Renal scarring and urinary tract infection after successful endoscopic correction of vesicoureteral reflux

Laparoscopic and Robot-assisted Laparoscopic Reimplantation for Lower Ureter Pathology. A Multi-institutional Comparative Study in 1343 Patients

OBJECTIVE

To evaluate the outcomes of children with vesicoureteral reflux (VUR) and obstructive megaureter (OM) utilizing various laparoscopic and robot-assisted approaches.

MATERIALS AND METHODS

Retrospective review of all pediatric laparoscopic and robot-assisted cases for lower ureter pathology was performed between 2016-2022 in 13 academic centers worldwide. Five surgical approaches were assessed: LEUR, LVCUR, LDECUR, RALUR, and RADECUR.

RESULTS

One thousand three hundred forty-three patients (490 boys and 853 girls) with a median age of 30 months (IQR 12-63) were treated at 13 centers. Nine hundred and eight patients (68%) underwent reimplantation due to VUR (unilateral in 818 and bilateral in 90 patients). Four hundred thirty-five (32%) had a surgery due to ureterovesical junction (UVJ) obstruction. Mean length of follow-up was 14 months (IQR 8-33). Median operative time was 202 minutes (IQR 142-220) in the robotic arm compared to 240 minutes (IQR 160-267) in the laparoscopic (P = .45). Intracorporeal excisional tapering was performed in 118 (8%) of the patients. Six patients in the OM group required additional surgery due to progressive obstruction. In the VUR group, 84% underwent voiding cystourethrography postoperatively. 5.6% showed residual reflux. Grade 1-2 Clavien-Dindo complications occurred in 10 patients (0.7%) and 6 (0.4%) in the laparoscopic and robotic arm, respectively. Grade 3 complications occurred in 17 (1.2%) and 8 (0.5%) in both arms, respectively. Surgical success was achieved in 96% of patients.

CONCLUSION

Laparoscopic and robot-assisted laparoscopic approaches are simple, safe, and effective for treating all grades of VUR and OM. Robot-assisted approach is beneficial in terms of operative time, intracorporeal suturing, and lower complications rate.

A novel endoscopic approach for management of hutch diverticulum concomitant vesicoureteral reflux with dextranomer/hyaluronic acid copolymer injection

INTRODUCTION

There are various treatment options for symptomatic bladder diverticulum, including robotic-assisted laparoscopic bladder diverticulectomy, open and endoscopic techniques. But, to date, the optimal surgical technique remains unclear.

OBJECTIVE

To present the preliminary long-term follow-up results of a novel technique of dextranomer/hyaluronic acid copolymer (Deflux) plus autologous blood injection for correction of hutch diverticulum in patients with concomitant vesicoureteral reflux (VUR).

PATIENT AND METHOD

We retrospectively reviewed four patients who had hutch diverticulum with concomitant VUR and had undergone submucosal Deflux following autologous blood injection. Patients with neurogenic bladder, posterior urethral valve, or voiding dysfunction were excluded from the study. Success was defined as the resolution of the diverticulum, hydronephrosis, and hydroureter on ultrasonography at a 3-month follow-up and long-term symptom-free period.

RESULTS

Four patients with hutch diverticula were included. The median age at the time of surgery was 6.1 (range 3-8) years. Three of them had unilateral VUR, and one had bilateral VUR. During the procedure, a mean of 0.625 ml Deflux plus a mean of 1.25 ml autologous blood were injected submucosally for correction of VUR. Additionally, a mean of 1.62 ml Deflux plus a mean of 1.75 ml autologous blood were injected submucosally to occlude the diverticulum. The median follow-up was 4.6 (range 4-8) years. This method had excellent success in all patients in the current study with no postoperative complications such as febrile urinary tract infection, or diverticulum, hydroureter, or hydronephrosis in follow-up ultrasounds.

CONCLUSIONS

Submucosal injection of Deflux plus autologous blood injection can be a successful endoscopic intervention for treatments of hutch diverticulum in patients with concomitant VUR. Deflux injection can be a simple and cost-effective technique.

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 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.

High-grade vesicoureteral reflux in infants: Our experience with endoscopic subureteric injections

BACKGROUND

Vesicoureteral reflux (VUR) is the most common urological anomaly in pediatric patients. Management options for VUR vary from continuous antibiotic prophylaxis (CAP) to surgery via either endoscopic subureteric injection of a bulking agent or open anti-reflux surgery. In this study, we assess the efficacy of subureteric injections of Dextranomer/Hyaluronic acid Copolymer (Deflux) in managing primary VUR in infant patients with high-grade VUR.

METHODS

From 2010 to 2015, children less than 1-year-old with primary high-grade VUR were observed prospectively following the administration of endoscopic subureteric injections of Dextranomer/Hyaluronic Acid Copolymer (Deflux). The diagnosis of VUR was based on MCUG, and all patients underwent a holistic clinical, laboratory, and radiological assessment before and after the intervention. Complete success was defined as the resolution of VUR on follow up 1 year post-operatively.

RESULTS

A total of 30 infants (50 renal units) with high-grade VUR (grades IV and V) were included in the study. The mean age at surgery was 6.3 ± 2.5 months. Most of the patients presented with a urinary tract infection (90%). Complete symptomatic relief was achieved in 27 patients (90%) at the first post-operative follow-up. Forty-four renal units received one injection, while six required a second injection as they did not meet our treatment success criteria. No patients required a third injection or referral for open surgery.

CONCLUSION

Endoscopic injection of Dextranomer/Hyaluronic acid Copolymer (Deflux) at the vesicoureteral junction is an effective minimally invasive intervention to treat high grades VUR (IV-V) infants.

Does endoscopic puncture of ureterocele provide not only an initial solution, but also a definitive treatment in all children? Over the 26 years of experience

PURPOSE

We have retrospectively evaluated all patients who underwent endoscopic puncture (EP) of ureterocele over the last 26 years with special reference to the need in the second intervention and disease-free status.

METHODS

78 (69%) of the 112 patients following EP and completed follow-up were included. 51 (65%) were diagnosed prenatally and 27 (35%) postnatally. 46 patients (60%) had intravesical, while 32 (40%) had ectopic ureterocele. Median age at time of puncture was 4 months. Median time of the follow-up was 12 years (range 1-26 years), while 23 (30%) followed over 10 years and 15 (19%) completed adolescent period.

RESULTS

Four children with ectopic ureterocele required secondary puncture. Ectopic ureterocele children had significantly more postoperative UTIs (13 (40%) ectopic vs 4 (19%) intravesical p = 0.047). 19 RRUs (44%) showed spontaneous resolution of VUR. 14 (18%) children required additional surgery: 7, endoscopic correction of VUR; 3, ureteral reimplantation and 4, partial nephrectomy. The need for additional surgery following puncture was higher in the group of children with ectopic ureterocele; however, this difference did not reach a statistical significance (p = 0.716).

CONCLUSIONS

Our data show that EP of ureterocele is a durable and long-term effective procedure in vast majority of the children.

Endoscopic Injection of Dextranomer/Hyaluronic Acid as First Line Treatment in 851 Consecutive Children with High Grade Vesicoureteral Reflux: Efficacy and Long-Term Results

PURPOSE

Endoscopic injection of dextranomer/hyaluronic acid is widely acknowledged as first line treatment of lower grade vesicoureteral reflux. We demonstrate its long-term efficacy and safety in eradicating high grade reflux.

MATERIALS AND METHODS

A total of 518 girls and 333 boys with a median age of 2.3 years (range 2 months to 13.7 years) underwent endoscopic correction of high grade vesicoureteral reflux using dextranomer/hyaluronic acid. Reflux was unilateral in 415 cases and bilateral in 436, comprising 1,287 refluxing units. Reflux was grade IV in 1,153 ureters (89.6%) and grade V in 134 (10.4%). ^99mTechnetium-dimercaptosuccinic acid scintigraphy identified renal scarring in 317 patients (37.3%). Followup ultrasound and voiding cystourethrogram were performed 3 months after intervention and renal ultrasound yearly thereafter. Median followup was 8.5 years (range 6 months to 16 years).

RESULTS

Overall resolution rate after the first endoscopic injection was 69.5% (895 of 1,287 cases), with resolution in 70.4% of grade IV and 61.9% of grade V cases. Reflux resolved after a second injection in 259 cases (20.1%) and after a third injection in 133 (10.4%). Persistent reflux after initial treatment was significantly more common in patients younger than age 1 year and in individuals with renal scarring. No significant postoperative complications were observed and no patient required ureteral reimplantation. Following reflux resolution febrile urinary tract infection developed in 43 children (5.1%), including 24 (55.8%) during the first year, 15 (34.9%) during the second year and 4 (9.3%) during year 3 or later. Of these patients 6 had reflux recurrence and 8 had neocontralateral grade III reflux, which was successfully treated with a single endoscopic injection of dextranomer/hyaluronic acid.

CONCLUSIONS

Endoscopic injection of dextranomer/hyaluronic acid is an efficient and safe long-term treatment for grade IV and V vesicoureteral reflux, and can easily be repeated in patients with treatment failure with a high subsequent resolution rate.

Contemporary Management of Vesicoureteral Reflux

CONTEXT

Vesicoureteral reflux (VUR) remains the most interesting topic of pediatric urology due to the dynamic nature of recent controversial publications. Starting from the need for a diagnosis to the necessity and effectiveness of treatment in preventing scars, VUR remains in the mist. Although recent strong evidence helped as fog lights in this blurriness, more data are required for achieving crystal clearance. This article aims to summarize and discuss the current state of the evidence regarding VUR management.

OBJECTIVE

To provide a comprehensive synthesis of the main evidence in the literature on the current and contemporary management of VUR in children; to discuss conservative management with continuous antibiotic prophylaxis (CAP), especially its effectiveness and safety; and to review the current evidence regarding contemporary surgical techniques.

EVIDENCE ACQUISITION

We conducted a nonsystematic review of the literature using the recent guidelines and PubMed database regarding surveillance, CAP, endoscopic, open, laparoscopic, and robot-assisted ureteral surgical treatment.

EVIDENCE SYNTHESIS

Despite the striking results of previous studies revealing the ineffectiveness of CAP, more recent studies and their two fresh meta-analyses revealed a positive role for CAP in the contemporary management of VUR. One of the most interesting findings is the redundant rising of endoscopic correction and its final settlement to real indicated cases. Patient individualization in the contemporary management of VUR seems to be the keyword. The evidence in the literature showed a safe and effective use of laparoscopic and robot-assisted laparoscopic reimplantations.

CONCLUSIONS

The goal of VUR treatment is to prevent the occurrence of febrile urinary tract infections and formation of scars in the renal parenchyma. The approach should be risk adapted and individualized according to current knowledge. Individual risk is influenced by the presentation age, sex, history of pyelonephritis and renal damage, grade of reflux, bladder bowel dysfunction, and circumcision status.

PATIENT SUMMARY

Vesicoureteral reflux is a nonphysiological reflux of urine from the bladder through the ureters to the kidney. Treatment depends on the presentation of the vesicoureteral reflux (VUR). Therapeutic options range from watchful waiting to open surgery. This article aims to summarize and discuss the current state of the evidence regarding VUR management.

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.

STING versus HIT technique of endoscopic treatment for vesicoureteral reflux: A systematic review and meta-analysis

AIM

Our study aimed to compare the efficacy of two endoscopic techniques used for the correction of vesicoureteral reflux (VUR): subureteral transurethral injection (STING) and hydrodistension implantation technique (HIT).

METHODS

A systematic review was conducted using MEDLINE, Google scholar, and Cochrane databases from 1984 to 2015. Meta-analysis of the selected studies was performed to compare the extent of reflux resolution following both techniques.

RESULTS

Six observational studies met the inclusion criteria for content. These comprised 632 ureters treated by STING and 895 ureters treated by HIT procedure. All included studies utilized dextranomer/hyaluronic acid (Deflux) as the bulking agent. The overall resolution of VUR was significantly higher in HIT (82.5%) compared to STING (71.4%) [pooled odds ratio (OR)=0.54; 95% confidence interval (CI) 0.42-0.69; P<0.0001; I²=8%]. A subgroup analysis showed that HIT had better outcomes than STING for both lower grade (I-III) [OR=0.43; 95% CI 0.23-0.82; P=0.01; I²=0%] and high-grade VUR (IV-V) [OR=0.43; 95% CI 0.20-0.91; P=0.03; I²=0%]. However, there was no statistical difference in the requirement of additional injections between STING and HIT groups.

CONCLUSION

HIT is superior to STING technique for resolution of VUR after Deflux injection. However, more randomized trials with longer follow-up are necessary to demonstrate the benefit of HIT compared to STING procedure.

LEVEL OF EVIDENCE

Retrospective comparative studies - level III.

Practice patterns among pediatric urologists in the use of Deflux® for vesicoureteral reflux: a survey

OBJECTIVES

This study aims to assess pediatric urology practice patterns and factors which influence the use of Deflux(®) in the management of vesicoureteral reflux among pediatric urologists.

METHODS

A 11-question survey was sent out to 476 pediatric urologists who are members of the Society for Pediatric Urology.

RESULTS

23.7% of pediatric urologists use Deflux(®) as first line therapy for Grade III reflux or higher. The presence of renal scarring is not a deterrent to the use of Deflux(®). 17.7% would use Deflux(®) before a trial of observation with or without chemoprophylaxis. In children who are on observation, 20.3% would perform Deflux(®) when they are at an age considered appropriate for surgery as opposed to continued observation. The majority of pediatric urologists cite Deflux(®) success rates of >70% to >80% for Grades II-III and >50% to >60% for Grades IV-V. 23.3% of respondents indicated that new evidence citing low long-term success rates at one year decreased their use of Deflux(®). 59.8% of respondents indicated they would perform a second injection after an initial failure. Ultrasound and VCUG are used as follow-up in 86.9% and 65.4% respectively after Deflux(®); the majority are performed within the first 3 months, rarely at one year.

CONCLUSION

The use of Deflux(®) is growing and whether it surpasses open reimplantation and chemoprophylaxis as first-line therapy remains to be seen. With new literature showing lower success rates, long-term follow-up with repeat imaging may be required.

Patients with a history of infection and voiding dysfunction are at risk for recurrence after successful endoscopic treatment of vesico ureteral reflux and deserve long-term follow up

Aim of the Study:

Subureteral endoscopic injection of a bulking agent is an attractive alternative to open surgery or antibiotic prophylaxis for vesico ureteral reflux (VUR). Little information is available about long-term risk of recurrence after an initially successful treatment. Aim of this paper was to review short- and long-term success rate of endoscopic treatment in a single Center series after risk stratification of individual patients.

Materials and Methods:

The records of 126 patients who underwent Deflux injection for primary VUR were examined. Indications to treatment were an unvaried high grade VUR (IV-V) at 1 year from diagnosis and/or and recurrent urinary tract infection (UTI) on antibiotic prophylaxis even in the presence of mild grade VUR (III grade). Gender, age and mode of diagnosis, infections (UTI), voiding dysfunctions, VUR grade and side, renal function, number of treatments were correlated to outcome. Long-term evaluation was planned at a minimum of 1 year from the last negative post-injection cystogram (MCUG). A new MCUG and DMSA scan were also offered to those complaining new UTI episodes. Late recurrences were correlated to history and grade of reflux. Data were analyzed with Graph Pad Instat software; the Chi-square test was used for univariate comparisons, the Fisher's exact test for categorical variables.and multiple regression tests for factors influencing outcome.

Results:

M/F ratio was 62 to 64; median age at diagnosis was 28 months. VUR affected 198 renal units. Preinjection VUR grade was I in 1, II in 27, III in 107, IV in 59, and V in 4 units. Reduced DMSA uptake was evidenced in 51 units and scarring in 24. Median age at treatment was 34.5 months, for persistent high grade VUR (IV–V) in 55 patients and recurrent IVU in 92. Two hundred sixty seven injections were performed on 198 ureters. Complete resolution was documented by MCUG at 3-5 months in 68%, low grading < II in 20%, persistence or unsignificant reduction in 11%. Preoperative recurrent UTI, higher grade VUR, and bilaterality were correlated to a poorer surgical outcome. Among 80 successfully treated cases, 12 complained of persistent UTI. Recurrence of VUR was demonstrated in 31% of them. Deteriorated uptake or additional scarring in 25% was independent from VUR recurrence. Preoperative recurrent UTI and voiding dysfunction correlated significantly to late outcome.

Conclusions:

Preoperative recurrent IVU, together with high-grade reflux, seem to correlate to lower success rate of Deflux injection for primary VUR. Even after successful endoscopic treatment, long-term surveillance may be needed among these cases, mainly if voiding dysfunction is also recorded. Late recurring VUR must be actively excluded in case of new IVU episodes.

Incidence of febrile urinary tract infections in children after successful endoscopic treatment of vesicoureteral reflux: a long-term follow-up

OBJECTIVE

To evaluate the incidence of febrile urinary tract infection (UTI) after successful endoscopic correction of intermediate and high-grade vesicoureteral reflux (VUR).

STUDY DESIGN

Medical records of 1271 consecutive children (male, 411; female, 903) who underwent successful endoscopic correction of VUR were reviewed. Factors potentially influencing postoperative UTIs, such as history of presentation, age, sex, grade of VUR, renal scarring, and agent used for the endoscopic injection, were analyzed.

RESULTS

Febrile UTI developed in 73 children (5.7%) after successful endoscopic correction of VUR. Thirty-nine children had a single episode of UTI, and 34 children had two or more episodes at 1 month to 5.9 years (median, 1 year) after correction of VUR. With multivariate analysis, female sex (P < .001), history of preoperative bladder/bowel dysfunction (BBD; P = .005), and BBD after endoscopic correction (P = .001) were revealed to be the most important independent risk factors for a febrile UTI after successful correction of VUR.

CONCLUSIONS

The incidence of febrile UTIs after successful correction of intermediate and high grade VUR is low. Female sex and BBD were the most important risk factors in the development of febrile UTI. Our data supports the importance of assessing bladder and bowel habits in older children with febrile UTIs after endoscopic correction of VUR.

The impact of vesicoureteral reflux treatment on the incidence of urinary tract infection

Vesicoureteral reflux (VUR) is a heterogeneous disease and its management remains one of the most controversial topics in pediatrics. Management options include surveillance, antibiotics, and surgery. The approval of dextranomer/hyaluronic acid (DHA) as a bulking agent by the Food and Drug Administration was followed by wide acceptance of endoscopic techniques as a major tool in the management of reflux. Pyelonephritis rather than VUR is the most common cause of kidney damage in children. It should be emphasized that the primary goal of diagnosing and treating VUR should be preventing this complication. There are no sufficient data in the literature to address the impact of the different treatment modalities on the incidence of febrile urinary tract infections (feb-UTIs) denoting pyelonephritis, with very few studies evaluating endoscopic treatment in light of this clear and well-defined outcome. The fact that we can correct the anatomy at the vesicoureteral junction with a simple and relatively safe outpatient procedure does not justify offering it to all patients. In this review, we attempt to critically evaluate the available literature pertaining to the impact of different treatment modalities on reducing the incidence of febrile UTIs and kidney damage, with a special emphasis on endoscopic treatment.

Surgical management of vesicoureteral reflux in children

Vesicoureteral reflux (VUR) is the most common uropathy affecting children. Compared to children without VUR, those with VUR have a higher rate of pyelonephritis and renal scarring following urinary tract infection (UTI). Options for treatment include observation with or without antibiotic prophylaxis and surgical repair. Surgical intervention may be necessary in patients with persistent reflux, renal scarring, and recurrent or breakthrough febrile UTI. Both open and endoscopic approaches to reflux correction are successful and reduce the occurrence of febrile UTI. Estimated success rates of open and endoscopic reflux correction are 98.1% (95% CI 95.1, 99.1) and 83.0% (95% CI 69.1, 91.4), respectively. Factors that affect the success of endoscopic injection include pre-operative reflux grade and presence of functional or anatomic bladder abnormalities including voiding dysfunction and duplicated collecting systems. Few studies have evaluated the long-term outcomes of endoscopic injection, and with variable results. In patients treated endoscopically, recurrent febrile UTI occurred in 0-21%, new renal damage in 9-12%, and recurrent reflux in 17-47.6% of treated ureters with at least 1 year follow-up. These studies highlight the need for standardized outcome reporting and longer follow-up after endoscopic treatment.

Endoscopic bulking materials for the treatment of vesicoureteral reflux: a review of our 20 years of experience and review of the literature

Purpose. We reviewed our 20 years of experience and the current literature regarding the long-term outcome of endoscopic treatment of vesicoureteric reflux (VUR) using the different tissue bulking substances with a special emphasis on the long-term efficacy. Material and Methods. Our own experience and the current literature on the long-term results after endoscopic treatment using various bulking agents were reviewed. Results. Short-term data following endoscopic treatment of VUR is similar to the various substances and comparable in the majority of the series to the success rate following open surgery. Recently, a relatively high recurrence rate was noticed especially with the use of dextranomer hyaluronic acid (Dx/HA) as a tissue augmenting material which raises the need for further search for alternative substances. Conclusions. Unfortunately, there is a significant shortage of evidence-based literature on the long-term followup after endoscopic correction of reflux with various substances. No doubt, there is a high recurrence rate during long-term followup after Dx/HA injection, and there is probably lack of proper evaluation regarding the long-term efficacy of other bulking materials. These facts demand long-term close observation and long-term studies beyond the routine protocols following endoscopic treatment of VUR and the correct parental counseling upon the endoscopic correction.

Endoscopic treatment of vesicoureteral reflux in an adult population: Can we teach our adult urology colleagues?

OBJECTIVE

Vesicoureteral reflux (VUR) is not well described or understood in adults. Since endoscopic correction of VUR has become a first-line therapy in children, we aimed to evaluate the efficacy of this technique in adult patients.

PATIENTS AND METHODS

In 1988-2008, 49 adult patients (6 males, 43 females) with a mean age of 33.6 years (range 18-64) underwent endoscopic treatment of VUR. Reflux was unilateral in 17 (34.7%) and bilateral in 32 (65.3%) patients, comprising 81 renal refluxing units (RRU). Of these, 71 (87.7%) were primary VUR. Reflux was Grade I in 14 (17%), Grade II in 46 (56.8%), Grade III in 17 (21%) and Grade IV in 4 (4.9%) RRU. Median renal function at surgery was 41.2%. Endoscopic correction utilized polytetrafluoroethylene (Teflon) in 38 (77.6%) and dextranomer/hyaluronic acid copolymer in 11 (22.4%) patients. Recurrent febrile urinary tract infection (UTI) was the only indication for surgery. Grade I VUR was treated only in patients with contralateral high-grade VUR.

RESULTS

The reflux was corrected in 63 (77.8%) RRU after a single injection, after second injection in 9 (10.6%) and after third in 4 (4.8%) RRU. In 3 (3.5%) RRU, VUR improved to Grade I. In 2 (2.4%), endoscopic correction failed, leading to open reimplantation. One patient with corrected VUR underwent nephrectomy due to non-functioning kidney and recurrent pyelonephritis. Fourteen (28.6%) patients suffered afebrile UTI. Five (10.2%) developed febrile UTI following successful endoscopic correction, leading to a diagnosis of VUR recurrence in two (4.1%) patients.

CONCLUSIONS

Endoscopic correction of VUR in adults is a simple and effective procedure, as in pediatric practice.

Long-term results of endoscopic treatment of vesicoureteric reflux with different tissue-augmenting substances

OBJECTIVE

To review the current literature regarding the outcome of endoscopic treatment of vesicoureteric reflux (VUR) using different tissue-augmenting substances, with special emphasis on long-term efficacy.

MATERIAL AND METHODS

The current literature, including our own experience, on long-term results after endoscopic treatment was reviewed by MEDLINE/PubMed search.

RESULTS

The short-term results are similar in the majority of series to those of open surgery, but there is a high recurrence rate with use of dextranomer/hyaluronic acid (Deflux) as a tissue-augmenting material.

CONCLUSIONS

There is a significant shortage of evidence-based literature on long-term follow-up after endoscopic correction of VUR utilizing dextranomer/hyaluronic acid. The high recurrence rate that has been reported after Deflux injection highlights a need for close observation beyond routine protocols and appropriate parental counseling upon endoscopic correction, and also the need to search further for alternative tissue-augmenting substances. The algorithm for treating VUR is yet to be finally determined.