Failure of subureteral bovine collagen injection for the endoscopic treatment of primary vesicoureteral reflux in long-term follow-up

Endoscopic treatment of primary vesicoureteral reflux in children with two different bulking agents, high success and low complication rates: Comparison of Dexell and Vantris

INTRODUCTION AND OBJECTIVES

To compare the results in terms of efficacy and safety of the endoscopic management for vesicoureteral reflux (VUR) in two different standardized primary VUR cohorts treated with Dexell and Vantris.

PATIENTS

128 refluxing renal units (RRU) in 87 patients with primary VUR (64 females, 23 males). Patients with secondary VUR and severe bladder and bowel dysfunction were excluded. A total of 22 continent children with mild bladder-bowel dysfunction underwent bladder-bowel training before the implantation. All procedures were performed in the presence of sterile urine using a conventional subureteral transurethral injection technique.

RESULTS

There were no statistically significant differences between groups in terms of mean age, sex, RRU side, ^99mTc-DMSA uptake, and reflux grade. The overall resolution rates based on the number of RRUs for up to three endoscopic treatments were 80% (56/70) in Dexell group and 94.8% (55/58) in Vantris group (P = .012). No postoperative recurrences or vesicoureteral junction obstructions were seen in any group.

CONCLUSIONS

Dexell and Vantris provided an effective and safe endoscopic VUR treatment in the early and mid-term follow up of children with primary VUR. The effectiveness of these substances, which can produce different mass effects with different particle sizes, in safe VUR resolution, needs further investigations.

Endoscopic treatment of primary vesicoureteral reflux in children with two different bulking agents, high success and low complication rates: comparison of Dexell and Vantris

INTRODUCTION AND OBJECTIVES

To compare the results in terms of efficacy and safety of the endoscopic management for vesicoureteral reflux (VUR) in two different standardized primary VUR cohorts treated with Dexell and Vantris.

PATIENTS

128 refluxing renal units (RRU) in 87 patients with primary VUR (64 females, 23 males). Patients with secondary VUR and severe bladder and bowel dysfunction were excluded. A total of 22 continent children with mild bladder-bowel dysfunction underwent bladder-bowel training before the implantation. All procedures were performed in the presence of sterile urine using a conventional subureteral transurethral injection technique.

RESULTS

There were no statistically significant differences between groups in terms of mean age, sex, RRU side, 99mTc-DMSA uptake, and reflux grade. The overall resolution rates based on the number of RRUs for up to three endoscopic treatments were 80% (56/70) in Dexell group and 94.8% (55/58) in Vantris group (p = 0.012). No postoperative recurrences or vesicoureteral junction obstructions were seen in any group.

CONCLUSIONS

Dexell and Vantris provided an effective and safe endoscopic VUR treatment in the early and mid-term follow up of children with primary VUR. The effectiveness of these substances, which can produce different mass effects with different particle sizes, in safe VUR resolution, needs further investigations.

Management of Vesicoureteral Reflux: What Have We Learned Over the Last 20 Years?

Vesicoureteral reflux (VUR) is associated with increased risks of urinary tract infection, renal scarring and reflux nephropathy. We review advancements over the last two decades in our understanding and management of VUR. Over time, the condition may resolve spontaneously but it can persist for many years and bladder/bowel dysfunction is often involved. Some factors that increase the likelihood of persistence (e.g., high grade) also increase the risk of renal scarring. Voiding cystourethrography (VCUG) is generally considered the definitive method for diagnosing VUR, and helpful in determining the need for treatment. However, this procedure causes distress and radiation exposure. Therefore, strategies to reduce clinicians' reliance upon VCUG (e.g., after a VUR treatment procedure) have been developed. There are several options for managing patients with VUR. Observation is suitable only for patients at low risk of renal injury. Antibiotic prophylaxis can reduce the incidence of UTIs, but drawbacks such as antibiotic resistance and incomplete adherence mean that this option is not viable for long-term use. Long-term studies of endoscopic injection have helped us understand factors influencing use and the effectiveness of this procedure. Ureteral reimplantation is still performed commonly, and robot-assisted laparoscopic methods are gaining popularity. Over the last 20 years, there has been a shift toward more conservative management of VUR with an individualized, risk-based approach. For continued treatment improvement, better identification of children at risk of renal scarring, robust evidence regarding the available interventions, and an improved VUR grading system are needed.

The comparison of dextranomer/hyaluronic acid and polyacrylate-polyalcohol copolymers in endoscopic treatment of vesicoureteral reflux

BACKGROUND

Dextranomer/hyaluronic acid (Dx/Ha;Dexell®) and polyacrylate-polyalcohol copolymer (PPC;Vantris®) are the popular tissue-augmenting substances using for the endoscopic injections of vesicoureteral reflux (VUR). The aim of the study is to evaluate and compare Dx/Ha and PPC in terms of effectiveness, injection techniques and complications with special emphasis on vesicoureteral junction obstruction (VUJO).

METHODS

A total of 95 patients who underwent endoscopic VUR treatment between 2009 and 2015 were retrospectively reviewed. The patients were divided into two groups: group 1: Patients underwent endoscopic treatment with PPC (n=50 patients, 70 renal refluxing units) group 2: Patients underwent endoscopic treatment with Dx/Ha (n=45 patients, 74 renal refluxing units).

RESULTS

The overall resolution rates based on the number of renal refluxing units studied was 88.6% and 70.3% in group 1 and group 2, respectively. Resolution rates were significantly better in group 1 compared to group 2. VUJO requiring ureteral reimplantation or stent insertion developed in 7 patients in group 1. No VUJO was observed in group 2. VUJO in group 1 was markedly higher than that in group 2.

CONCLUSIONS

Endoscopic treatment of VUR with PPC promises better resolution rates but higher VUJO rates compared to Dx/Ha.

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.

Combination of calcium hydroxyapatite and autologous blood for endoscopic treatment of vesicoureteral reflux in children

OBJECTIVE

To report the results of endoscopic correction of vesicoureteral reflux (VUR) with concomitant injection of pure calcium hydroxyapatite (CaHA) and autologous blood.

PATIENTS AND METHODS

Records of patients who underwent endoscopic correction of VUR using concomitant injection of CaHA and autologous blood from 2008 through 2010 were retrospectively reviewed. Data regarding patients' demographics, preoperative VUR grades, febrile urinary tract infections, complications of procedure, postoperative VUR grades and cure rates were collected. Voiding cystourethrography was performed 3 months postoperatively.

RESULTS

Total number of 23 children (9 girls and 14 boys) with 40 refluxing ureters were included. The mean age of children was 1.9 ± 0.97 (SD) years. Reflux grades were II to IV in 14, 11 and 15 renal refluxing units (RRUs), respectively. The mean follow-up period was 44 months. VUR was successfully treated in 87.5% of RRUs after three injections. Significant statistical difference was found between VUR grades before and after the first, second and third injections (p < 0.001, p = 0.001 and p = 0.011, respectively). Moreover, there was a significant difference between primary reflux grade and treatment success (p = 0.031). Febrile UTI was resolved in 85% of patients (17 of 20 patients with febrile UTI) after endoscopic treatment which shows significant improvement (p < 0.001). The procedure was uneventful in all patients, and no obstruction was reported during the follow-up period.

CONCLUSION

Concomitant injection of pure CaHA without any additives (hyaluronic acid, etc.) and autologous blood can be an effective, repeatable and cost-benefit approach for the management of children suffering VUR with a success rate of 87.5% after three injections.

Intraoperative contrast-enhanced urosonography during endoscopic treatment of vesicoureteral reflux in children

BACKGROUND

There are many controversies surrounding the effectiveness of endoscopic treatment of vesicouretheral reflux (VUR) in children, thus it is of highest priority to analyze factors influencing the outcome of therapy and to search for new methods that would increase the success rate and reduce the number of reinjections.

OBJECTIVE

The aim of the study was to analyze whether intraoperative contrast-enhanced urosonography (ce-US) may increase the effectiveness of endoscopic anti-reflux therapy.

MATERIALS AND METHODS

Intraoperative contrast-enhanced urosonography (ce-US) with SonoVue® was performed in 17 patients (25 ureteral units) undergoing endoscopic treatment of VUR. Ce-US was performed in the operating room before the procedure and after injection of the bulking material. When VUR persisted, the operator repeated the injection, which was followed by ce-US. The results were compared with those obtained from a control group (15 patients; 22 ureteral units).

RESULTS

A repeat injection during a single endoscopic treatment was required in 24% of cases. The overall success rate confirmed at 6-12 months' follow-ups was 84%. The success rate was significantly higher in comparison to the control group (success: 64%).

CONCLUSION

Intraoperative ce-US performed during endoscopic treatment of VUR enables immediate monitoring of outcome and provides the opportunity for repeat injection during the same procedure, thus increasing the efficacy of the procedure and reducing the number of reinjections.

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.

Transurethral injection therapy with carbon-coated beads (Durasphere®) for treatment of recurrent pyelonephritis in kidney transplant patients with vesico-ureteral reflux to the allograft

INTRODUCTION AND OBJECTIVES

Recurrent transplant pyelonephritis (RTP) secondary to vesico-ureteral reflux (VUR) to the transplant kidney (KTx) remains a significant cause of infectious complications with impact on patient and graft outcomes. Our objective was to verify the safety and efficacy of transurethral injection of Durasphere(®) to relieve RTP secondary to VUR after renal transplantation.

PATIENTS AND METHODS

Between June 2004 and July 2008, eight patients with RTP (defined as two or more episodes of pyelonephritis after transplantation) and VUR to the KTx were treated with subureteral injections of Durasphere(®). The mean age at surgery was 38.8 ± 13.8 yr (23-65). The patients were followed regularly every six months. The mean interval between the KTx and the treatment was 76 ± 74.1 (10-238 months). The mean follow-up was 22.3 ± 16.1 months (8-57 months).

RESULTS

Six patients (75%) were free of pyelonephritis during a mean period of follow-up of 23.2 ± 17.1 months (8-57 months). Two of them had no VUR and four cases presented with G II VUR (pre-operative G IV three cases and one case G III). In one case, symptomatic recurrent cystitis made a second treatment necessary. This patient remained free of infections for three yr after the first treatment and for 18 months after the second treatment. Of the remaining two patients, one had six episodes of RTP before treatment in a period of three yr and only two episodes after treatment in two yr of follow-up. The last case had a new episode of pyelonephritis five months after treatment.

CONCLUSIONS

Transurethral injection therapy with Durasphere(®) is a safe and effective minimally invasive treatment option for KTx patients with recurrent RTP. A second treatment seems to be necessary in some cases.

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.

Long-term results after endoscopic VUR-treatment using dextranomer / hyaluronic acid copolymer - 5-year experience in a single-center

Background

A number of bulking agents have been used for the endoscopic correction of vesicoureteral reflux in children. We present our long-term results of endoscopic use of dextranomer/hyaluronic acid copolymer (Deflux^®) for VUR treatment in children.

Patients and methods

Between 2004 and 2008, 21 children underwent endoscopic subureteral injection of Deflux^® in 30 ureters as an outpatient procedure. Twelve children had unilateral reflux (2 duplicated systems) and nine had bilateral reflux. Median age was 5-years (6-months to 14.9-years). Six weeks postoperatively, a voiding cystourethrogram was performed. This study examined the disappearance of VUR and urinary tract infection (UTI) in the long-term follow-up as well as QoL (questionnaire of the parents).

Results

No intra- or postoperative complications had been noticed. In 25 ureters (83%), VCUG showed no VUR 6-weeks postoperatively. Three children received a 2nd injection (two successful). After a median follow-up of 2.5 years, 27 ureters in 17 children (90%) had no urinary tract infection and VUR. The questionnaire results in regard to quality of life (QoL) were very good in the successfully treated children and the parents would choose the same treatment option again.

Conclusion

Subureteral injection of Deflux^® for children with VUR is an effective treatment option with a low complication rate.

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.

[Long-term results after endoscopic subureteral injection for VUR using dextranomer/hyaluronic acid copolymer : a five years experience]

BACKGROUND

A number of bulking agents have been used for the endoscopic correction of vesicoureteral reflux in children. We present the long-term results of endoscopic use of dextranomer/hyaluronic acid copolymer (Deflux) for VUR grade I-IV in children.

PATIENTS AND METHODS

Between 2004 and 2008, 21 children underwent endoscopic subureteral injection of Deflux in 30 ureters as an outpatient procedure. Twelve children had a unilateral reflux (two duplicated systems) and nine had a bilateral reflux. The median age was 5 years (6 months to 14.9 years). Six weeks postoperatively a voiding cystourethrogram (VCUG) was performed. This study examined the disappearance of VUR and urinary tract infection (UTI) as well as the quality of life (parents' questionnaire) during long-term follow-up.

RESULTS

No intra- and postoperative complications were noticed. In 25 ureters (83%) VCUG showed no VUR 6 weeks postoperatively. In three children a second injection was done (two were successful). After a median follow-up of 2.5 years 27 ureters in 17 children (90%) had no UTI and VUR. The results of the questionnaire regarding quality of life were very good in the successfully treated children and the parents would choose the same treatment option again.

CONCLUSION

Subureteral injection of Deflux for children with VUR is an effective treatment option for VUR with a low complication rate.

Controversies in the management of vesicoureteral reflux: the rationale for the RIVUR study

The current management of vesicoureteral reflux (VUR) focuses on the prevention of urinary tract infections (UTI), with curative surgery being limited to those children that fail conservative measures. This is based on the assumption that UTIs are preventable with the use of prophylatic antibiotics, leading to reduction of renal scarring, and the possibility that VUR in children can resolve spontaneously.

METHODS

Review of the recent literature has demonstrated a growing concern that antibiotic prophylaxis may not lead to prevention of UTIs. Additionally, data indicate that renal scarring may not be preventable with antibiotic prophylaxis or even surgical correction of VUR. An overview of all of the current controversies is presented in this paper.

RESULTS

Does antibiotic prophylaxis lead to reduction in UTIs in children with VUR? To address this question, the National Institutes of Health have developed a randomized placebo-controlled study of children with VUR (the RIVUR Study), identified following the development of a UTI.

CONCLUSIONS

There are far reaching consequences of the results of the RIVUR Study. If antibiotic prophylaxis does not prevent UTI in children with VUR, or lead to reduction in renal scarring, does identification of VUR provide any benefits? Perhaps appropriate treatment of UTI may be all that is necessary for preserving renal function. Final answers will have to wait until the completion of this study.

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.

Management of vesicoureteral reflux without indwelling catheter and drain, using trigonoplasty technique

PURPOSE

Gil-Vernet trigonoplasty is a simple, fast and effective technique for treating primary VUR, and is the only technique used to manage unilateral reflux that does not result in contralateral new reflux, due to its inherent bilateral nature. We have tried to further simplify postoperative management of the procedure by eliminating the use of an indwelling urethral catheter and drain.

PATIENTS AND METHODS

In a prospective study during a 15-month period, 65 children with 103 refluxing units (56 girls, nine boys), aged 1-15 years, underwent the designed surgery.

RESULTS

Preoperative voiding cystourethrogram revealed bilateral reflux in 38 and unilateral reflux in 27 children. Of 130 renal units, 103 were associated with reflux grade I, II, III, IV and V in 8.73%, 24.27%, 35.92%, 30.9% and 0.9% units, respectively. Of 103 refluxing units, 97 units had stopped refluxing on cystogram 3 months after surgery, giving the overall success rate of 94.1% for all grades of reflux included in the study. Only 7.6% of the children needed urethral catheterization after surgery. No ureteral obstruction occurred. Two patients developed urinary extravasation, both managed conservatively. No patient needed reoperation. The procedure was done on an outpatient basis in 40% of cases, while 60% of the children were hospitalized with a mean admission time of 3.4 days.

CONCLUSION

The Gil-Vernet trigonoplasty technique is simple, safe and effective. Our study further simplified postoperative management by avoiding an indwelling catheter and drain. Also, we have shown that this can be done as an outpatient procedure.

Treatment of vesicoureteral reflux after puberty

Vesicoureteral reflux is uncommonly diagnosed and treated after puberty. The natural history of uncorrected VUR after puberty is not documented. Postpubertal patients with recurrent pyelonephritis and VUR should be considered for treatment. Ureteral reimplantation, endoscopic injections, and laparoscopic or robotic ureteral reimplantation may be utilized. Endoscopic injection is an appealing option for these patients. The role of laparoscopic or robotic ureteral reimplantation in these patients is evolving.

The Deflux Procedure Reduces the Incidence of Urinary Tract Infections in Patients with Vesicoureteral Reflux

PURPOSE

The aim of this study was to review the experience of a single institution with the Deflux (Q-Med Scandinavia; Uppsala, Sweden) procedure and assess its effectiveness in reducing the incidence of urinary tract infections (UTIs) in children with vesicoureteric reflux (VUR).

MATERIALS AND METHODS

After institutional review board approval, the charts of 100 patients with VUR, who presented between June 2003 and June 2005, were prospectively reviewed. Data collected included: demographics, the number of preoperative and postoperative UTIs, a radiologic grade of VUR on a voiding cystourethrogram (VCUG) and the presence of VUR on a radionuclide VCUG 3 months after the procedure. Patients were continued on oral antibiotics until urine culture at 3 months was negative and no reflux was demonstrated on VCUG. The student's t test was used for data analysis.

RESULTS

The mean age was 3.8 +/- 0.3 years, and 76% were girls. From 155 ureters treated, 10 had Grade I reflux, 42 Grade II, 76 Grade III, 25 Grade IV, and 2 Grade V. A second injection was required in 22 ureters (14.2%). The overall success rate of the procedure (Grade 0 reflux at 3 months) was 77.4% after the first injection and 83.9% after a second injection. The success rate per grade was: 100% for Grade I, 88.1% for Grade II, 86.8% for Grade III, 64% for Grade IV, and 50% for Grade V. The mean follow-up was 446 +/- 20 days. The mean volume injected/ureter was 0.6 +/- 0.03 mL. Thirteen (13) patients had UTIs after the procedure, compared to 75 before. There was a 5-fold reduction in the incidence of UTIs/year, from a mean of 0.68 +/- 0.09 pre- to 0.12 +/- 0.04 postinjection (P = 0.001). The majority of UTIs were caused by Escherichia coli (74% pre- and 82% postinjection).

CONCLUSIONS

We conclude that the Deflux procedure is effective not only in eliminating VUR on radiologic studies, but also in reducing the incidence of UTIs and antibiotic use in children with VUR.

Symptomatic Calcification of Subureteral Collagen Ten Years After Injection

Bovine glutaraldehyde cross-linked collagen is an injectable bulking agent used to treat urinary incontinence and vesicoureteral reflux. A 16-year-old girl had previously undergone left subureteral injection of collagen at the age of 6 years. She presented to our clinic after passing a 7-mm calcification with a history of hematuria and intermittent back pain. Computed tomography showed two hyperdense foci measuring 2 mm each in the region of the left ureterovesical junction that did not change on follow-up imaging. On cystoscopy, two submucosal calcifications were located medially and inferiorly to the left ureteral orifice and were removed endoscopically.

Treatment of vesicoureteral reflux in children using stabilized non-animal hyaluronic acid/dextranomer gel (NASHA/DX): a long-term observational study

OBJECTIVE

Vesicoureteral reflux (VUR) can be treated with open surgery, antibiotic therapy or endoscopic injection. A goal in children is to reduce the incidence of febrile urinary tract infections (UTIs). The present long-term observational study investigated outcomes and experiences of endoscopic treatment with stabilized non-animal hyaluronic acid/dextranomer, NASHA/Dx.

PATIENTS AND METHODS

Children treated with NASHA/Dx between 1993 and 1998 were sent a questionnaire by mail in 2005. Patients included in the study (n=231) had VUR grade III-V before treatment and grade 0-II afterwards. Patients completed 21 questions, with parental assistance if required. The questionnaire assessed clinical outcome, and the attitudes of both patients and their parents to their experiences of treatment with NASHA/Dx gel. Patients reporting UTI after treatment were contacted and their records analyzed.

RESULTS

Questionnaires were completed by 179 eligible patients. Most (72%) received a single injection of NASHA/Dx gel, and all experienced febrile UTI before treatment. After treatment, 45 patients (25%) experienced UTI; 25 of these reported fever. Patient records and telephone interviews revealed no evidence of febrile UTI in 19 cases; febrile UTI was confirmed in six cases, an incidence of 3.4%. When asked about the worst aspect of VUR treatment, 9% indicated treatment with NASHA/Dx compared to 19% for medication and 72% for voiding cystourethrogram (VCUG); parent-rated responses were 19%, 24% and 57%, respectively.

CONCLUSIONS

Endoscopic treatment with NASHA/Dx gel was associated with a low number of febrile UTIs following treatment, viewed positively and considered less bothersome than medication or VCUG. These findings support this treatment as a primary intervention for VUR.

Extraperitoneal Laparoscopic Trigonoplasty for Treatment of Vesicoureteral Reflux: Novel Technique Duplicating its Open Counterpart

PURPOSE

We describe a novel technique of extraperitoneal laparoscopic trigonoplasty for the treatment of vesicoureteral reflux.

MATERIALS AND METHODS

Three boys and 24 girls with 41 refluxing units underwent extraperitoneal laparoscopic trigonoplasty. A 10 mm incision was made below the umbilicus. With sharp, blunt finger dissection and balloon dilation an extraperitoneal space was created. The bladder was opened using a laparoscopic scissors. Two 3Fr ureteral catheters were inserted intracorporeally into the ureters. A transverse superficial incision was made in the epithelium between the ureteral orifices. The medial aspect of the ureters was cleared of the muscles and attachments, and sutured in the midline with 4-zero polyglactin sutures.

RESULTS

Operative time ranged from 60 to 240 minutes (mean 147). Blood loss was less than 50 ml. Adequate extraperitoneal space, bladder opening, epithelial incision, ureteral approximation with secure suturing in the midline and bladder closure were carried out in all cases. Peritoneal perforation was noted in 4 patients while creating the extraperitoneal space, with suturing needed for 1 large perforation. Hospital stay was 1 to 6 days (mean 2.7). At 4 to 19 months of followup (mean 8.2) reflux had resolved in 38 units (93%).

CONCLUSIONS

Extraperitoneal laparoscopic trigonoplasty is technically feasible. Results are comparable to open techniques. The major advantage of this procedure is the avoidance of peritoneum. Other advantages include a shorter hospital stay and good cosmesis. More followup is necessary to establish the long-term results.

Lack of Usefulness of Positioned Instillation of Contrast Cystogram After Injection of Dextranomer/Hyaluronic Acid

PURPOSE

Positioned instillation of contrast cystograms have been touted as possibly being more sensitive than standard cystograms for evaluation of vesicoureteral reflux. We performed positioned instillation of contrast cystograms intraoperatively, immediately after the injection of dextranomer/hyaluronic acid to treat vesicoureteral reflux, to determine whether they might be predictive of operative success and obviate the need for the standard postoperative voiding cystourethrogram, which is usually performed at 3 months.

MATERIALS AND METHODS

Patients with vesicoureteral reflux and no confounding conditions were treated with dextranomer/hyaluronic acid and subsequent positioned instillation of contrast cystogram while under the same anesthesia between November 2003 and March 2005. The results of this intraoperative cystogram were compared to the results of the postoperative voiding cystourethrogram performed 3 to 4 months later.

RESULTS

A total of 61 patients met the inclusion criteria and underwent positioned instillation of contrast cystogram after dextranomer/hyaluronic acid injection. Only 53 patients (86 ureters) completed the necessary postoperative evaluation. Positioned instillation of contrast cystogram added 4 minutes to the procedure and required about 4 seconds of fluoroscopy per ureter evaluated. The overall success rate for correcting reflux was 84% (72 of 86 ureters cured). None of the 14 ureters with persistent postoperative reflux was identified by intraoperative cystogram, and 3 patients were misidentified as having reflux despite cure confirmed postoperatively. Intraoperative positioned instillation of contrast cystogram was predictive of treatment failure 0% of the time (sensitivity 0%). There were no complications.

CONCLUSIONS

Positioned instillation of contrast cystogram performed immediately after injection of dextranomer/hyaluronic acid was not useful in predicting which patients would have persistent reflux postoperatively. Patients are best served with the extant protocol of conventional cystography 3 to 4 months postoperatively.

Endoscopic subureteral injection treatment with calcium hydroxylapatite in primary vesicoureteral reflux

INTRODUCTION

In this study, we aimed to evaluate efficiency of subureteral injection of calcium hydroxylapatite treatment for primary vesicoureteral reflux (VUR).

MATERIALS AND METHODS

A total of 25 children (mean age 6.9 +/- 2.7 years) underwent subureteral injection of calcium hydroxylapatite for primary VUR. Reflux was present in 39 ureteral units that were unilateral in 11 cases and bilateral in 14 cases. According to "International Reflux Classification"; grade II in 12 (30.8%), grade III in 18 (46.2%) and grade IV in 9 (23.1%) ureteral units were found.

RESULTS

The refluxes were resolved in 23 (59.0%) ureteral units after a single injection and 5 ureteral units (12.8%) after a second injection. Overall success rate of reflux treatment with calcium hydroxylapatite was 71.8% in all ureteral units.

CONCLUSION

Endoscopic subureteral injection of calcium hydroxylapatite in children with primary low-grade VUR appears to be an effective, safe and minimally invasive technique.

Evaluation of a Calcium Hydroxylapatite-Based Implant (Radiesse) for Facial Soft-Tissue Augmentation

BACKGROUND

Soft-tissue fillers have become increasingly prominent in the practice of facial aesthetic medicine. The authors sought to evaluate the long-term clinical efficacy and safety of a calcium hydroxylapatite-based filler (Radiesse) for facial soft-tissue augmentation.

METHODS

A total of 609 subjects received calcium hydroxylapatite injections in several facial areas: the nasolabial folds, marionette lines, oral commissure, cheeks, chin, lips, and radial lip lines. Follow-up patient satisfaction surveys were conducted at 6 months and again between 12 and 24 months. Treatment satisfaction was based on a scale of 1 (least satisfied) to 5 (most satisfied) using subjective self-evaluation of preoperative photographs. Subjects were also asked whether they would use the treatment again. Adverse events were recorded immediately after treatment and at follow-up visits.

RESULTS

Of the total number of survey requests, 155 subjects provided 6-month follow-up data and 112 subjects provided long-term 12- to 24-month data. The average satisfaction rating at 6 months was 3.94. A total of 138 of 155 subjects (89 percent) at 6 months and 83 of 112 (74 percent) at 12 to 24 months stated that they would use the treatment again. The only side effect observed was the development of easily treated nodules, reported by 42 of 338 of lip mucosa augmentation subjects (12.4 percent) and six of 163 of subjects (3.7 percent) who had treatment for radial lip lines. The proportion of subjects with lip nodules decreased to 8.8 percent when the implant volume was decreased.

CONCLUSIONS

The calcium hydroxylapatite-based implant is a safe, long-lasting, highly effective, and well-tolerated agent for many areas of facial soft-tissue augmentation.

Endoscopic treatment with polydimethylsiloxane in children with dilating vesico-ureteric reflux

OBJECTIVE

To report our experience of treating dilating vesico-ureteric reflux (VUR) in children, using an injectable form of polydimethylsiloxane (Macroplastique, MPQ; Uroplasty BV, Geleen, The Netherlands), as medical treatment for moderate or severe VUR is associated with a high proportion of persistence or development of new scars.

PATIENTS AND METHODS

The study included 32 children (40 ureters) with VUR; 13 (32%) were grade III, 20 (50%) grade IV and seven (18%) grade V. They were treated over a period of 42 months, 66% for some form of bladder dysfunction and 38% had associated diseases. The main indications were VUR grade, recurrent urinary tract infection and progression of reflux nephropathy. MPQ was injected under general anaesthesia via an 11 F cystoscope, x 30 objective, with a 5 F working channel.

RESULTS

The mean (sd) follow-up was 28.5 (10.2) months; VUR resolved in 80% of patients and improved to minimal VUR in the remaining 20%. The resolution/improvement rate was 72% after the first injection, 97% after the second and 100% after the third. There were no significant complications.

CONCLUSION

The endoscopic implantation of MPQ always corrected VUR even though 68% of the cases were grade IV-V. It should become the treatment of choice for severe VUR.

The effect of microsphere degradation rate on the efficacy of polymeric microspheres as bulking agents: An 18-month follow-up study

The injection of bulking substances has been proposed as a new therapy to treat urinary incontinence and vesicoureteral reflux. Our previous study demonstrated that poly(lactic-co-glycolic acid) (PLGA) microspheres have the potential to serve as a bulking agent for urological injection therapies. Hybrid tissues exhibiting a bulking effect were formed in vivo by PLGA microsphere injection, but long-term volume stability was not proven. In this study, we hypothesized that the biodegradation rate of the bulking substance (polymer microspheres) would affect the duration of volume conservation of the induced hybrid tissue. To test this hypothesis, rapidly degrading 75:25 PLGA microspheres and slowly degrading poly(L-lactic acid) (PLLA) microspheres were used as injectable bulking agents for the injection therapy. In vitro degradation tests showed that the mass losses of PLLA and PLGA were 16 and 96% of the initial masses, respectively, at 30 weeks. PLLA and PLGA microspheres were injected into the subcutaneous dorsum of mice. Both types of microspheres were easily injectable through 24-gauge needles. Histological examinations at various time points indicated that host cells from the surrounding tissues migrated to the spaces between both types of injected microspheres and formed new hybrid tissue structures. Lymphocyte migration was noted around the implanted PLGA and PLLA microspheres, but the inflammatory reaction diminished with time. Importantly, the volume of the PLLA hybrid tissues slowly decreased to 52% of the initial volume at 12 months and maintained that volume until 18 months, whereas the volume of the PLGA hybrid tissues rapidly decreased to 22% at 6 months, and the PLGA hybrid tissues disappeared at 11 months. These results show that the biodegradation rate of the bulking substance may be useful for controlling the duration of volume conservation of the induced hybrid tissue.

Complicaciones del tratamiento endoscópico del reflujo vesicoureteral en la infancia

INTRODUCTION

Nowadays, around 1% of children suffer from vesicoureteral reflux (VUR), which represents a risk factor for long-term kidney damage. In the last decade, development in this field has shown that subureteric endoscopic injection of bulking agents for childhood VUR is an acceptable alternative unlike long-term antibiotic prophylaxis and open surgery.

OBJECTIVE

To establish the complications of childhood VUR endoscopic treatment.

MATERIAL AND METHODS

A retrospective analysis was carried out for every patient treated endoscopically in our department from January 1999 to September 2003, with a total amount of 516 implants of submucous bulking agents. All patients were assessed with an ultrasound as a first diagnostic technique so as to establish the complications associated with it, especially ureteral obstruction and injected agent migration.

RESULTS

Out of 516 cases, Macroplastique was used in 455, Deflux in 44 and Polytef in 17. 10 patients (1.9%) (5 girls/ 5 boys), with ages ranging from 15 months to 11,4 years, presented some kind of complications (Macroplastique was used in 8cases and Deflux in 2). Among them, 5 were remarkable due to an ureterohydronefrosis, 2 of which needed a nephrostomy. 3 patients presented an implant migration, 1 epididymitis and 1 bladder edema.

CONCLUSIONS

Endoscopic bulking agent injection has become a safe alternative to open surgery in childhood VUR management.

Submucosal injection of poly(lactic-co-glycolic acid) microspheres in rabbit bladder as a potential treatment for urinary incontinence and vesicoureteral reflux: preliminary results

Endoscopic injection of bulking agents has been gaining attention as a therapy for urinary incontinence and vesicoureteral reflux because this therapy is simpler, less operation time-consuming and less painful than traditional surgical operations. The ideal bulking agent for the injection therapies must be easily injectable, biocompatible, volume-stable, non-antigenic and non-migratory. We evaluated poly(lactic-co-glycolic acid) (PLGA) microspheres as an injectable bulking agent for urologic injection therapies. To determine whether PLGA microspheres meet the requirements of an ideal bulking agent, PLGA microspheres were injected into the submucosal sites of a rabbit bladder wall. The microspheres were easily injectable. Two and five weeks post-implantation, histological examinations indicated that host cells from the surrounding bladder tissues migrated to the space between the injected microspheres and formed new hybrid tissue structures. Lymphocyte migration was noted around the implanted microspheres, but the inflammatory reaction diminished at 5 weeks. The hybrid tissue volume did not significantly decrease over time. There was no evidence of microsphere migration to the distant organs. Although long-term studies are needed to evaluate the therapeutic potential of this method, these preliminary results suggest the possibility of PLGA microspheres as a potentially useful injection material for urinary injection therapies.

Subureteral injection of Deflux for correction of reflux: analysis of factors predicting success

OBJECTIVES

To review, prospectively, our experience with endoscopic Deflux injection and evaluate the volume injected, grade, endoscopic appearance after injection, and presence or absence of voiding dysfunction as predictors of success. Subureteral injection of dextranomer/hyaluronic acid copolymer (Deflux) has become an effective treatment of vesicoureteral reflux.

METHODS

A total of 52 patients (50 females and 2 males; 80 ureters) were treated with a single subureteral injection of Deflux. The mean patient age was 7.6 years (range 14 months to 22 years). The presence or absence of voiding dysfunction was evaluated with a preoperative questionnaire and patient history. The volume of Deflux injected in each ureter was recorded. The endoscopic appearance after injection was recorded as "volcano" or "other." Success was defined as no reflux on postoperative voiding cystourethrography.

RESULTS

The success rate by grade of reflux in individual ureters was 82%, 84%, 78%, and 73% for grade 1, 2, 3, and 4 vesicoureteral reflux, respectively. No statistically significant difference was found in the cure rate by grade (P = 0.76). The overall cure rate by ureter was 80% and by patient was 71%. New contralateral reflux developed in 12.5% of patients. No statistically significant difference was found in the cure rate with respect to the volume injected or the presence or absence of voiding dysfunction. The ureteral cure rate with volcano and alternate morphology was 87% and 53%, respectively (P = 0.004).

CONCLUSIONS

Mound morphology was the only statistically significant predictor of a successful outcome, with an associated cure rate of 87%. Concomitant voiding dysfunction did not have an adverse effect on the cure rate. In our experience, no statistically significant difference was found in the cure rate for grades 1 through 4 vesicoureteral reflux after a single injection of Deflux.

Vesicoureteral reflux – current treatment options

Vesicoureteral reflux has long been recognised as a major child and public health problem. Widespread recognition and screening of at-risk populations has the potential to significantly reduce long-term morbidity in both children and adults. Advances in pharmacotherapy, materials science and surgery, have caused many experts to reassess established dictums of treatment. Concern regarding the overuse of antibiotics and surgery has led to efforts to tailor therapy more narrowly for those who are at the highest risk from recurrent urinary tract infection and pyelonephritis. Children after a certain age, without underlying voiding dysfunction, might not require treatment at all. Newer surgical and anaesthetic techniques have the potential of transforming surgical correction from a painful experience to an ambulatory procedure, with a rapid return to daily activities. Both the promise and pitfalls of these newest advances will be discussed in this review.

Vesicoureteral reflux: surgical approaches

The treatment of vesicoureteral reflux has evolved over the past half-century from primarily surgical to nonoperative treatments. Although the benefits of surgical correction versus medical management are debated, the surgical techniques that have evolved are highly effective in correcting vesicoureteral reflux. Recently, the US Food and Drug Administration has approved an injectable implant of dextranomer/hyaluronic acid copolymer for use in children, making the endoscopic treatment of reflux a potential alternative to open surgical correction. This article reviews the different surgical techniques,postoperative management, and complications, as well as the various implants used in the endoscopic correction of vesicoureteral reflux and their outcomes.

Endoscopic Treatment of Vesicoureteral Reflux with Autologous Chondrocytes: Postoperative Sonographic Features

PURPOSE

To analyze sonographic imaging features of renal collecting systems, ureters, and bladder in 32 children after endoscopic treatment of vesicoureteral reflux with autologous chondrocytes and to determine whether any features are associated with persistent reflux.

MATERIALS AND METHODS

Sonograms obtained at mean intervals of 1.4 and 12 months after treatment were compared with cystograms obtained at mean intervals of 2.7 and 12 months. Sonograms were analyzed for chondrocyte mound contour and volume, changes in mound volume over time, and presence of hydroureteronephrosis. Mean differences in mound volume were detected with paired t tests in 14 patients with early and late sonograms available for review.

RESULTS

Early cystograms and sonograms were available for 25 of 32 patients (45 of 56 treated ureters). Reflux occurred in 16 of 45 ureters. In 16 ureters, chondrocyte mounds were absent in six, unilobed in seven, and multilobed in three. In 29 treated ureters without reflux, mounds were unilobed in 28 and multilobed in one. Three patients had mild hydronephrosis and one had distal hydroureter; these conditions resolved. Late cystograms and sonograms were available in 18 of 22 patients (30 of 38 treated ureters). Reflux occurred in seven of 30 ureters. In seven ureters, mounds were unilobed in five and multilobed in two. In 23 treated ureters without reflux, mounds were unilobed in 21 and multilobed in two. One patient had mild hydronephrosis that resolved. In 14 patients with early and late sonograms available for review, mean mound volume in late group (0.37 cm3 +/- 0.25 [standard deviation]) was significantly smaller than that in early group (0.56 cm3 +/- 0.39; P =.004, paired t test).

CONCLUSION

Absence of chondrocyte mound or presence of multilobed mound contour was associated with persistent reflux. Mean mound volume decreased over time. Treatment-induced hydroureteronephrosis was uncommon and self-limited.

Cystoscopic correction of reflux

Vesicoureteral reflux is a well-recognized cause of childhood illness and renal damage. In the past, surgical reimplantation had been the only procedure available to gain the immediate cessation of reflux. The development of an endoscopic injection technique as a less morbid alternative to traditional surgery began in the 1980s. Teflon was the first injectable agent to be investigated. The record of Teflon is one of efficacy and apparent patient tolerance. However, concerns regarding possible migration and other side effects led to a search for other injectable agents. The most recently investigated agents are polydimethylsiloxane and dextranomer polymer. These agents do not have the long-term follow-up of Teflon, but appear to be effective and safe. Time will tell which agent will become the implant of choice, but it seems clear that endoscopic management will play an increasingly larger role in the care of vesicoureteral reflux.

Poly(lactic-co-glycolic acid) microspheres as a potential bulking agent for urological injection therapy: Preliminary results

Injection of bulking substances has been introduced as a new therapy to treat urinary incontinence and vesicoureteral reflux. Currently available bulking substances for the injection therapies include liquid or particulated silicone, collagen gel, and polytetrafluoroethylene paste. However, these materials have shown shortcomings such as inflammation, rapid volume decrease, and particle migration to distant organs. In the present study, we evaluated poly(lactic-co-glycolic acid) (PLGA) microspheres as a potential injectable bulking agent for the injection therapies. PLGA microspheres (52 microm in average diameter) were injectable through various gauges of needles, as the injected microspheres showed no tendency to obstruct the needles and microsphere size exclusion was not observed upon injection through the needles. After injection of PLGA microspheres into the subcutaneous dorsum of mice, inflammation, new tissue volume change, and microsphere migration were examined. Host cells from the surrounding tissues migrated to the implanted microspheres and formed new hybrid tissue structures. The volume of the newly generated tissues was maintained approximately constant for 7 weeks. Histological analyses showed no evidence of migration of the implanted microspheres to the distant organs. In summary, PLGA microspheres were injectable and able to induce a new hybrid tissue formation without initial volume decrease or particle migration. These preliminary results suggest that this material may be a potentially useful bulking agent for urological injection therapies.

Treatment of Vesicoureteral Reflux by Endoscopic Injection of Dextranomer/Hyaluronic Acid Copolymer: Preliminary Results

PURPOSE

Endoscopic subureteral injection of tissue augmenting substances has become an established alternative to long-term antibiotic prophylaxis and open surgery for the management of vesicoureteral reflux (VUR) in children. Recently, dextranomer/hyaluronic acid copolymer (Deflux, Q-Med AB, Uppsala, Sweden) a biodegradable injectable material has been reported to be a promising alternative to other tissue augmenting substances. However, the experience with dextranomer/hyaluronic acid copolymer is limited. We prospectively evaluate the effectiveness of dextranomer/hyaluronic acid copolymer in the endoscopic treatment of VUR.

MATERIALS AND METHODS

A total of 32 males and 81 females with a median age of 1 year (range 3 months to 10 years) underwent endoscopic correction of primary VUR with dextranomer/hyaluronic acid copolymer. Reflux was unilateral in 58 cases and bilateral in 54, affecting 166 ureters. Reflux was grades II to V in 7 (4.2%) cases, 91 (54.8%), 63 (38%) and 5 (3%), respectively. All patients underwent endoscopic correction as a day procedure and have been followed for 3 months to 1 year.

RESULTS

The reflux was corrected in 143 (86%) of the 166 ureters after a single injection, and resolved after a second and third injection in 22 (13%) and 1 (1%) ureter, respectively. No untoward effects were seen in any of these patients with the use of dextranomer/hyaluronic acid copolymer as an injectable material.

CONCLUSIONS

Dextranomer/hyaluronic acid copolymer is an effective tissue augmenting substance in the endoscopic treatment of all grades of VUR.

Endoscopic Treatment of Vesicoureteral Reflux With Dextranomer/Hyaluronic Acid Copolymer is Effective in Either Double Ureters or a Small Kidney

PURPOSE

Endoscopic injection of dextranomer/hyaluronic acid (Dx/HA) copolymer is an increasingly established treatment for primary vesicoureteral reflux (VUR) in children. We performed a retrospective analysis to assess this treatment for VUR associated with either double ureters or a small kidney.

MATERIALS AND METHODS

The study included 68 children with duplex ureters and 40 with a small kidney (1 kidney contributing 10% to 35% of total renal function) who underwent endoscopic treatment with Dx/HA copolymer for VUR. Followup consisted of voiding cystourethrography 3 and 12 months after injection. Positive response was defined as reflux grade 0 or I. As many as 2 repeat injections were offered to nonresponders, and those with persistent reflux were referred for open surgery. Long-term clinical followup with renal function testing was continued for 4 to 9 years.

RESULTS

A positive response was observed in 63% of children with duplex ureters, with only 17 (25%) patients requiring open surgery. Among children with a small kidney the response rate was 70%, and open surgery was performed in 9 (23%). In both treatment groups a positive response to treatment was sustained throughout the followup period in all cases. The treatment was well tolerated, with no complications associated with the procedure.

CONCLUSIONS

Endoscopic treatment with Dx/HA copolymer appears to be an effective and well tolerated alternative to open surgery for first line treatment of VUR associated with double ureters or a small kidney.

Treatment of vesico-ureteric reflux: a new algorithm based on parental preference

Authors from Rome evaluated parental preference for treatment in children with grade III VUR. Parents were provided with detailed information about the three treatment options: antibiotic treatment, open surgery, endoscopic treatment. Most parents chose endoscopic management; with this in mind, the authors proposed a new treatment algorithm for VUR.

OBJECTIVE

To assess parental preference (acknowledged in treatment guidelines as important when choosing therapy) about treatments for vesico-ureteric reflux (VUR, commonly associated with urinary tract infection and which can cause long-term renal damage if left untreated), as at present there is no definitive treatment for VUR of moderate severity (grade III).

SUBJECTS AND METHODS

The parents of 100 children with grade III reflux (38 boys and 62 girls, mean age 4 years, range 1-15) were provided with detailed information about the three treatment options available for treating VUR (antibiotic prophylaxis, open surgery and endoscopic treatment), including the mode of action, cure rate and possible complications, and the practical advantages and disadvantages. They were then presented with a questionnaire asking them to choose their preferred treatment.

RESULTS

Most parents preferred endoscopic treatment (80%), rather than antibiotic prophylaxis (5%) or open surgery (2%); 13% could not decide among the three options and endoscopic treatment was recommended.

CONCLUSION

Given the strong preference for endoscopic treatment we propose a new algorithm for treating VUR; endoscopic treatment would be considered as the first option for persistent VUR, except in severe cases where open surgery would still be recommended.

Minimally invasive treatment of vesicoureteral reflux with endoscopic injection of dextranomer/hyaluronic acid copolymer: the Children's Hospitals of Atlanta experience

PURPOSE

Emerging data demonstrate that injection of dextranomer/hyaluronic acid (Dx/HA) copolymer (Deflux, Q-Med Scandinavia, Uppsala, Sweden) is a safe and effective treatment for most patients with vesicoureteral reflux (VUR). We sought to determine the efficacy and factors predictive of outcome in patients treated with Dx/HA.

MATERIALS AND METHODS

A total of 180 children 7 months to 15 years old (mean age 4.6 years) underwent subureteral injection of Dx/HA for VUR between October 2001 and February 2003. Dx/HA was injected submucosally within or beneath the intramural ureter. The average volume of injected material was measured for each ureter. At 2 weeks and 3 months postoperatively bladder ultrasounds were performed to measure the volume of Dx/HA (mm3) in the trigone using the volume of an ellipsoid (V = 4/3pir(1)r(2)r(3)). Renal sonography was performed to determine whether hydronephrosis was present. At 3 months fluoroscopic voiding cystourethrograms were used to evaluate for the presence of VUR.

RESULTS

A total of 292 ureters in 180 children were treated (112 bilateral cases). There were 141 girls and 39 boys. Mean maximum grade per patient was 2.6 (out of 5). Average injected volume per ureter was 0.83 +/- 0.03 ml (830 +/- 30 mm3). At 2 weeks the average measured volume was 663 +/- 70 mm3 (18% decrease from original volume), which decreased an additional 1% by 3 months to 656 +/- 103 mm3. There were no cases of hydronephrosis at up to 12 months postoperatively.There were 134 patients with at least 3 months of followup. After 1 treatment 72% (96) were cured (grade 0), while 55% of the failures (21 of 38) were improved. New contralateral VUR was seen in 6 patients (4.5%) who had neither a history of VUR nor an abnormal appearing ureteral orifice at cystoscopy. A lower success rate (60%) was seen in the first 20 patients compared with the last 20 patients (80%). The cure rate per grade was 90% for grade I, 82% for grade II, 73% for grade III and 65% for grade IV reflux. Local migration of material caudal to the ureteral orifice was seen in 61% of patients (11 of 18) at the time of reinjection of Dx/HA after initial treatment failure. There was no statistically significant difference in age, grade, volume injected, bilaterality or gender when successes were compared with failures.

CONCLUSIONS

The majority of patients (72%) undergoing minimally invasive treatment of VUR with Dx/HA are cured after 1 treatment. Contralateral treatment of nonrefluxing ureters should be considered in view of the increased incidence of new reflux (4.5%) and absence of morbidity with Dx/HA injection. There is a definite learning curve with injection therapy. The location of injected material and experience with the technique appear to correlate with the outcome of the procedure.

Endoscopic treatment of primary grades IV and V vesicoureteral reflux in children with subureteral injection of polytetrafluoroethylene

PURPOSE

We evaluated our experience with endoscopic STING (subureteral polytetrafluoroethylene injection) for grades IV and V vesicoureteral reflux.

MATERIALS AND METHODS

We reviewed the records of 221 boys and 305 girls who underwent STING for primary grades IV (430) and V (96) vesicoureteral reflux between 1984 and 2000. Median patient age at STING was 3 years (range 3 months to 14 years). Reflux was unilateral and bilateral in 335 and 191 children, respectively (717 refluxing units). Median followup was 11.6 years (range 1 to 17).

RESULTS

Reflux was corrected in 420 of the 717 refluxing units (58%) after a single injection. Reflux resolved after a second and third injection in 185 ureters (26%). High grade reflux was converted to grades I and II in 112 ureters (15%) and did not require any further treatment. STING failed to correct reflux in 7 units (0.9%), which were managed by ureteral reimplantation (5) and nephrectomy (2) due to poor renal function. Voiding cystourethrography showed recurrent vesicoureteral reflux in 9 units (1.2%), including 2 with low grade reflux for which no treatment was given. Seven ureters required repeat injection due to grades III and IV reflux. No untoward effects were noted in any patients in whom polytetrafluoroethylene was used as the injected material.

CONCLUSIONS

STING is a simple, safe and effective outpatient procedure for grades IV and V vesicoureteral reflux.

Tissue engineering in urology: where are we going?

Tissue engineering in urology is a broad term used to describe the development of alternative tissue sources for diseased or dysfunctional native urologic tissue. This article reviews the recently published techniques involving synthetic and natural biodegradable matrices alone, known as "unseeded" scaffolds, and the latest data on "seeded" scaffolds, which are impregnated with cultured cells from urologic organs. Recent discoveries in reporter gene labeling of urologic tissue are discussed as a new method to identify and track the fates of these transplanted cells in vivo. This article also investigates how these bioengineering techniques are applied to synthetic and natural scaffolds, such as polyglycolic acid and porcine small intestine submucosa, to increase bladder capacity, repair urethral strictures, and replace corporal plaques in Peyronie's disease. Furthermore, recently published reports that these materials have been seeded with chondrocytes to create corporal rods for penile prostheses and stents for ureteral and urethral stricture disease are discussed. With these latest developments as a foundation, the future directions of tissue engineering in urology are presented.

Outcome of endoscopic treatment for vesicoureteral reflux in children using polydimethylsiloxane

PURPOSE

We reviewed the outcome of subureteral injection of polydimethylsiloxane as a bulking agent for endoscopic treatment for vesicoureteral reflux in patients younger than 12 years.

MATERIALS AND METHODS

A total of 40 children (59 ureters) with primary grades II to IV vesicoureteral reflux were treated with a single subureteral injection from 1997 to 2001 and followed an average of 26 months (range 4 to 45). Results in 38 patients (55 ureteral units) were available for review. Each child underwent preoperative voiding cystourethrography, renal ultrasound, dimercapto-succinic acid scan and urine culture. Treatment was done on an outpatient basis. With the patient general anesthesia polydimethylsiloxane implant was injected transurethrally below the ureteral opening of the affected renal unit. Renal ultrasound at 1 week and voiding cystourethrography at 2 months were done to rule out obstruction at the injection site and/or persistent reflux, respectively. Cure was defined as absent vesicoureteral reflux on voiding cystourethrography 2 months after injection.

RESULTS

After a single injection polydimethylsiloxane cured vesicoureteral reflux in 45 ureteral units (81.8%), while in 5 (9.1%) the condition was improved. The remaining 5 ureteral units (9.1%) showed no change in reflux grade. In 1 patient (1.9%) with unilateral grade IV vesicoureteral reflux contralateral reflux developed. None of the cured patients had recurrent reflux during followup. In 1 patient ureteral obstruction was successfully treated with ureteral reimplantation.

CONCLUSIONS

Endoscopic subureteral injection of polydimethylsiloxane implant in children with primary grades II to IV vesicoureteral reflux appears to be an effective, safe and minimally invasive technique.

Endoscopic injection therapy for treatment of vesicoureteric reflux: A 20-year perspective

OBJECTIVE

To review the application and outcome of endoscopic injection therapy for vesicoureteric reflux in regard to its evolution over the past two decades.

DATA SOURCES

Review articles, original reports and abstracts pertaining to endoscopic injection therapy were obtained through a PubMed search of English, German and French publications from 1981 to 2001.

DATA SELECTION

A total of 46 studies were selected. Four were selected to support basic concepts in the management of vesicoureteric reflux, and the remainder pertained specifically to endoscopic injection therapy for vesicoureteric reflux.

DATA EXTRACTION

The reports were analyzed with focus on the physical properties of the biomaterial injected, results of treatment in regard to the cure of vesicoureteric reflux, duration of cure, and possible adverse effects and clinical benefits engendered by the use of injectable materials.

DATA SYNTHESIS

Endoscopic injection therapy successfully cures vesicoureteric reflux in 60% to 80% of cases. Success rates are higher with particulate materials (Teflon and Macroplastique) than with bovine collagen or autologous chondrocytes. Long term data regarding cure are scant. Although concerns about particulate migration and autoimmune disease exist, these have not been borne out of clinical experience. Endoscopic injection may be accomplished on an outpatient basis, with less morbidity than with open ureteroneocystostomy.

CONCLUSIONS

Endoscopic injection therapy should be offered as an alternative treatment in patients with indications to consider ureteroneocystotomy, but should not change the indications for surgical intervention. The ideal biomaterial for injection has yet to be developed, but the field of autologous tissue engineering holds promise for future development.

Review of the available urethral bulking agents

PURPOSE OF REVIEW

Newer tissue bulking agents used to treat stress urinary incontinence and vesicoureteral reflux provide for similar rates of success as older agents, but with greater safety and hopefully with greater durability. We review the new studies on the development and on the current trials of bulking agents.

RECENT FINDINGS

Recent reports suggest that periurethral bulking agents are as effective for genuine stress urinary continence as for intrinsic sphincter deficiency, expanding the indications for injectable agents to include patients desiring less invasive procedures due to personal preference or as a result of medical necessity. Newer bulking agents, Durasphere and Macroplastique, appear safe and as efficacious as older agents in early trials. Durability remains a question for these agents. Injectable tissue matrices and autologous cells may prove useful in the future.

SUMMARY

If durable and safe, these minimally invasive bulking agents may prove useful for all types of stress urinary incontinence. The price of minimal invasiveness may be lower efficacy, but their use does not compromise further therapy, should it be needed.

Vesicoureteral reflux: a new treatment algorithm

Vesicoureteral reflux (VUR) affects about 1% of all children and carries an increased risk of pyelonephritis and long-term renal impairment. There are several approaches to the treatment of VUR: antibiotic prophylaxis (conservative treatment), open surgery, and endoscopic treatment. For many patients, endoscopic treatment cures VUR with a single procedure, eliminating the need for long-term antibiotic treatment and avoiding the trauma of a major surgical procedure. The choice of material for endoscopic treatment is of key importance, and, until recently, all available materials were associated with concerns regarding safety and efficacy. Emerging data demonstrate that dextranomer/hyaluronic acid (Dx/HA) copolymer has good long-term safety and efficacy in treating VUR. A new treatment algorithm is, therefore, proposed, recommending that most children with persistent VUR (longer than 1 year) be offered endoscopic treatment with Dx/HA copolymer as an alternative to prolonged antibiotic prophylaxis or open surgery.

Long-term followup of children treated with dextranomer/hyaluronic acid copolymer for vesicoureteral reflux

PURPOSE

Dextranomer/hyaluronic acid copolymer is a novel substance that has favorable properties for endoscopic treatment of vesicoureteral reflux. We assess the long-term efficacy and safety of this treatment of children.

MATERIALS AND METHODS

Children 1 to 15 years old with grade III or greater vesicoureteral reflux were eligible for enrollment in our study. All patients received endoscopic treatment with dextranomer/hyaluronic acid copolymer and were scheduled to have a voiding cystourethrogram 3 and 12 months after implantation. Children with reflux grade III or greater after treatment received up to 2 more implantations, and those with persistent reflux were referred for open surgery. In some cases long-term clinical followup was accompanied by a late voiding cystourethrogram.

RESULTS

A total of 228 patients received endoscopic treatment. The efficacy population was comprised of 221 children, including 67 who received 2 and 8 who received 3 implantations. Endoscopic treatment was performed without complications in all cases. Patients were followed clinically for 2 to 7.5 years (mean 5). On the last voiding cystourethrogram 68% of patients had a positive response (grade I or less) and 81% had no dilating reflux. The corresponding results for treated ureters were 75% and 85%, respectively. Only 27 (12%) patients were referred for open surgery. A late voiding cystourethrogram was performed in 49 patients 2 to 5 years after treatment. Of the ureters free of reflux (grade 0) 3 to 12 months after treatment 96% remained free of dilating reflux. Adverse events occurred in association with implantation in only 2% of patients, although urinary tract infection subsequently developed in 8%.

CONCLUSIONS

Endoscopic treatment with dextranomer/hyaluronic acid copolymer was effective and well tolerated in children with vesicoureteral reflux. Long-term followup indicated that there was no deterioration in patients responding positively to treatment.