Outcome of endoscopic treatment for vesicoureteral reflux in children using polydimethylsiloxane

Evaluation of renal oxygenation by near-infrared spectroscopy during endoscopic injection of bulking agents in children with vesicoureteral reflux

BACKGROUND

Near infrared spectroscopy (NIRS) is the measuring of regional tissue oxygenation (rSO2) by interpreting oxyhemoglobin and deoxyhemoglobin signals that come back by transmitting near infrared light to tissues. The effect of endourological interventions on renal perfusion in children is largely unknown.

AIMS

To evaluate the effects of endoscopic injection of bulking agents (EIBA) for vesicoureteral reflux (VUR) on renal oxygenation (RO) using renal NIRS monitoring, which shows renal perfusion and oxygenation changes.

STUDY DESIGN

Case-control study.

METHODS

Group I had bilateral inguinal surgery, Group II cystoscopy, and Group III, EIBA for VUR with 30 patients in each group. During the operation, vital signs, peripheral oxygen saturation, end-tidal carbon dioxide, and renal regional oxygen saturation index (rSO2) values by bilateral renal NIRS monitoring were recorded. NIRS values before induction (T0) to postoperative (Tend) were determined. A 20% or more reduction in renal rSO2 (%20↓rSO2) was considered significant. Group III was also evaluated as subgroup III-A (not having "%20↓rSO2") and subgroup III-B ("%20↓rSO2").

RESULTS

The rSO2 decrease was observed in the first 5 min for both sides in group III. The most significant drop was at T30 for the right kidney and a significant decrease in rSO2, 20% or more, was observed in 6 renal units of 4 patients having higher SFU grading and renal scar in group III.

CONCLUSION

EIBA may transitionally impair renal oxygenation. Higher SFU grading and renal scar may increase the risk of renal hypoxia during EIBA.

Macroplastique and Botox are superior to Macroplastique alone in the management of neurogenic vesicoureteric reflux in spinal cord injury population with presumed healthy bladders

CONTEXT/OBJECTIVE

Vesico-ureteric reflux(VUR) is a known complication of neuropathic bladder in spinal cord injury(SCI) population. Bulking agents such as Macroplastique are new minimally-invasive treatment option for VUR with good results. The aim of this study is to assess the efficacy of Macroplastique alone or in combination with Botox(BTX-A), in managing VUR in SCI population with presumed healthy bladders and correlate the pre-and post-injection urodynamic findings with the outcome.

DESIGN

Retrospective comparative study.

PARTICIPANTS

SCI patients with VUR and presumed health bladders (normo-compliant, low filling pressures), treated with macroplastique alone or in combination with BTX-A, who had pre and post-intervention Video-urodynamics (VUDS) and followed up for at least 12 months.

INTERVENTIONS

Macroplastique and BTX-A injections, VUDS.

OUTCOME MEASURES

The primary end point was the overall treatment rate of VUR at 3 months and the secondary outcomes were the success rate (treated + improved) and the comparison of urodynamic parameters (pre-and post-injection).

RESULTS

We studied 34 intervention-naïve SCI patients. 19 had only Macroplastique (Group 1) and 15 had Macroplastique and BTX-A (Group 2). The overall treatment rate was 65.4% for group 1 and 88.9% for group 2 (P = 0.029). The overall success rate (treated + improved) was 80.8% and 94.4% respectively (P = 0.123). The comparison of follow up VUDS parameters showed a statistically significant rise in the detrusor pressure of group 1 (34.04cmH2O vs.19.2cmH2O, P = 0.008) and a drop in compliance (19.8mls/cmH2O vs.26.3mls/cmH2O, P = 0.018) as compared to baseline.

CONCLUSION

The combination of BTX-A and Macroplastique is more effective that Macroplastique alone in the management of secondary VUR in SCI patients with presumed healthy bladders.

Postoperative ureteral obstruction after endoscopic treatment for vesicoureteral reflux

Purpose

We undertook this study to evaluate the incidence, risk factors, management, and outcome of postoperative ureteral obstruction after endoscopic treatment for vesicoureteral reflux (VUR).

Materials and Methods

Ninety patients undergoing endoscopic treatment for VUR were retrospectively reviewed and classified into two groups according to ureteral obstruction: the nonobstruction group (83 cases, 122 ureters; mean age, 7.0±2.8 years) and the obstruction group (7 cases, 10 ureters; mean age, 6.2±8.1 years). We analyzed the following factors: age, sex, injection material, laterality, voiding dysfunction, constipation, renal scarring, preoperative and postoperative ultrasound findings, endoscopic findings, injection number, and injection volume. Additionally, we reviewed the clinical manifestations, natural course, management, and outcome of ureteral obstruction after endoscopic treatment.

Results

The incidence of ureteral obstruction after endoscopic treatment was 7.6% (10/132 ureters). The type of bulking agent used and injection volume tended to be associated with ureteral obstruction. However, no significant risk factors for obstruction were identified between the two groups. Three patients showed no symptoms or signs after the onset of ureteral obstruction. Most of the patients with ureteral obstruction experienced spontaneous resolution within 1 month with conservative therapy. Two patients required temporary ureteral stents to release the ureteral obstruction.

Conclusions

In our experience, the incidence of ureteral obstruction was slightly higher than in previous reports. Our study identified no predictive risk factors for developing ureteral obstruction after endoscopic treatment. Although most of the ureteral obstructions resolved spontaneously within 1 month, some cases required drainage to relieve symptoms or to prevent renal function deterioration.

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.

Endoscopic Subureteral Injection for the Treatment of Vesicoureteral Reflux in Children: Polydimethylsiloxane (Macroplastique(R)) versus Dextranomer/Hyaluronic Acid Copolymer (Deflux(R))

Purpose

The aim of this study was to compare cure rates and complications of polydimethylsiloxane (Macroplastique®) and dextranomer/hyaluronic acid copolymer (Deflux®) in the treatment of vesicoureteral reflux (VUR).

Materials and Methods

From April 2001 to March 2008, 29 boys and 42 girls (total of 115 ureters) with a mean age of 6 years who had undergone endoscopic subureteral transurethral injection for VUR were enrolled. A single subureteral injection of Macroplastique was performed in 31 ureters in 23 children (group I; grade II: 4; grade III: 12; grade IV: 9; grade V: 6), and a single subureteral injection of Deflux was performed in 84 ureters in 48 children (group II; grade II: 24; grade III: 14; grade IV: 25; grade V: 21). Renal ultrasound was done 1 day after injection, and voiding cystourethrography (VCUG) was done at 3 months. Successful reflux correction was defined as absent or grade I reflux on follow-up VCUG.

Results

No significant difference in success rates was observed between group I and group II [80.6% (25/31) vs. 78.6% (66/84), respectively, p>0.05]. The following postoperative complications developed: ureteral obstruction in 2 ureters of group I and 3 ureters of group II, asymptomatic urinary tract infection in 3 patients of group I and 2 patients of group II, and bladder calcification by erosion or mucosal necrosis in 2 patients of group I.

Conclusions

Despite differences in material properties, both Macroplastique and Deflux were safe for the treatment of children with VUR. Because of the risk of bladder mucosal necrosis and substantial decreases in volume after implantation, long-term follow-up is required.