Dextranomer/Hyaluronic Acid Copolymer Implant Calcification Mimicking Distal Ureteral Calculi on Ultrasound

"Urinary tract dilatation and vesicoureteral reflux - Adult outcomes, who should be followed, and how to follow them"

Long-term adult outcomes of children diagnosed with urinary tract dilatation (UTD) and vesicoureteral reflux (VUR) are not clearly documented in the literature. Likewise, follow-up protocols for these patients as they transition through adolescence and into adulthood vary with institution and cultures. Several studies have shown that individuals diagnosed with VUR in childhood are at higher risk of urinary tract infection (UTI) throughout their lives, even in the setting of prior VUR resolution or surgical correction. This is particularly relevant in patients with renal scarring, who are at higher risk of UTIs, hypertension and renal function deterioration in pregnancy. The risk of adverse maternal and fetal outcomes in pregnancy are higher for women with significant chronic kidney disease (CKD). Patients who underwent endoscopic injection or reimplantation should be counselled on the long-term particular risks associated with each intervention, including calcification of ureteric injection mounds, and the potential challenges of future endoscopic procedures following reimplantation. Although there is no evidence for the direct correlation between conservatively managed UTD in childhood, and symptomatic UTD diagnosed in adulthood, all patients should be aware of the long-term risks of persistent upper tract dilatation. Lastly, bladder-bowel dysfunction (BBD) management in adolescence can be more challenging and may contribute to symptomatic recurrence in this age group.

Migrated Bulking Material (Solesta) Presenting as a Vaginal "Cyst": Histopathologic and Chemical Analytical Features

Performing injections with a bulking agent consisting of nonanimal stabilized hyaluronic acid and dextranomer is a well-tolerated and efficacious treatment for mild to moderate fecal incontinence. Here, we discuss a case of a patient with a history of a bulking procedure for fecal incontinence who presented to the obstetrics/gynecology clinic for evaluation of a new vaginal "cyst," which was excised. Histopathologic examination revealed migrated bulking agent within the excised specimen.

The color Doppler twinkling artifact of implants after endoscopic treatment of vesicoureteral reflux in children: A common finding with high potential for misdiagnosis

BACKGROUND

Endoscopic treatment of vesicoureteral reflux (VUR) is a common therapeutic procedure in children. Over the last years several studies reported on calcified deflux implants that were misinterpreted as ureteral stones leading to unnecessary diagnostic and therapeutic procedures.

OBJECTIVE

Based on an own case, where a calcified implant with a strong twinkling artifact was misdiagnosed as a ureteral stone, the purpose of our study was to evaluate the sonographic imaging appearance of implants after endoscopic VUR repair with special emphasis on the color twinkling artifact.

MATERIAL AND METHODS

In 40 children (mean age 9.5 years) with 62 treated ureteral units follow-up sonography was performed after a mean time interval of 48.8 months after surgery. The injected deposit was evaluated with B-mode sonography and color Doppler sonography and deposit volume, posterior acoustic shadowing and the appearance and extension of the twinkling artifact were evaluated.

RESULTS

47 of 62 injected units (75.8%) could be identified on follow-up sonography. In 13 of 47 units (27.7%) posterior acoustic shadowing was noted. On color Doppler sonography a twinkling artifact appeared in 26 of the 47 visible cases (55.3%). There was a statistically significant correlation between a positive twinkling sign and the deposit age.

CONCLUSION

In conclusion our study shows that the twinkling artifact is a common finding in follow-up sonography of children after endoscopic treatment of VUR. As the twinkling artifact is a sensitive imaging sign for the detection of ureteral calculi the risk of misinterpretation and mistreatment is given.

Incidence and risk factors for calcification after dextranomer/hyaluronic acid (Dx/HA) copolymer injection for vesicoureteral reflux

INTRODUCTION

Since the first case of dextranomer/hyaluronic acid (Dx/HA) implant calcification in 2008, concern about the long-term sequelae of Dx/HA injection has been growing. According to previous reports, the incidence of Dx/HA calcification 4 years after injection would be around 2%.

AIM

The primary aim was to estimate the incidence of Dx/HA implant calcification after endoscopic treatment of vesicoureteral reflux in pediatric patients. Secondary objectives were to establish risk factors and to perform a survival analysis after Dx/HA injection.

STUDY DESIGN

Patients undergoing Dx/HA endoscopic injection from 2007 to 2014 were prospectively registered. The database included clinical, surgical and radiological outcomes. Patients that showed Dx/HA implant calcification during follow-up were compared to those who did not. Univariable and survival statistical analyses were performed.

RESULTS

30 implants calcified over 355 ureters endoscopically treated. Age at first treatment was lower in patients with implant calcification (2.4 ± 1.3 years vs 3.6 ± 2.5 years; p < 0.005). The risk of implant calcification was 8.45% (95% CI: 5.96-11.85%). Median follow-up was 7.6 years (IQR: 5.2-9.5). The incidence rate was 12.06 cases per 1000 ureters-year. The period of highest hazard of implant calcification was between 3 and 5 years after injection. The only risk factor related to implant calcification was the age at first injection: relative risk of implant calcification was 4.4 (95% CI: 1.6 to 12.4; p = 0.002) for patients first treated before the age of 3.5 years.

DISCUSSION

The risk and the incidence rate of Dx/HA implant calcification were higher than previous data. The period of highest hazard and detection of implant calcification were consistent with previous reports. Patients first treated before the age of 3.5 had shorter survival time without implant calcification. These are the first data about risk factors and survival function of Dx/HA implant calcification. However, our conclusions about the clinical significance of Dx/HA implant calcification were limited because the patients with implant calcification were asymptomatic. Further studies with larger sample and longer follow-up should confirm the clinical significance and life-long tendency of Dx/HA implant calcification.

CONCLUSIONS

The risk and the incidence rate of Dx/HA implant calcification were higher than expected. The hazard of calcification was higher between 3 and 5 years after injection. The risk was especially higher in patients treated before the age of 3.5. Caution should be taken not to confuse implant calcifications with ureteric stones. A 5-year follow-up would set a better understanding of the actual incidence and clinical significance of implant calcification.

Distal Ureteral Calculus or Deflux Calcification?

Background: There have been >50,000 dextranomer-hyaluronic acid implants performed since 2001, and each has the potential to calcify. Although they are most often asymptomatic, these calcifications may mimic large distal ureteral calculi and are often misidentified on CT performed for suspected urolithiasis or other complaints. Case Presentation: We report the case of a 21-year-old woman who presented with symptoms consistent with obstructive uropathy who was reported to have bilateral ureteral-vesicular junction calculi on abdominal CT evaluation. On further questioning she relayed the history of a vague urologic procedure as a child but was unable to characterize it further. On the basis of her relatively mild symptoms, urinalysis and renal ultrasonography were obtained demonstrating bilateral ureteral jets and she was diagnosed with nonobstructing bilateral dextranomer-hyaluronic acid calcifications and a presumed urinary tract infection that resolved with empiric antibiotic therapy. Conclusion: Accurate diagnosis of implant calcification is critical to effective therapy and avoiding unnecessary radiation or anesthesia. This diagnosis should be suspected with radiologically demonstrated large ureteral calculi but relatively mild presenting symptoms. As dextranomer-hyaluronic acid implantation is routinely performed in young patients it is also possible that this relevant history will not be reported.

Ultrasound-guided fine-needle aspiration of a rectal submucosal nodule

Although endoscopic biopsy of a rectal submucosal nodule may be nondiagnostic, endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) can be an important tool to make diagnosis. We report a case of a female patient who had an EUS-FNA of a submucosal nodule after a nondiagnostic rectal biopsy. The original diagnosis was erroneously rendered as concerning for necrotic neoplasm. The correct diagnosis of Solesta-induced foreign body reaction was made on reviewing the slides once the history of remote Solesta injection was made available. This case illustrates the pathognomonic features of Solesta-induced rectal nodule and underscores the importance of detailed history as well as inclusion of iatrogenic diseases in the differential to prevent erroneous diagnosis and management. Potential pitfalls in cytopathological diagnosis are discussed.

Endoscopic, Ultrasonographic, and Histologic Descriptions of Dextranomer/Hyaluronic Acid in a Case of Fecal Incontinence

OBJECTIVE

To present a case of fecal incontinence treated with dextranomer/hyaluronic acid (Solesta®) injections, which later caused clinical confusion and avoidable interventions. The endoscopic, ultrasonographic, and histologic appearances of dextranomer/hyaluronic acid will also be reported.

CASE PRESENTATION

A middle-aged Hispanic male who failed conservative management of his fecal incontinence was injected with dextranomer/hyaluronic acid in an attempt to alleviate symptoms. An unrelated screening colonoscopy was performed soon after, revealing a submucosal rectal lesion. Flexible sigmoidoscopy and endoscopic rectal ultrasound with FNA were scheduled for patient for further evaluation. An unknown foreign material was noted under microscopy and, upon attaining additional history, the gastroenterologist uncovered the patient's recent injections of dextranomer/hyaluronic acid.

CONCLUSION

Dextranomer/hyaluronic acid for the treatment of fecal incontinence has become more common in recent years. Though the imaging and histologic appearance of this gel-like material is seen in other areas of medicine, equivalent descriptions are limited in the anorectal region. To curb misdiagnoses and prevent unnecessary interventions, it is important to expound on the endoscopic, imaging, and histopathologic features of this tissue-bulking agent in the setting of fecal incontinence and to encourage communication, proper documentation, and easy accessibility to patient health information by all medical staff.

[A CASE OF DEXTRANOMER-HYALURONIC ACID COPOLYMER (Deflux®) IMPLANTS CALCIFICATION MIMICKING DISTAL URETERAL CALCULI]

Since 2011, endoscopic correction of vesicoureteral reflux using dextranomer-hyaluronic acid copolymer (Deflux^®) has been widely accepted in Japan due to its safety and minimally invasive nature. However, long-term complications are unknown. We present a case of Deflux^® implants calcification mimicking distal ureteral calculi in a 12-year-old boy with a history of Deflux^® injection performed at three years of age for primary VUR. We should be aware of this complication to avoid misdiagnosis and unnecessary invasive examination such as radiological imaging or endoscopy.

Incidence of Deflux® calcification masquerading as distal ureteric calculi on ultrasound

OBJECTIVE

Dextranomer-hyaluronic acid (Deflux(®)), the most widely used compound in the endoscopic treatment of vesico-ureteric reflux (VUR) today, is believed to provoke only minimal inflammation. Reports of calcification of Deflux(®) are increasing. We ascertain the incidence of Deflux(®) calcification appearing as distal ureteric calculi on ultrasound.

METHODS

Three cases (2 external patients) of ureteroscopy for calcified submucosal Deflux(®) prompted a retrospective review of the notes and imaging of all children treated with Deflux(®) for VUR between December 2000 and January 2011 at Great Ormond Street Hospital.

RESULTS

232 children (M:F = 5:3) received Deflux(®) for VUR at median age 2 years (range 2 months-12 years). Follow-up annual ultrasound, performed in all, identified calcification in 2. The interval between Deflux(®) injection and presentation of its calcification was 4 years. 104 of the 232 children had been followed up for 4-10 years. Considering the observed lag-period, after 4 years the incidence of calcification of Deflux(®) on ultrasound was 2% (2/104).

CONCLUSIONS

Patients should be warned that calcification of Deflux(®) can occur. Misinterpretation as ureteric stones is common and may lead to unnecessary ureteroscopy. In this series, the incidence of calcification of Deflux(®) on ultrasound after 4 years was 2%.

Endoscopic treatment of vesicoureteral reflux--a 20-year follow-up

Endoscopic reflux therapy has gained more and more popularity, and the use of this method is increasing. These imaging patterns (well known by pediatric radiologists) should be known by the general radiologist as the first young patients treated 20 years ago are now adults.

Dextranomer-hyaluronic acid implants misdiagnosed as bladder tumor on transvaginal ultrasonography

BACKGROUND

The endoscopic injection of dextranomer-hyaluronic acid has become a popular treatment for childhood vesicoureteral reflux. Treated children are predominantly girls, and many are now entering adulthood. It has been reported in children that the radiographic appearance of implants may lead to misdiagnoses and unnecessary, invasive diagnostic procedures.

CASE

We report the case of a woman treated with dextranomer-hyaluronic acid for childhood vesicoureteral reflux misdiagnosed with a bladder tumor on transvaginal ultrasonography. Renal ultrasound examination and urinalysis results were normal. Invasive testing was avoided given the history and characteristic ultrasonographic appearance of retained implants.

CONCLUSION

It is important for health care providers to be aware of the radiographic appearance of dextranomer-hyaluronic acid implants in adults and to elicit an appropriate past medical history to avoid misdiagnosis and invasive diagnostic procedures.

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.