULTS

The mean renal part function (DMSA scan) on the left and right sides was 53.5% (15-74%) and 47.3% (26-85%), respectively. Twenty-one out of 24 patients (87.5%) showed no evidence of any febrile UTIs postoperatively. One patient (4.2%) experienced a further febrile UTI 6 months after treatment. Two other patients (8.3%) had one questionable afebrile UTI, 4 and 3 years after therapy. Pressure-flow electromyography confirmed a dysfunctional voiding pattern in 12 patients (50%) treated with pelvic floor therapy and behavioural interventions before endoscopic therapy.

CONCLUSIONS

Injection of bulking agent seems to be a suitable treatment for occult VUR in females to prevent further febrile UTIs. Patients with occult VUR should undergo a careful evaluation of possible urodynamic disorders such as dysfunctional voiding. These findings should be studied in prospective trials before drawing any conclusions.

Endoscopic treatment of vesicoureteral reflux in pediatric patients

Endoscopic treatment is a minimally invasive treatment for managing patients with vesicoureteral reflux (VUR). Although several bulking agents have been used for endoscopic treatment, dextranomer/hyaluronic acid is the only bulking agent currently approved by the U.S. Food and Drug Administration for treating VUR. Endoscopic treatment of VUR has gained great popularity owing to several obvious benefits, including short operative time, short hospital stay, minimal invasiveness, high efficacy, low complication rate, and reduced cost. Initially, the success rates of endoscopic treatment have been lower than that of open antireflux surgery. However, because injection techniques have been developed, a recent study showed higher success rates of endoscopic treatment than open surgery in the treatment of patients with intermediate- and high-grade VUR. Despite the controversy surrounding its effectiveness, endoscopic treatment is considered a valuable treatment option and viable alternative to long-term antibiotic prophylaxis.

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.

Observational, medical or surgical management of vesicoureteric reflux

The clinical management of vesicoureteric reflux includes observational, medical and surgical procedures. The choice of management is often a joint decision made between the paediatric nephrologist and urologist. The use of prophylactic antibiotics has become increasingly debated. In recent years, the surgical treatment of reflux (including endoscopic intervention or ureteral reimplantation) has mainly been limited to cases of high-grade reflux. There are several important risk factors that influence the final outcome which need to be identified and treated. The aim of reflux management is no longer to treat imperatively, but rather to avoid renal damage. It is perhaps time to revise the classic saying 'diagnosed reflux - treated reflux' with a new objective 'diagnosed reflux - evaluated reflux'.

CONCLUSION

The management and follow-up of childhood reflux is a joint decision between the paediatric urologist and nephrologist and should be decided on a case-by-case basis.

Selective endoscopic treatment of the non-refluxing contralateral ureter prevents new contralateral vesicoureteral reflux

OBJECTIVE

The objective of this study was to evaluate risk factors for new contralateral vesicoureteral reflux (NCVUR) and to investigate whether assessment of the non-refluxing contralateral ureter (NRCU) by hydrodistention and selective treatment can reduce the incidence of NCVUR.

MATERIALS AND METHODS

From 2001 to 2007, 339 of 841 patients (40%) were treated for unilateral VUR by endoscopic injection. While in the first 267 patients the NRCU was only assessed by hydrodistention but not injected (observation group), NRCUs of the subsequent 72 patients were prophylactically treated if deemed at high risk for NCVUR (H2 or H3) (prophylaxis group).

RESULTS

NCVUR occurred in 30 of 267 patients (11.2%) whose NRCUs were observed. No statistically significant risk factors for NCVUR were found in this group. In the subsequent 72 patients, whose H2 and H3 ureters were selectively injected (N = 56), no cases of NCVUR were seen.

CONCLUSIONS

Prophylactic endoscopic treatment of NRCU H2 and H3 ureters successfully prevented the occurrence of NCVUR.

Intraureteral injection of NASHA/Dx gel under direct ureteroscopic visualization for the treatment of primary high-grade vesicoureteral reflux

OBJECTIVE

To present a preliminary experience with the modified technique of extravesical intraureteral injection of non-animal-stabilized hyaluronic acid/dextranomer (NASHA/Dx) gel under direct ureteroscopic visualization for the treatment of primary high-grade vesicoureteral reflux (VUR).

PATIENTS AND METHODS

The medical records of all pediatric patients (age range, 0-14 years) who underwent intraureteral injection of NASHA/Dx gel under direct ureteroscopic visualization for the treatment of primary high-grade VUR during the period June 2006-June 2010 were reviewed.

RESULTS

Eighty-nine children (61 boys, 28 girls; M:F ratio, 2.1) underwent intraureteral injection of NASHA/Dx gel under direct ureteroscopic visualization for the treatment of primary high-grade VUR during the study period. VUR completely disappeared after the injection of NASHA/Dx gel into 105 (73%) of 144 ureters, with no further treatment required. Thirty-five (24.3%) required a second injection, and 2 (1.4%) required a third injection for resolution of their VUR. No intraoperative complications were observed. No ureteral obstruction during follow-up was observed using ultrasound or micturition studies.

CONCLUSIONS

Intraureteral injection of NASHA/Dx gel under direct ureteroscopic visualization is safe and effective in the treatment of primary high-grade VUR, including cases with ureteral duplication, if the ureteral meatus is easy to pass through without mechanical dilation. This approach represents an effective and safe alternative to antibiotic prophylaxis alone and open surgery.

Intermediate to long-term follow-up indicates low risk of recurrence after Double HIT endoscopic treatment for primary vesico-ureteral reflux

PURPOSE

Follow-up of patients undergoing dextranomer/hyaluronic acid injection for vesico-ureteral reflux (VUR) is controversial. The purpose of our study was to test the hypothesis that patients undergoing the double hydrodistention-implantation technique (Double HIT) have a higher clinical and radiographic success rate.

MATERIALS AND METHODS

Patients undergoing Double HIT endoscopic injection for VUR were prospectively identified. Patients underwent an ultrasound at 6 weeks to assess the implants, and, if visible, prophylactic antibiotics were discontinued and patients were scheduled for a 1-year voiding cystourethrogram (VCUG). Radiographic success was defined as a negative VCUG and clinical success as no febrile urinary tract infections at 1 year.

RESULTS

A total of 54 patients underwent endoscopic injection for VUR. Twenty-five (51%) were compliant with the 1 year follow-up; 18 non-compliant patients were contacted and their clinical status assessed. Thirty patients eventually completed the 1-year VCUG at a mean of 12.2 months (range 10-20). Among the 60% of patients with 1-year radiographic follow-up, 2 had persistent VUR for a radiologic success rate of 93%. All radiographic failures were infection-free. Of the 80% (43/54) of patients with available clinical data, 3 (7%) had afebrile UTI for a clinical success rate of 93%.

CONCLUSIONS

The Double HIT leads to a 93% clinical and 93% radiographic intermediate/long-term success rate. With this technique, better outcomes were achieved with fewer recurrences than previously reported. These favorable results challenge the need for postoperative VCUG in asymptomatic patients after the Double HIT.

Does compliance status predict clinical status in patients undergoing endoscopic management of vesico-ureteral reflux?

OBJECTIVE

Previous studies of endoscopic management of vesico-ureteral reflux (VUR) have had non-compliance rates around 50%. We examined success rates of patients non-compliant with a delayed follow up protocol after endoscopic injection for VUR.

MATERIALS AND METHODS

Patients undergoing Double HIT, dextranomer/hyaluronic acid copolymer endoscopic injection for VUR were enrolled in a 1-year, delayed voiding cysto-urethrogram (VCUG) study. All patients non-compliant with the VCUG were contacted and information on their clinical status was collected. Non-compliant patients were re-scheduled for a VCUG.

RESULTS

49/54 (91%) patients underwent endoscopic injection for VUR and completed the 6-week ultrasound. At 1-year 49% (24/49) were non-compliant with a VCUG; 75% (18/24) were contacted and provided clinical information. All but one patient agreed to the VCUG. Patients compliant with the 1-year VCUG showed 96% (24/25) clinical and 92% (23/25) radiologic success rates. Non-compliant patients had an 89% (16/18) clinical success rate; 5 (21%) non-compliant patients underwent VCUGs with a 100% success rate.

CONCLUSIONS

Long-term compliance remains an issue for patients treated endoscopically for VUR, but compliance does not predict clinical status as both groups have favorable clinical outcomes. The repeat VCUG is a barrier to long-term follow up as only 21% of patients underwent the study.

Endoscopic treatment of vesicoureteral reflux in a paediatric surgery ambulatory unit

BACKGROUND:

Vesicoureteral reflux (VUR) is a major urological problem in children. Its incidence ranges from 1 to 3% in healthy children.

MATERIALS AND METHODS:

We treated 38 children and analysed their data on age, sex, reflux grade, laterality, and results of endoscopic treatment (ET), at the different grades of reflux. All children were operated on an Ambulatory Surgery basis, studying the complications and post-operative course.

RESULTS:

Thirty-eight patients were operated during a period of six years, of age between one and twelve years. VUR was bilateral in 24 (63%) patients, unilateral in 14 (34%), with a collection of a total of 62 renal units or ureters. In 29 children (76%), 46 refluxing ureters (70%) completely disappeared after just 1 ET. Nine patients (24%) with 16 ureteral units (30%) received a second ET, with the reflux disappearing successfully in seven children (12 ureteral units), changing the success rate in the disappearance of VUR, after two injections of Deflux, to 90% of the total group of ureters (58 of 62).

CONCLUSION:

The endoscopic treatment of VUR has become the first choice of treatment to control the primary reflux, not just because of the good results, but because of the low post-operative morbidity and the direct relationship with the Ambulatory Surgery Unit.