Symptomatic Calcification of Subureteral Collagen Ten Years After Injection

Proprietary non-animal stabilized hyaluronic acid/dextranomer gel (NASHA/Dx) for endoscopic treatment of grade IV vesicoureteral reflux: Long-term observational study

BACKGROUND

Since 1993, children aged >1 year with persistent grade III-V vesicoureteral reflux (VUR) and febrile urinary tract infections (UTIs) attending Uppsala University Hospital have undergone endoscopic injection with proprietary non-animal stabilized hyaluronic acid/dextranomer gel (NASHA/Dx; Deflux®).

OBJECTIVE

Investigate long-term incidence of UTI, bladder dysfunction, ureteral reimplantation and overall clinical findings following endoscopic injection of NASHA/Dx.

STUDY DESIGN

Children with grade IV VUR diagnosed by voiding cystourethrogram (VCUG) and dilating VUR persisting for >1 year were included in this study. 15-25 years after endoscopic treatment, patients' hospital charts were studied. Information on bladder function and UTIs was obtained via questionnaire, 8-18 years after endoscopic treatment.

RESULTS

185 patients (69 boys, 116 girls) were included in the study; 237 grade IV VUR ureters were treated. All study patients were diagnosed with VUR after a febrile UTI (i.e. pyelonephritis). According to the last voiding cystourethrogram, 69% of ureters showed a positive response (VUR grade 0-I), 7% had VUR grade II and 23% had VUR grade ≥ III. 46 patients (25%) required ureteral reimplantation during follow-up. Among patients treated during the second 5-year period compared with the first (1998-2003 versus 1993-1998), there was a significant decrease in the rate of ureteral reimplantation (31% vs 16%; p = 0.0365). This difference may be attributable to developments over time in the injection technique. UTIs occurred in 30 patients (21% of the evaluable population): 28 females and 2 males. Febrile UTIs were reported in 14 patients (10%), all females. Forty-nine patients (34%) had bladder problems (e.g. underactivity, overactivity, incontinence). Five patients underwent ureteral reimplantation 'late', 6-10 years after the last endoscopic injection. In one male patient, calcification around the NASHA/Dx implantation site was observed during routine examination 2 years after endoscopic treatment; no intervention was required. No safety issues were observed in the remaining 97% of the study population.

CONCLUSIONS

This study represents the longest published follow-up of Grade IV VUR patients undergoing endoscopic treatment. Three-quarters of patients did not need ureteral reimplantation. Optimal injection technique and higher injection volume were associated with a reduced ureteral reimplantation rate. Treatment with NASHA/Dx was durable and well tolerated: long-term risks of UTI, bladder dysfunction and recurrent VUR were low.

Primary Squamous Cell Carcinoma Arising From a Cutaneous Ureterovesical Stoma (Modified Mitrofanoff): Case Report and Review of Literature

Squamous cell carcinoma arising from a urinary stoma is exceedingly rare, and none so far is reported from a cutaneous ureterovesical stoma. Squamous cell carcinoma usually occurs as a late complication of urinary diversion, and we report the first such case in a cutaneous ureterovesical stoma with a review of published literature.

Vesicoureteral Reflux in Pediatric Age: Where are we Today?

Although the diagnosis of vesicoureteral reflux and of reflux nephropathy is a well-established and shared procedure, its treatment nowadays is still very controversial. New developments on the knowledge of pathophysiology of renal damage associated to reflux opened the way towards a different diagnostic work-up and different therapeutic approaches.

Recently, the “top-down” diagnostic approach has gained wider interest, versus the “down-top” protocol. The attention has recently focused on the renal parenchyma damage and less interest has been given to the presence and the radiological degree of vesicoureteral reflux.

The review criteria were based on an in-depth search of references conducted on PubMed, using the terms “vesicoureteral reflux”, “children”, “incidence”, “etiology”, “diagnosis”, “treatment” and “outcomes”. The selection of the papers cited in this review was influenced by the content and the relevance to the points focused in the article.

Conservative approaches include no treatment option with watchful waiting, long-term antibiotic prophylaxis and bladder rehabilitation. The operative treatment consists of endoscopic, open, laparoscopic and robotic procedures to stop the refluxing ureter.

No final consensus has been achieved in literature yet, and further studies are necessary in order to better define the subset of children at risk of developing progression of renal damage.

This review aims to clarify the diagnostic management and the urological-nephrological treatment of reflux in pediatric age, on the basis of a review of the best-published evidence.

Ureterovesical opaque densities after ureterovesical reflux injection therapy: diagnostic and therapeutic dilemma

Primary vesicoureteral reflux can be treated by injection of a bulking agent into the wall of the ureterovesical junction. Over time, the bulking agent can get calcified. Radiological images of the area show findings that mimic those seen in ureterovesical junction calculi. In this report, we present the imaging findings of this phenomenon and discuss its challenging aspects.

Implantation of autologous urine derived stem cells expressing vascular endothelial growth factor for potential use in genitourinary reconstruction

PURPOSE

We evaluated the effects of vascular endothelial growth factor overexpression on urine derived stem cell survival and myogenic differentiation to determine whether these cells could be used as a novel cell source for genitourinary reconstruction.

MATERIALS AND METHODS

Urine derived stem cells were isolated from 31 urine samples of 6 healthy individuals 3 to 27 years old. Urine derived stem cells were infected with an adenoviral vector containing the mouse VEGF gene. These cells were then mixed with human umbilical vein endothelial cells (total 5×10(6)) in a collagen-I gel. These cell containing gels were subcutaneously implanted along with 6 other controls into 18 athymic mice. The grafts were assessed up to 28 days after injection for gross appearance and immunocytochemistry.

RESULTS

Vascular endothelial growth factor levels in the media from infected urine derived stem cell cultures reached a peak value on day 10 after infection. Grafts composed of urine derived stem cell/adenoviral vector containing the mouse VEGF gene and human umbilical vein endothelial cells were larger and better vascularized compared to uninfected urine derived stem cell control grafts. Additionally more implanted cells expressed human nuclear markers in the vascular endothelial growth factor expressing grafts. Vascular endothelial growth factor expressing grafts also contained more cells expressing the endothelial markers CD-31 and von Willebrand factor, and smooth muscle markers (α-smooth muscle actin, desmin and myosin). Also, more nerve fibers were present in urine derived stem cell/adenoviral vector containing mouse VEGF gene plus human umbilical vein endothelial cell grafts than in controls.

CONCLUSIONS

Vascular endothelial growth factor overexpression combined with human umbilical vein endothelial cells enhanced in vivo survival and myogenic differentiation of urine derived stem cells. Neovascularization and nerve regeneration were also enhanced within the implanted grafts.

Diagnosis and management of vesicoureteral reflux in children

Critical evaluation of previously accepted dogma regarding the evaluation and treatment of vesicoureteral reflux (VUR) has raised significant questions regarding all aspects of VUR management. Whereas the standard of care previously consisted of antibiotic prophylaxis for any child with VUR, it is now unclear which children, if any, truly benefit from antibiotic prophylaxis. Operative intervention for VUR constitutes overtreatment in many children, yet there are limited data available to indicate which children benefit from VUR correction through decreased rates of adverse long-term clinical sequelae. Studies with longer follow-up demonstrate decreased efficacy of endoscopic therapy that was previously hoped to approach the success of ureteroneocystostomy. Prospective studies might identify risk factors for pyelonephritis and renal scarring without antibiotic prophylaxis. Careful retrospective reviews of adults with a history of reflux might allow childhood risk factors for adverse sequelae to be characterized. Through analysis of multiple characteristics, better clinical management of VUR on an individualized basis will become the new standard of care.

Dextranomer/hyaluronic acid copolymer (Deflux) implants mimicking distal ureteral calculi on CT

Periureteral or subtrigonal injection of dextranomer/hyaluronic acid (Dx/HA) copolymer (Deflux, Q-Med, Uppsala, Sweden) is an increasingly common endoscopic treatment for vesicoureteral reflux. We report a confusing radiographic finding of bilateral calcified Dx/HA injections initially thought to represent bilateral distal ureteral stones in a boy who presented with intermittent periumbilical pain. Urologists, radiologists, and emergency room physicians should be aware of the potential for calcification of ureteral implants of Dx/HA, and of the potentially confusing radiographic images that may result.