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

Efficacy and safety of Hyadex for treatment of vesicoureteral reflux: a multicenter experience

OBJECTIVE

This study was performed to evaluate the efficacy and safety of dextranomer/cross-linked hyaluronic acid (Hyadex) in patients with a clinical diagnosis of vesicoureteral reflux (VUR).

METHODS

In this cross-sectional multicenter observational study, Hyadex was used in four different centers for the endoscopic treatment of VUR from 2020 to 2022. The study involved 74 patients (93 renal units) who were diagnosed with VUR according to voiding cystourethrography (VCUG) findings and were considered suitable for subureteric endoscopic treatment. The follow-up time (control VCUG time) was 3 months.

RESULTS

In the VCUG evaluation, grade I VUR was found in 13 renal units, grade II in 23 renal units, grade III in 42 renal units, and grade IV in 12 renal units. The success rates of Hyadex treatment according to the degree of VUR were as follows: 84.6% for grade I, 82.6% for grade II, 71.4% for grade III, and 66.0% for grade IV. No major complications were observed.

CONCLUSION

Endoscopic subureteric Hyadex injection had high success rates in appropriately selected patients with VUR and may be used as the first-line treatment for children with VUR.

A comprehensive review on hydrogel materials in urology: Problems, methods, and new opportunities

Hydrogel materials provide an extremely promising group of materials that can find an increasingly wide range of use in treating urinary system conditions due to their unique properties. The present review describes achievements to date in terms of the use and development prospects of hydrogel materials applications in the treatment and reconstruction of the urinary system organs, which among others include: hydrogel systems of intravesical drug delivery, ureteral stents design, treatment of vesicoureteral reflux, urinary bladder and urethral defects reconstruction, design of modern urinary catheters and also solutions applied in urinary incontinence therapy (Figure 4). In addition, hydrogel materials find increasingly growing applications in the construction of educational simulation models of organs and specific conditions of the urinary system, which enable the education of medical personnel. Numerous research efforts are underway to expand the existing treatment methods and reconstruction of the urinary system based on hydrogel materials. After conducting the further necessary research, many of the innovative solutions developed to date have high application potential.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Flow induced stability of pluronic hydrogels: Injectable and unencapsulated nucleus pulposus replacement

Poloxamers, or pluronics, have been proposed as biomimetic substitutes for physiological gels. Concern regarding their ability to resist swelling under fluid flows has impeded their implementation. Using a combination of techniques including cryo-TEM and rapid X-ray imaging, we found that rapid flow rates stabilized the gels against dissolution. Energy balance calculations confirmed that disentanglement of individual micelles was not possible at time scales faster than the reptation time when the system response was that of a solid which dissipated the hydrodynamic force field via cooperative deformation. In-vivo tests were performed where the hydrogel was injected as a substitute for the nucleus pulposus following discectomy in dogs. The results indicated that the gel was still present after 3 months, and radiographs indicated that compression of the disc space was prevented despite the gel being exposed to constant perfusion. STATEMENT OF SIGNIFICANCE: This paper demonstrates a highly unexpected result and counter intuitive result, namely the inverse dependence of the dissociation rate of a physical hydrogel on the flow velocity of the liquid medium. Using cryo-electron microscopy we demonstrate that the gel responds like deformable solid in high flow rates, with minimal dissociation. Since these gels are thermoreversible, they were injected into dogs, where we show that they were a viable alternative to the nucleus pulposus, without dissolution in physiological fluid flows for at least three months.

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.

What are the predictive factors leading to ureteral obstruction following endoscopic correction of VUR in the pediatric population?

BACKGROUND

It is extremely important to not only address the short-term success following endoscopic correction of vesicoureteral reflux (VUR) but also the long-term efficacy and safety of the tissue augmenting substance utilized for endoscopic correction.

OBJECTIVE

This study retrospectively evaluated all cases of ureterovesical junction (UVJ) obstruction following endoscopic treatment of VUR over the last 5 years utilizing two tissue augmenting substances, with special emphasis on the safety of Vantris^®, and performed clinical and histological review of these patients.

METHODS

The study population comprised 2495 patients who underwent endoscopic correction of VUR utilizing Deflux^® (1790) and Vantris^® (705). Tissue sections were stained with hematoxylin & eosin and trichrome, and examined under a light microscope. Nine primary obstructive megaureters after ureteral re-implantation served as controls.

RESULTS

Nine (0.5%) children (three female and six male) in the Deflux group and nine (1.3%) (five females and four males) in the Vantris group developed UVJ obstruction and required ureteral re-implantation. Obstruction developed during the period ranging 2-49 months (average 16 months) following endoscopic correction. The primary reflux grade was III in seven, IV in six, and V in six children. The mean volume of the injected material in all obstructed patients was 1.2 ± 0.6 cc (mean ± SD). Histopathological analysis revealed a pseudocapsule composed of fibrous tissue and foreign-body giant cells surrounding the Vantris implant in all patients. The distal part of the ureters demonstrated significant ureteral dilatation without ureteral fibrosis. In all patients, additional biopsies from the muscularis propria adjacent to the injection site were examined and showed no significant abnormalities. There was an increased collagen deposition in the juxtavesical segment of the obstructive ureters following Deflux and Vantris injections, and of primary obstructive megaureter. No significant difference was found in the tissue response between Deflux and Vantris patients and controls. Statistical analysis of the nonhomogeneous population demonstrated higher obstruction rates in patients from the Vantris group. However, no statistical difference was demonstrated regarding the obstruction rate in the homogenous group with relation to gender, age and reflux grade group of patients. Moreover, univariate analysis revealed that Grade V reflux, the presence of beak sign on the reviewed pretreatment, and inflamed bladder mucosa upon injection were significant independent risk factors leading to obstruction.

DISCUSSION

This study suggested that the underlining ureteral pathology lead to UVJ obstruction following Vantris injection. There was increased collagen deposition in the juxtavesical segment of the obstructive ureters following Vantris injection. Furthermore, these findings were similar to those discovered in patients who underwent endoscopic correction with Deflux, and in patients who required ureteral reimplantation due to primary obstructive megaureter. Additional biopsies from the muscularis propria adjacent to the injection site showed no significant abnormalities, ironing out the fact that Vantris did not led to adverse tissue reaction following injection. Univariate analysis further ironed out the hypothesis that underlying ureteral pathology was responsible for the increased incidence of UVJ obstruction and demonstrated that Grade V reflux, the presence of beak sign on the reviewed pretreatment VCUG, and inflamed bladder mucosa upon injection were significant independent risk factors leading to obstruction.

CONCLUSION

Data showed that Vantris injection did not lead to any different ureteral fibrosis or inflammatory changes to the tissue augmenting substances utilized in past and present clinical practice, and therefore did not seem to increase the incidence of UVJ obstruction. High reflux grade, presence of obstructive/refluxing megaureter and inflamed bladder mucosa were the only statistically significant and independent predictive factors for UVJ obstruction following endoscopic correction of VUR.

Avoiding routine postoperative voiding cystourethrogram: Predicting radiologic success for endoscopically treated vesicoureteral reflux

INTRODUCTION

Variability in the success rates for the endoscopic correction of vesicoureteral reflux (VUR) has prompted a debate regarding the use of routine postoperative voiding cystourethrogram (VCUG). This study examines the predictive performance of intraoperative mound morphology (IMM) and the presence of a postoperative ultrasound mound (PUM) on radiologic success, as well as investigates the role of using these two predictive factors as a composite tool to predict VUR resolution after endoscopic treatment.

METHODS

This retrospective study included children with primary VUR who underwent endoscopic correction with a double hydrodistension-implantation technique (HIT) and dextranomer/hyaluronic acid copolymer. IMM was assessed intraoperatively. The presence of a PUM and VUR resolution were assessed by postoperative ultrasound (US) and VCUG, respectively. Radiologic success was defined as VUR resolution.

RESULTS

A total of 70 children (97 ureters) were included in the study. The overall radiologic success rate was 83.5%. There was no statistically significant association between radiologic success and IMM (85.2% with excellent and 87.5% with "other" morphology; p=0.81). The sensitivity and specificity of PUM for radiologic success in this study was 98% and 71%, respectively, while the sensitivity and specificity of the combined prediction model were 81.9% and 85.7%, respectively.

CONCLUSIONS

We objectively demonstrated that IMM was a poor predictor of radiologic success and should be used with caution. In addition, the performance of a combined prediction model was inferior to the presence of a PUM alone. As such, selective use of postoperative VCUG may be guided solely by the presence of a PUM.

Controversies Regarding Management of Vesico-ureteric Reflux

The primary goal in the management of a child with urinary tract infection (UTI) is to prevent recurrence of UTI and acquired renal damage. Approximately 15% of children develop renal scarring after a first episode of febrile UTI. Vesico-ureteric reflux (VUR) is diagnosed in 30-40% of children imaged after first febrile UTI. The 'top-down' approach involving ultrasound and dimercaptosuccinic acid scan (DMSA) first after an appropriate interval following UTI, can help in avoiding voiding cystourethrogram (VCUG), an invasive test with higher radiation exposure. The majority view remains that VCUG should be done after the second attack of UTI in girls and first attack of UTI in boys. Although the evidence in favour of antibiotic prophylaxis remains doubtful in preventing renal scars associated with VUR, it remains the first line treatment for high-grade reflux (grade 3-5) with an aim to prevent UTI and allow spontaneous resolution of VUR. Early identification and appropriate treatment of associated bowel bladder dysfunction is an essential part of successful medical management of VUR. Endoscopic treatment of VUR, using a bulking agent, is useful in grade 3 VUR. The main controversy regarding intervention (endoscopic/open surgical intervention) involves absence of strong evidence for these interventions in reducing renal scarring on randomized controlled trials. However, several recent trials have found the surgical interventions to be effective in reducing recurrent pyelonephritis and repeated hospital admissions.

The treatment of vesicoureteral reflux in children by endoscopic sub-mucosal intra-ureteral injection of dextranomer/hyaluronic acid: A case-series, multi-centre study

BACKGROUND

Vesicoureteral reflux is a risk factor for progressive renal damage. In addition to long-term antibiotic prophylaxis and open surgical re-implantation, endoscopic sub-mucosal intra-ureteral injection of implant material is a therapeutic alternative that gained a world-wide preference.

OBJECTIVE

The aim of this study was to determine the effectiveness and safety of the implant material, dextranomer/hyaluronic acid, in a cohort of Saudi children with vesicoureteral reflux.

METHODS

In this case-series study, 61 patients with vesicoureteral reflux, who were 7 months to 10 years old (mean age 2.6 years), underwent sub-mucosal intra-ureteral injection of dextranomer/hyaluronic acid at our institutions in the period from October 2003 to October 2013. The operative protocol was the same in all institutions. Dextranomer/hyaluronic acid was injected submucosally within the intramural ureter (modified STING). Renal ultrasonography was performed to detect the presence of hydronephrosis. At 6 weeks' fluoroscopic voiding cystourethrograms were used to evaluate the success of the technique. Data were analysed by SPSS version 19 using Pearson Chi square, Fisher's Exact and Cramér's V test.

RESULTS

Reflux was corrected in 44 patients out of 61 (72.13%) and in 60 (75.00%) out of 80 ureteric units. Statistically, there was no significant difference (p>0.05) in success rate of the technique according to gender, age group and unilateral vs. bilateral cases. The success rate was significantly (p=0.025) higher in the lower grades (I-III) (87.50%) compared to grade IV (73.53%) and grade V (50.00%). No complications related to the technique were reported. The technique had failed in 17 patients (27.87%) or 20 ureters (25.00%). These cases underwent open surgery.

CONCLUSION

Sub-mucosal intra-ureteral implantation with dextranomer/hyaluronic acid by the modified STING technique is a simple, safe and effective outpatient procedure for vesicoureteral reflux.

Novel method for the depletion of cariogenic bacteria using dextranomer microspheres

Streptococcus mutans is recognized as one of the key contributors to the dysbiotic state that results in dental caries. Existing treatment strategies reduce the incidence of tooth decay, but they also eliminate both the cariogenic and beneficial microbes. Here we introduce a novel treatment alternative using Sephadex, cross-linked dextranomer microspheres (DMs), typically used for gel filtration chromatography. In addition DM beads can be used for affinity purification of glucosyltransferases (GTFs) from S. mutans. In this study we take advantage of the native pathogenic mechanisms used by S. mutans to adhere, form a biofilm and induce dental caries through the expression of surface-associated GTFs. We demonstrate that planktonic and biofilm-grown (adhered to hydroxyapatite-coated pegs to mimic the tooth surface) S. mutans, specifically and competitively attach to DMs. Further investigation demonstrated that DMs are a specific affinity resin for S. mutans and other cariogenic/pathogenic oral streptococci, whereas other commensal and probiotic strains failed to readily adhere to DMs. Using antimicrobial cargo loaded into the DM lumen, we demonstrate that when in co-culture with non-binding to even modestly binding commensal species, S. mutans was selectively killed. This proof of concept study introduces a novel means to safely and effectively reduce the pool of S. mutans and other pathogenic streptococci in the oral cavity with limited disturbance of the necessary commensal (healthy) microbiota when compared with current oral healthcare products.

[Secondary megaureter: A rare complication of Deflux® endoscopic management of vesicoureteral reflux in children]

Endoscopic management is the gold standard for symptomatic low-grade vesicoureteral reflux (VUR) in children. Deflux^® (hyaluronic acid/dextranomer) injection is highly effective and has very few complications. We report on two cases of secondary megaureter after Deflux^® injections. In the first case, a boy presented with Grade 4 VUR. He received a bilateral Deflux^® injection with a total of three syringes. The postoperative ultrasound was normal. However, a check-up ultrasound 3 years later showed a significant ureteropyelocalyceal dilatation, with stasis and decreased renal function on scintigraphy, the reason why antireflux surgery (Cohen procedure) was performed. In the second case, a girl diagnosed with bilateral VUR at birth received bilateral injections with one syringe on each side at the age of 12 months. One month later, the ultrasound showed a dilation of the distal ureters (diameter of the right ureter, up to 10mm; left ureter, up to 6.7mm). The child underwent surgery 8 months later (Cohen procedure) because of iterative pyelonephritis and persistent ureter dilatation. Only one previous case has been described in the literature. In our experience, this complication has occurred only twice in 452 injections (4‰). In conclusion, endoscopic treatment with hyaluronic acid/dextranomer injection is a minimally invasive procedure that improves the situation in cases of VUR. It has few complications. Other than failure, there is a low risk of secondary expansion requiring, in our opinion, ultrasound verification over the long term.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Retrospective comparative studies - level III.

Increased radiosensitivity of colorectal tumors with intra-tumoral injection of low dose of gold nanoparticles

The potential of gold nanoparticles (GNPs) as radiosensitizers for the treatment of malignant tumors has been limited by the large quantities of GNPs that must be administered and the requirement for low-energy X-ray irradiation to optimize radiosensitization. In this study, we enhance the radiosensitivity of HCT116 human colorectal cells with tiopronin-coated GNPs (Tio-GNPs) combined with a low-energy X-ray (26 keV effective energy) source, similar to the Papillon 50 clinical irradiator used for topical irradiation of rectal tumors. Sensitizer enhancement ratios of 1.48 and 1.69 were measured in vitro, when the HCT116 cells were incubated with 0.1 mg/mL and 0.25 mg/mL of Tio-GNPs, respectively. In nude mice bearing the HCT116 tumor, intra-tumoral (IT) injection of Tio-GNPs allowed a 94 times higher quantity of Tio-GNPs to accumulate than was possible by intravenous injection and facilitated a significant tumor response. The time following irradiation, for tumors growing to four times their initial tumor volume (4Td) was 54 days for the IT injection of 366.3 μg of Tio-GNPs plus 10 Gy, compared to 37 days with radiation alone (P=0.0018). Conversely, no significant improvement was obtained when GNPs were injected intravenously before tumor irradiation (P=0.6547). In conclusion, IT injection of Tio-GNPs combined with low-energy X-rays can significantly reduce the growth of colorectal tumors.

Polyacrylamide Hydrogel as a Bulking Agent for the Endoscopic Treatment of Vesicoureteral Reflux: Long-Term Results and Safety

PURPOSE

Polyacrylamide hydrogel has been shown to offer good short-term success for the endoscopic treatment of vesicoureteral reflux. Our objective was to provide long-term results of its efficacy and safety.

MATERIALS AND METHODS

We performed a prospective study using polyacrylamide hydrogel to treat all grades of vesicoureteral reflux. Every patient underwent endoscopic injection of polyacrylamide hydrogel followed by 3-month postoperative renal ultrasound and voiding cystourethrogram. Renal ultrasound was repeated at 12 and 36 months. Treatment success was defined as the absence of de novo or worsening hydronephrosis and the absence of reflux. Safety elements included new or worsening hydronephrosis, calcifications of the injected material and urinary tract infections.

RESULTS

A total of 76 patients (123 refluxing renal units) were assessed. Median age at surgery was 45 months and median followup was 36 months. Median injected volume of hydrogel per refluxing renal unit was 1.0 ml. The overall success rate 3 months after a single injection was 71%. During long-term followup 68 of 70 eligible patients underwent 12-month ultrasound and 40 of 46 underwent 36-month ultrasound. No upper tract deterioration or bulking agent calcifications were reported. Nine (12%) and 2 patients (3%) presented with nonfebrile and febrile urinary tract infections, respectively.

CONCLUSIONS

The success rate of polyacrylamide hydrogel for endoscopic treatment of vesicoureteral reflux is comparable to published results of dextranomer hyaluronic acid. The long-term safety data and potential lower cost of polyacrylamide hydrogel provide further support for the use of this nonparticulate bulking agent to treat reflux.

Ultrasonographic mound height as predictor of vesicoureteral reflux resolution after endoscopic treatment in children

PURPOSE

Endoscopic dextranomer/hyaluronic acid copolymer (Dx/HA) injection is a safe and efficacious treatment option for vesicoureteral reflux (VUR) in children. Endoscopic appearance, hydrodistention and amount of injected Dx/HA have been demonstrated not to be reliable predictors of outcome. Aim of this study was to evaluate Dx/HA mounds on ultrasound scans (US) and find out any eventual correlation with reflux resolution.

METHODS

We selected patients treated with endoscopic injection for moderate to high VUR, renal scaring or repeated infections under antibiotic prophylaxis. Success was defined by absence of VUR at control 3months after surgery; at 3months we also measured mound height ultrasonographically.

RESULTS

We considered a total of 32 children (15 male, 17 female; 53 ureters) with a median age of 3years (±24months). Overall success rate was 77% per ureter. Success rate correlates directly with age and inversely with VUR grade. Mound height is the major predictive parameter for reflux resolution (sensitivity 100%, specificity 65.9%); mean mound heights of success-group vs. persistence-of-reflux group were 9.97±1.61mm and 7.29±1.74mm respectively (p<0.0005).

CONCLUSION

A mound measuring at least 9.8mm at post-operative US scan is a predictor of reflux resolution. Age and grade also seems to influence success rate.

Is a secondary procedure necessary in every case of failed endoscopic treatment for vesicoureteral reflux?

Purpose

Endoscopic treatment (ET) has become a widely accepted procedure for treating vesicoureteral reflux (VUR). However, patients followed up after ET over long periods have reported persistent or recurrent VUR. We evaluated the natural course of failed ET in patients who required further treatments to help physicians in making decisions on the treatment of VUR.

Materials and Methods

We retrospectively reviewed the medical records of patients who were diagnosed with VUR and underwent ET from January 2006 to December 2009. A total of 165 patients with 260 ureters underwent ET. We compared the parameters of the patients according to ET success or failure and evaluated the natural course of the patients after ET failure.

Results

Mean VUR grade and positive photon defect were higher in the failed ET group than in the successful ET group. Six months after the operation, persistent or recurrent VUR was observed in 76 ureters (29.2%), and by 16.3 months after the operation, VUR resolution was observed in 18 ureters (23.7%). Twenty-five ureters (32.9%) without complications were observed conservatively. Involuntary detrusor contraction was found in 1 of 9 (11.1%) among the secondary ET success group, whereas in the secondary ET failure group, 4 of 6 (66.7%) had accompanying involuntary detrusor contraction.

Conclusions

Patients in whom ET fails can be observed for spontaneous resolution of VUR unless they have febrile urinary tract infection or decreased renal function. Urodynamic study may be helpful in deciding whether a secondary procedure after ET failure is necessary.

Endoscopic correction of complex cases of vesicoureteral reflux utilizing Vantris as a new non-biodegradable tissue-augmenting substance

PURPOSE

We aimed to evaluate prospectively the efficacy of Vantris as a new non-biodegradable tissue-augmenting substance in children with complex cases of VUR.

MATERIALS AND METHODS

Over the last 4 years, 37 children (28 female and 9 male) with a mean age of 5.8 ± 3.1 years (mean ± SD) underwent endoscopic correction of complex VUR. A total of 38 renal refluxing units (RRU) was treated as 5 had persistent reflux after open surgery, 16 had duplication, 4 had Hutch diverticulum, 6 had small poorly functioning kidneys (less than 20% of relative renal function) with grade V VUR, 2 had ureterocele after puncture, 3 had persistent stump reflux, 1 had prune belly syndrome, and 1 had urogenital sinus. VUR was Grade I in 2, Grade II in 9, Grade III in 11, Grade IV in 10, and Grade V in 6 RRU, respectively.

RESULTS

The reflux was corrected in 34 (89.4%) RRU after a single injection, after second injection in 2 (5.3%) RRU. In 2 (5.3%) RRU, VUR downgraded to Grade I (1RRU) and Grade II (1RRU) and they were taken off antibiotic prophylaxis. VCUG was performed in 11 (73.3%) of 15 children who completed 1 year and in 3 (33.3%) of 9 who completed 3 years of follow up as a part of the routine protocol. None showed VUR recurrence. US demonstrated normal appearance of kidneys in all patients.

CONCLUSION

Our data show that Vantris injection provides a high level of reflux resolution in complex cases of VUR.

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.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Endoscopic treatment of vesicoureteric reflux with dextranomer/hyaluronic acid copolymer (Deflux): Single-surgeon experience with 48 ureters

Purpose:

VUR is a common urologic problem in children. Cystoscopic injection of bulking agents (most commonly Deflux) has gained popularity as the first line treatment in the west. However, primarily due to cost factors, it has not gained much popularity in our country. We present our initial experience with cystoscopic Deflux injection for VUR.

Materials and Methods:

We reviewed our 3-yr experience with the use of Dx/HA (Deflux) for correction of VUR in children and adolescents. All children were evaluated with Ultrasound, MCUG and DMSA renal cortical scan. The indications for surgical correction of VUR included breakthrough infections while on antibiotic prophylaxis, persistent high-grade VUR beyond 3 yrs of age, and presence of significant renal damage on DMSA at diagnosis (in those children presenting with UTI). All children underwent cystoscopic Deflux injection using the standard technique of subureteral injection (0.4-1 ml per ureter). All children received antibiotic prophylaxis for 3-6 months after the injection. USG was done at 1 month and MCUG at 3-6 months after the injection.

Results:

33 patients (48 ureters) underwent cystoscopic Deflux injection for correction of VUR. Mean age was 4.5 yrs (1-17 yrs); there were 12 boys and 21 girls. Thirteen children had antenatally diagnosed HDN, while 20 children presented with febrile UTI. All children had primary VUR except one child with persistent VUR 4 yrs after PUV fulguration. The VUR was grade 1-2 in 8, grade 3-4 in 37, and grade 5 in 3 ureters. Every child had at least one ureter with dilating reflux (grades 3,4 or 5). When present, low grade VUR (grade 1or 2) was always on the contralateral side. Only one child received a 2^nd injection after 6 months. Follow-up MCUG was done in 28 children (41 ureters). Complete reflux resolution was achieved in 27 ureters (65%), and the reflux was downgraded in 2 (5%). There were no complications of Deflux injection.

Conclusions:

Endoscopic correction of VUR in children is a safe and effective minimally invasive treatment for VUR. It stops or downgrades VUR in 70% of ureters. At present, we recommend it as a first-line treatment for grades 1-4 VUR requiring surgical management. Cost is the major factor limiting its use in our country.

The incidence of urinary tract infection after open anti-reflux surgery for primary vesicoureteral reflux: early and long-term follow up

OBJECTIVES

Controversy exists regarding the benefit of open anti-reflux surgery (OS) in reducing the incidence of urinary tract infection (UTI). We, therefore, reviewed our short and long term data in children who have undergone OS.

METHODS

153 children (131F, 22M; ages 2-16 yrs, mean 8 yrs) underwent OS from 1990 to 2008. Reasons for presentation were UTI-131; sibling survey-19; prenatal hydronephrosis-3. Major reasons for OS were: breakthrough UTI-74 (48%), high grade (IV or V)-49 (32%), poor compliance with prophylaxis-15 (10%). Of 153 pre-operative DMSA scans, 60 (39%) had defects. Post-operative studies were performed 6 months after surgery and 151 (99%) had negative voiding cystourethrograms (VCUG's). All underwent urine cultures 6 months post-op and prophylaxis was stopped. 56 (37%) were later contacted at an average 7 yrs post-op (range: 2-13 yrs).

RESULTS

23 (15% of 153 followed short term, 40% of 56 followed long term)-20F, 3M-had non-febrile UTI's (nfUTI's) and one girl (0.6%) had a febrile UTI (fUTI). Of those who had nfUTI's 7 (30%) had high grade reflux and 16 (70%) had pre-op breakthrough UTI's. 11 (48%) had DMSA scans with defects. 2 had UTI's within 1 year after a negative VCUG and 21 had UTI's later (1-8 yrs). 1 girl had a fUTI 1 month after a negative VCUG.

CONCLUSIONS

Successful OS effectively eliminates fUTI. Families should be counseled that nfUTI may occur many years after surgery, especially in girls with a history of breakthrough UTI and renal scarring.

Randomized clinical trial comparing endoscopic treatment with dextranomer hyaluronic acid copolymer and Cohen's ureteral reimplantation for vesicoureteral reflux: long-term results

PURPOSE

To compare efficacy of Cohen's ureteral reimplantation and endoscopic treatment with Dx/HA in patients with primary VUR grades II, III and IV.

METHODS

From April 2002 to June 2004, patients over 1 year old with VUR grade I, II, III or IV were included. Patients were randomized into two groups: endoscopic treatment (ET) or ureteral reimplantation (UR). In the ET group, an ultrasonography study was performed 24 h and 1 month after surgery, and two voiding cystourethrographies at 3 and 6 months post treatment. In the UR group, an ultrasonography study was done 7 days and 1 month after surgery and a micturial cystography 6 months post surgery. A postoperative nuclear direct cystogram was performed 5 years later in both groups.

RESULTS

A total of 41 patients were included in this study: in ET 22 patients with 35 refluxing ureters and in UR 19 patients with 32 refluxing ureters. The VUR grades in ET were: 16 grade II, 16 grade III and 3 grade IV; and in UR: 15 grade II, 12 grade III and 5 grade IV. VUR was resolved in 91% (32/35) of ET (28% of ureters needed a second injection), and in 100% of UR group. Five years after the procedure, VUR was still resolved in 30/32 of ET and 32/32 of UR.

CONCLUSION

Short- and long-term follow up shows that multiple endoscopic treatment of VUR grades II, III and IV with Dx/HA is as effective as ureteral reimplantation.

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.

Long-term results of endoscopic treatment of vesicoureteral reflux in children: comparison of different bulking agents

OBJECTIVE

To determine the long-term effect in children of endoscopic treatment of vesicoureteral reflux (VUR) using different bulking agents. VUR status, recurrence of urinary tract infection (UTI), and recurrence of febrile UTI were evaluated as endpoints.

METHODS

From 1993 to 2005, we injected 229 refluxive ureters (VUR grade II-IV) in 135 children. Mean age of the children was 55.7 months. We used collagen in 98 (years 1993-2000), polydimethylsiloxane in 32 (years 1999-2000), and dextranomer/hyaluronic acid copolymer (Dx/HA) in 99 ureters (years 2000-2005). Of the 135 children, 127 underwent a voiding cystourethrogram (VCUG) (radiologic or nuclid) 3 months after the first injection, and 88 children a second VCUG (nuclid) after 37 months (mean) postoperatively. Clinically, patients were monitored for non-febrile or febrile UTI. Data were collected and analyzed retrospectively by chart review.

RESULTS

After first injection with collagen, polydimethysiloxane and Dx/HA, 52%, 55% and 81.5% of the children were without VUR, respectively. Repeated injections were successful in only 21% (collagen) to 42% (Dx/HA). Of the 88 with a second VCUG, 48.5% of the initially reflux-free children developed relapse VUR after collagen, 45.5% after polydimethylsiloxane and 21.5% after Dx/HA injection. Clinically, there was a significant difference in postoperative UTI occurrence in favor of the Dx/HA group.

CONCLUSIONS

Clinically and radiologically, Dx/HA exhibited the best results, giving better protection against UTIs and a better VUR cure rate. There was still a risk of VUR recurrence in successfully treated children after 3 years of follow up.

Is the appearance of the dextranomer/hyaluronic acid mound predictive of reflux resolution?

PURPOSE

After endoscopic correction of vesicoureteral reflux, we correlated the appearance of the Deflux® mound with the outcome.

MATERIAL AND METHODS

We created an online survey based on 11 primary vesicoureteral reflux cases, including 6 failed and 9 successful procedures in a total of 15 renal units. Cases were selected randomly from our video library. All cases were performed by a single surgeon using the double hydrodistention implantation technique until a satisfactory mound was achieved and corrected. An online survey questionnaire was e-mailed to 234 members of the Society for Pediatric Urology. Each survey question contained a preoperative voiding cystourethrogram image as well as images of the ureteral orifice before and after injection. Respondents were asked to predict whether they thought that the appearance of the Deflux mound would be associated with successful reflux resolution on voiding cystourethrogram 3 months postoperatively. We analyzed the percent of correctly answered questions as well as the sensitivity, specificity and predictive value of the ability of experts to predict the outcome.

RESULTS

A total of 104 pediatric urologists responded to the survey. Overall, 66.4% of respondents predicted reflux resolution based on mound appearance, including 66% and 67% who correctly predicted success and failure, respectively. Mean outcome predictability per respondent was 66% (range 26% to 86%).

CONCLUSIONS

The appearance of the Deflux mound and lack of hydrodistention at the completion of the procedure are not reliable predictors of outcome. Based on this experience, postoperative voiding cystourethrogram is still required to truly determine reflux resolution.

Intraureteral injection of NASHA/Dx gel under direct ureteroscopic visualization for the treatment of primary high-grade vesicoureteral reflux

OBJECTIVE

To present a preliminary experience with the modified technique of extravesical intraureteral injection of non-animal-stabilized hyaluronic acid/dextranomer (NASHA/Dx) gel under direct ureteroscopic visualization for the treatment of primary high-grade vesicoureteral reflux (VUR).

PATIENTS AND METHODS

The medical records of all pediatric patients (age range, 0-14 years) who underwent intraureteral injection of NASHA/Dx gel under direct ureteroscopic visualization for the treatment of primary high-grade VUR during the period June 2006-June 2010 were reviewed.

RESULTS

Eighty-nine children (61 boys, 28 girls; M:F ratio, 2.1) underwent intraureteral injection of NASHA/Dx gel under direct ureteroscopic visualization for the treatment of primary high-grade VUR during the study period. VUR completely disappeared after the injection of NASHA/Dx gel into 105 (73%) of 144 ureters, with no further treatment required. Thirty-five (24.3%) required a second injection, and 2 (1.4%) required a third injection for resolution of their VUR. No intraoperative complications were observed. No ureteral obstruction during follow-up was observed using ultrasound or micturition studies.

CONCLUSIONS

Intraureteral injection of NASHA/Dx gel under direct ureteroscopic visualization is safe and effective in the treatment of primary high-grade VUR, including cases with ureteral duplication, if the ureteral meatus is easy to pass through without mechanical dilation. This approach represents an effective and safe alternative to antibiotic prophylaxis alone and open surgery.

Endoscopic treatment of vesicoureteral reflux in children with subureteral dextranomer/hyaluronic acid injection: a single-centre, 7-year experience

BACKGROUND

The goals of medical intervention in patients with vesicoureteral reflux are to allow normal renal growth, prevent infections and pyelonephritis, and prevent renal failure. We present our experience with endoscopic treatment of vesicoureteral reflux in children by subureteral dextranomer/hyaluronic acid copolymer injection.

METHODS

Under cystoscopic guidance, dextranomer/hyaluronic acid copolymer underneath the intravesical portion of the ureter in a subureteral or submucosal location was injected in patients undergoing endoscopic correction of vesicoureteral reflux.

RESULTS

A total of 282 patients (120 boys and 162 girls) underwent the procedure. There were 396 refluxed ureters altogether. The mean age of patients was 4.9 years. The mean overall follow-up period was 44 months. Among the 396 ureters treated, 76% were cured with a single injection. A second and third injection raised the cure rate to 93% and 94%, respectively. Twenty-two (6%) ureters failed all 3 injections, and were converted to open surgery.

CONCLUSION

Endoscopic treatment of vesicoureteral reflux can be recommended as a first-line therapy for most cases of vesicoureteral reflux, because of the short hospital stay, absence of complications and the high success rate.

Delayed onset ureteral obstruction following Deflux® injection for vesicoureteral reflux

Endoscopic injection treatment of vesicoureteral reflux is an increasingly common and successful option. Obstruction is an infrequent postoperative complication, occurring in 1% of patients; delayed onset of obstruction is even rarer. There is a paucity of literature describing possible treatments. We present a novel approach by excision of the implanted material.

Efficacy of hydrodistention implantation technique in treating high-grade vesicoureteral reflux

Purpose

In the endoscopic treatment of vesicoureteral reflux, the relatively high rate of success, the simplicity of the procedure, high patient compliance, and a lack of complications has led to the increased development of injection materials and techniques. We report a method of identifying and maintaining a clear visual field during ureteral and bladder submucosal wall injection of a dextranomer/hyaluronic acid copolymer (Deflux, Oceana, Therapeutics Inc.) by use of the hydrodistention implantation technique (HIT) with the aid of temporary ureteral catheter insertion.

Materials and Methods

We prospectively reviewed patients with grade IV or V reflux who received an endoscopic injection of Deflux. Reflux grade was evaluated before and after treatment (3 months) by use of voiding cystourethrograms. Conventional sub-trigonal injection (STING) was performed with injection of Deflux underneath the bladder mucosa at the 6 o'clock position. HIT was performed either with hydrodistention or with guidewire insertion. These techniques increase visualization of the intramural portion of the distal ureteral wall. Patients with treatment failures were offered reinjection up to three times.

Results

Sixty-three patients completed endoscopic injection and follow-up of 3 months. The overall resolution rate for conventional STING was 58%, i.e., 67% for grade IV and 43% for grade V. The overall resolution rate for HIT was 80%, i.e., 93% for grade IV and 66% for grade V. The modified methods showed higher resolution rates for overall cure owing to the success in patients with grade IV reflux (p=0.026). Although the success of grade V treatment was higher with the modified method, the success rate was not statistically significant (p=0.27).

Conclusions

HIT with the use of either hydrodistention or a guidewire to aid in visualization of the intramural portion of the distal ureter is an effective treatment for high-grade vesico-ureteral reflux.

Preliminary data on endoscopic treatment of vesicoureteric reflux with polyacrylate polyalcohol copolymer (Vantris®): surgical outcome following single injection

PURPOSE

The aim of this study was to evaluate the efficacy of single injection of a new non-biodegradable agent (Vantris(®)) Manufactured by Promedon, Cordoba, Argentina for treatment of vesicoureteric reflux (VUR).

PATIENTS AND METHODS

38 children (11 males and 27 females) with a mean age of 5.3 ± 3.8 years underwent endoscopic treatment of VUR using Vantris. VUR was unilateral in 17 and bilateral in 21 patients, comprising 59 renal refluxing units (RRU). The VUR was primary in 42 RRU and 17 comprised complex cases: 3 duplex systems, 1 with prune belly syndrome, and 13 after failed previous endoscopic correction with Deflux(®). VUR was Grade I in 5, II in 11, III in 23, IV in 15 and V in 5 RRU.

RESULTS

All patients completed 3 months of follow up. The reflux was corrected in 56 (94.9%) of the 59 RRU (35/38 patients) after a single injection. Of the 38 patients, 21 completed 1 year of follow up, at which time ultrasound demonstrated no change compared with 1 month after injection. Eight of these 21 children underwent 1 year radionuclide cystography, and no reflux recurrence was shown.

CONCLUSIONS

Our short-term data show that Vantris injection provides a high level of reflux resolution. Long-term follow up with this tissue-augmenting substance is required.

Endoscopic treatment of vesicoureteral reflux: current practice and the need for multifactorial assessment

Vesicoureteral reflux (VUR) affects around 1% of all children. It carries an increased risk of febrile urinary-tract infections (UTIs) and is associated with impaired renal function. Antibiotic prophylaxis is an established approach to managing the condition, but it does not protect against UTI and encourages bacterial resistance. Ureteral re-implantation (open surgery) is a relatively traumatic procedure typically requiring hospitalization, and there is a risk of significant post-treatment complications. Endoscopic treatment with NASHA/Dx gel (Deflux®) is minimally invasive, well tolerated and provides cure rates approaching those of open surgery: 80-90% in several studies. It has also been shown to be effective in a variety of 'complicated' cases. Thus, endoscopic treatment is generally preferable to open surgery and long-term antibiotic prophylaxis. Non-treatment of VUR is being discussed as an alternative option, although this mainly appears suitable for children with low-grade reflux and normal kidneys. A new approach to managing VUR may be considered, with treatment decisions based not only on the grade of reflux but also on factors such as age, sex, renal scarring and bladder dysfunction. Open surgery would be reserved only for use in the 10-15% of children not responding to endoscopic treatment and those with severe ureteral anomalies.

Presence of dextranomer-hyaluronic acid (DxHA) mound on postoperative ultrasound does not predict resolution of vesicoureteral reflux

OBJECTIVE

Dextranomer-hyaluronic acid (DxHA) injection is an accepted treatment for vesicoureteral reflux (VUR), with success rates as high as 85-90% in selected patients. The DxHA mound can often be seen on postoperative ultrasound. We sought to determine whether the presence or absence of this mound on ultrasound can predict resolution of VUR on voiding cystourethrogram (VCUG).

MATERIALS AND METHODS

A retrospective study evaluating patients who underwent cystoscopy and injection of DxHA from 2003 to the present was performed. Demographic variables, laterality and grade of VUR, postoperative ultrasound findings, and presence of VUR on postoperative VCUG were recorded.

RESULTS

Fifty-one patients (95 ureters) underwent DxHA injection and had a postoperative ultrasound and VCUG for review. Five patients with persistent voiding dysfunction were excluded, leaving 46 patients and 86 ureters for review. The mean age at time of injection was 5.2 years (range 0.75-11 years) and mean grade of VUR was 2.5 (range 1-5). After DxHA injection, 75% of the ureters showed resolution of VUR, while 25% demonstrated persistent VUR. No correlation was made between the presence of DxHA mound and resolution of VUR on VCUG.

CONCLUSION

In this series, the presence of a DxHA mound on initial postoperative ultrasound does not predict resolution of VUR. A larger prospective study is needed to evaluate additional parameters.

Single injection results of endoscopic treatment of vesicoureteric reflux with different tissue-bulking substances in patients with end stage renal failure

PURPOSE

To evaluate the outcome of subureteral injections by using calcium hydroxyapatite (CaHa), dextranomer/hyaluronic acid copolymer (Dx/HA), and polydimethylsiloxane (PDS) in patients with end-stage renal failure (ESRF) who have vesicoureteral reflux (VUR).

PATIENTS AND METHODS

One hundred-one patients (166 renal units) with ESRF secondary to VUR were included in this retrospective study. The reflux was bilateral in 65 of the cases. CaHa, Dx/HA and PDS were used in 57, 26, and 18 patients, respectively. All patients were reviewed with regard to age, sex, reflux grade, type of injected materials, injectable agent volume, and outcome.

RESULTS

The reflux resolved completely in 30 patients (50/96 renal units, 52.1%), in 17 patients (27/44 renal units, 61.4%), and in 4 patients (5/26 renal units, 19.2%) with CaHa, Dx/HA, and PDS, respectively. Regression rates of reflux to grade I with these agents in the same order were 3.1% (2 patients, 3/96 renal units), 4.5% (1 patient, 2/44 renal units), and 11.5% (2 patients, 3/26 renal units). Thus, the overall success rate were noted as 55.2%, 65.9%, and 30.7%, respectively. There was no difference among these three injectables with regard to overall success rates (P = 0.062). No significant correlation with age, reflux grade, agent volume, and significant difference with sex were observed (P > 0.05).

CONCLUSIONS

In this group of patients, the success rate of the subureteral injection treatment does not appear to be affected by the type of the injectable agent. In addition, the cure rates were independent from the individual factors, reflux grades, and injected volumes.

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.

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

OBJECTIVE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Cross-sectional evaluation of parental decision making factors for vesicoureteral reflux management in children

PURPOSE

Parental decision making in children with vesicoureteral reflux has potentially become more complex with the evolution of ethnic diversity in the United States, the Internet, the publication of contradictory clinical data and the emergence of minimally invasive surgery. We performed a cross-sectional study of parental management for pediatric vesicoureteral reflux.

MATERIALS AND METHODS

We administered a 26-item questionnaire to parents of children with vesicoureteral reflux seen at Texas Children's Hospital urology offices or undergoing antireflux surgery at that institution. Univariate and multivariate analysis was done on patient disease characteristics, demographics, predicted reflux duration, surgery success rate, antibiotic cessation, complication risk, financial considerations, urologist recommendations, Internet information, friend recommendations, and postoperative voiding cystourethrography, renal ultrasound and recovery.

RESULTS

Enrolled in the study were 15 boys and 49 girls with a mean age of 3.5 years and a mean reflux grade of 2.8. Of the cases 37 were bilateral. Parents chose endoscopic treatment in 38 children, open ureteroneocystostomy in 9, antibiotic prophylaxis in 14 and observation without antibiotics in 3. Univariate analysis suggested that Hispanic parents rated ultrasound and financial considerations as more important than white parents (p <0.05). Multivariate analysis revealed that differences seen on univariate analysis may have been due to an association between race and income. Finally, 93.6% of parents rated urologist opinion as very or extremely important.

CONCLUSIONS

Data indicate that the parents of our patients highly value the opinion of the pediatric urologist when choosing treatment for their children with vesicoureteral reflux. Despite social changes the physician-parental relationship remains critical. Differences in parental decision making may be linked to associations between race and income.

[Dextranomer beads in stabilized non-animal sodium hyaluronate gel (NASHA/Dx gel) for vesicoureteral reflux: multi-center study in Japanease patients]

PURPOSE

To investigate the efficacy and safety of endoscopic treatment with the injectable gel of dextranomer beads in stabilized non-animal sodium hyaluronate (NASHA/Dx gel) administered submucosally close to the proximity of ureteral orifice, we performed the multi-center open study of Japanese patients with vesicoureteral reflux (VUR). We herein report the results of the study.

SUBJECTS AND METHODS

Patients aged > or = 1 year with grade II-IV VUR underwent endoscopic injection with NASHA/Dx gel. Post-treatment assessment was done by voiding cystourethrography (VCUG) at 3 and 12 months. Patients with VUR grade II-IV at 3 months underwent re-treatment, with VCUG assessment 3 and 12 months after retreatment. Positive response to treatment was defined as reflux grade 0 or 1.

RESULTS

The initial treatment was conducted to 116 ureters in 73 patients. The per-protocol efficacy population included 97 ureters in 71 patients. On a per-ureter basis, the positive response rate at 12 months after the last endoscopic treatment was 69.1%, compared with 62.0% on a per-patient basis. Improvement in reflux grade was shown to be statistically significant at both 3 months post initial treatment and 12 months post last treatment. Positive response rate decreased with increasing baseline reflux grade. There were only two mild adverse events (AEs) and one moderate laboratory fluctuation which were potentially relating to NASHA/Dx gel.

CONCLUSIONS

This study has shown that endoscopic injection of NASHA/Dx gel is effective and well tolerated in Japanese patients with VUR. First-line use of this treatment for VUR could potentially be considered for Japan also.

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.

Dextranomer/hyaluronic acid for pediatric vesicoureteral reflux: systematic review

OBJECTIVE

Published success rates of dextranomer/hyaluronic acid (Dx/HA) injection for pediatric vesicoureteral reflux (VUR) vary widely. Our objective of this study was to assess whether underlying patient or study factors could explain the heterogeneity in reported Dx/HA success rates.

METHODS

We searched the Cochrane Controlled Trials Register and Medline, Embase, and Scopus databases from 1990 to 2008 for reports in any language, along with a hand search of included study bibliographies. Articles were assessed and data abstracted in duplicate, and differences were resolved by consensus. Conflict of interest (COI) was determined by published disclosure. Meta-regression was performed to adjust for patient as well as study-level factors.

RESULTS

We identified 1157 reports, 89 of which were reviewed in full with 47 included in the pooled analysis. Of 7303 ureters that were injected with Dx/HA, 5633 (77%) were successfully treated according to the authors' definition. Injection success seemed to vary primarily on the basis of the preoperative reflux grade. After adjustment for VUR grade, other factors, such as the presence or absence of COI disclosure, were not significant. Studies were markedly heterogeneous overall.

CONCLUSIONS

The overall per-ureter Dx/HA success rate was 77% after 3 months, although success rates varied widely among studies. Increased VUR grade negatively affected success rates, whereas COI, patient age, and injected Dx/HA volume were not significantly associated with treatment outcome after adjustment for VUR grade. There is a significant need for improved reporting of VUR treatments, including comparative studies of Dx/HA and other VUR treatments.