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Escolino M, Kalfa N, Castagnetti M, Caione P, Esposito G, Florio L, Esposito C. Endoscopic injection of bulking agents in pediatric vesicoureteral reflux: a narrative review of the literature. Pediatr Surg Int 2023; 39:133. [PMID: 36806763 PMCID: PMC9938816 DOI: 10.1007/s00383-023-05426-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/09/2023] [Indexed: 02/21/2023]
Abstract
In the last 20 years, endoscopic injection (EI) has affirmed as a valid alternative to open surgery for management of pediatric vesicoureteral reflux (VUR). This study aimed to investigate and discuss some debated aspects such as indications, bulking agents and comparison, techniques of injection and comparison, predictive factors of success, use in specific situations. EI is minimally invasive, well accepted by patients and families, with short learning curve and low-morbidity profile. It provides reflux resolution rates approaching those of open reimplantation, ranging from 69 to 100%. Obviously, the success rate may be influenced by several factors. Recently, it is adopted as first-line therapy also in high grade reflux or complex anatomy such as duplex, bladder diverticula, ectopic ureters. The two most used materials for injection are Deflux and Vantris. The first is absorbable, easier to inject, has lower risk of obstruction, but can lose efficacy over time. The second is non-absorbable, more difficult to inject, has higher risk of obstruction, but it is potentially more durable. The two main techniques are STING and HIT. To date, the ideal material and technique of injection has not yet clearly established, but the choice remains dependent on surgeon's preference and experience.
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Affiliation(s)
- Maria Escolino
- Pediatric Surgery Unit, Federico II University Hospital, Via Pansini 5, 80131, Naples, Italy.
| | - Nicolas Kalfa
- Pediatric Surgery Unit, University Hospital of Montpellier, Montpellier, France
| | | | - Paolo Caione
- Pediatric Urology Unit, Salvator Mundi International Hospital, Rome, Italy
| | | | - Luisa Florio
- Pediatric Surgery Unit, Federico II University Hospital, Via Pansini 5, 80131, Naples, Italy
| | - Ciro Esposito
- Pediatric Surgery Unit, Federico II University Hospital, Via Pansini 5, 80131, Naples, Italy
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2
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Shumaker AD, Kord E, Dubrov V, Bondarenko S, Visman Y, Stav K, Zisman A, Neheman A. Laparoscopic Ureteral Reimplantation after Failed Open Surgery: Incorporating the Psoas Hitch Maneuver for Sufficient Tunnel Length. Eur J Pediatr Surg 2023; 33:41-46. [PMID: 35858643 DOI: 10.1055/a-1905-4636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Failure after open ureteral reimplantation has been reported to occur in 2 to 7% of cases. While a second open reconstructive surgery is appropriate in most cases, there are data suggesting similar outcomes utilizing the laparoscopic approach. The objective of this study is to describe a modification and report our experience with laparoscopic ureteral reimplantation after failed open reimplantation reinforced with a psoas hitch. MATERIALS AND METHODS A retrospective review of pediatric patients who underwent laparoscopic ureteral reimplantation after failed open surgery between September 2012 and April 2018 at three different academic centers was performed. Patient demographics, surgical indications, complications, and outcomes were reviewed. Either ipsilateral ureteral reimplantation with a combined intravesical and extravesical approaches or a cross-trigonal extravesical approach was utilized, depending on the length of the ureter. In all cases, a psoas hitch was performed to gain a longer submucosal tunnel and relieve tension, thus facilitating an efficient antireflux mechanism. RESULTS Seventeen patients underwent a laparoscopic ureteral reimplantation after failed open surgery. Median age at second surgery was 106 months (interquartile range [IQR]: 53-122.5). Ipsilateral ureteral reimplantation with a combined intravesical and extravesical approaches was performed in 11 cases and cross-trigonal extravesical approach in 6 cases. Median ureteral diameter before the redo surgery was 16 mm (IQR: 14.5-18.5) and after surgery was 6 mm (IQR: 3.5-8.5) (p < 0.001). Postoperative mercaptoacetyltriglycine renal scan showed a nonobstructive pattern and stable renal function in all cases. CONCLUSION Laparoscopic ureteral reimplantation with incorporation of a psoas hitch after failed open reimplantation is safe and effective.
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Affiliation(s)
- Andrew D Shumaker
- Department of Urology, Shamir Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eyal Kord
- Department of Urology, Shamir Medical Center, Zerifin, Israel
| | - Vitaly Dubrov
- Department of Urology, Children's City Clinical Hospital, Minsk, Belarus
| | - Sergey Bondarenko
- Department of Urology, Municipal Hospital, Volgograd, Russian Federation
| | | | - Kobi Stav
- Department of Urology, Shamir Medical Center, Zerifin, Israel
| | - Amnon Zisman
- Department of Urology, Shamir Medical Center, Zerifin, Israel
| | - Amos Neheman
- Department of Urology, Shamir Medical Center, Zerifin, Israel.,Department of Infectious Diseases, Shamir Medical Center, Zerifin, Israel
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3
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Benya EC, Prendergast FM, Liu DB, Wyers MR. Assessment of distal ureteral and ureterovesical junction visualization on contrast-enhanced voiding urosonography. Pediatr Radiol 2021; 51:1406-1411. [PMID: 33576846 DOI: 10.1007/s00247-021-04979-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 11/20/2020] [Accepted: 01/21/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Contrast-enhanced voiding urosonography (CEVUS) uses intravesically administered microbubble contrast to detect vesicoureteral reflux (VUR) and urethral anomalies with ultrasound. Multiple studies have suggested CEVUS can replace voiding cystourethrogram (VCUG) as a radiation-free alternative. Analysis of the ureterovesical junction and ureters on VCUG documenting the ureterovesical junction position, ureteral duplication, periureteral diverticula and ureteroceles is important as anatomical variations may affect management and surgical approach. OBJECTIVE Our purpose was to assess distal ureteral and ureterovesical junction region visualization in children with VUR detected on CEVUS. MATERIALS AND METHODS CEVUS studies performed between June 2018 and March 2019 with reported VUR were retrospectively reviewed by two pediatric radiologists to confirm VUR and to qualitatively assess the ureterovesical junction region for each renal moiety using a 3-point scale for clear, limited or absent visualization of the distal ureter, ureterovesical junction, ureteral duplication, periureteral diverticula and ureteroceles. RESULTS Thirty-four studies with VUR on CEVUS were identified. Sixty-seven renal moieties were evaluated including a solitary kidney in one child. VUR was detected in 52 moieties by reader 1 and in 53 by reader 2. A single moiety with discrepancy between readers regarding VUR was excluded from statistical analysis. No diverticula were detected by either reader and one ureterocele was detected by both readers. Visualization of the ureterovesical junction was described as clear in 5/52, limited in 14/52 and absent in 33/52 refluxing renal moieties by reader 1 and as clear in 12/52, limited in 20/52 and absent in 20/52 by reader 2. The ureterovesical junction was clearly visualized in 5/52 (9.6%) by reader 1 and 12/52 (23.1%) by reader 2. The Kappa value of -0.29 (confidence interval [CI] -0.25, 0.21) reveals a lack of agreement between the readers for clear versus limited or absent ureterovesical junction visualization. Distal ureteral visualization was described as clear in 14/52, limited in 16/52 and absent in 22/52 refluxing renal moieties by reader 1 and as clear in 27/52, limited in 7/52 and absent in 18/52 by reader 2. The distal ureter was clearly visualized in 14/52 (26.9%) by reader 1 and 27/52 (51.9%) by reader 2. The Kappa of 0.43 (CI 0.22, 0.64) reveals moderate agreement between the readers for clear versus limited or absent distal ureteral visualization. Duplication of the renal collecting system was identified in 13/52 refluxing kidneys by reader 1 and 11/52 refluxing kidneys by reader 2. Visualization of ureteral duplication was described as clear in 9, limited in 4 and absent in 39 of 52 refluxing renal moieties by reader 1 and as clear in 9, limited in 2 and absent in 41 by reader 2. Ureteral duplication was clearly visualized in 9/52 (17.3%) by reader 1 and 9/52 (17.3%) by reader 2. Kappa of 0.87 (CI 0.68, 1) reveals high agreement between the readers for clear versus limited or absent identification of ureteral duplication. CONCLUSION The distal ureter and ureterovesical junction region frequently are not clearly visualized in refluxing renal moieties on CEVUS. Awareness of this limitation is important as there may be implications when evaluating patients for surgical management of VUR.
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Affiliation(s)
- Ellen C Benya
- Department of Medical Imaging, Ann & Robert Lurie Children's Hospital, 225 E. Chicago Ave., Chicago, IL, 60611, USA.
| | - Francis M Prendergast
- Department of Medical Imaging, Ann & Robert Lurie Children's Hospital, 225 E. Chicago Ave., Chicago, IL, 60611, USA
| | - Dennis B Liu
- Department of Urology, Ann & Robert Lurie Children's Hospital, Chicago, IL, USA
| | - Mary R Wyers
- Department of Medical Imaging, Ann & Robert Lurie Children's Hospital, 225 E. Chicago Ave., Chicago, IL, 60611, USA
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Al Hindi S, Mubarak M, Al Aradi H. High-grade vesicoureteral reflux in infants: Our experience with endoscopic subureteric injections. Urologia 2020; 89:120-125. [PMID: 33063631 DOI: 10.1177/0391560320966187] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Saeed Al Hindi
- Department Surgery, Salmaniya Medical Complex, Manama, Kingdom of Bahrain
| | - Mohamed Mubarak
- Department Surgery, Salmaniya Medical Complex, Manama, Kingdom of Bahrain
| | - Husain Al Aradi
- Department Surgery, Salmaniya Medical Complex, Manama, Kingdom of Bahrain
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Miyakita H, Hayashi Y, Mitsui T, Okawada M, Kinoshita Y, Kimata T, Koikawa Y, Sakai K, Satoh H, Tokunaga M, Naitoh Y, Niimura F, Matsuoka H, Mizuno K, Kaneko K, Kubota M. Guidelines for the medical management of pediatric vesicoureteral reflux. Int J Urol 2020; 27:480-490. [PMID: 32239562 PMCID: PMC7318347 DOI: 10.1111/iju.14223] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 02/10/2020] [Indexed: 12/27/2022]
Abstract
Urinary tract infection is a bacterial infection that commonly occurs in children. Vesicoureteral reflux is a major underlying precursor condition of urinary tract infection, and an important disorder in the field of pediatric urology. Vesicoureteral reflux is sometimes diagnosed postnatally in infants with fetal hydronephrosis diagnosed antenatally. Opinions vary regarding the diagnosis and treatment of vesicoureteral reflux, and diagnostic procedures remain debatable. In terms of medical interventions, options include either follow‐up observation in the hope of possible spontaneous resolution of vesicoureteral reflux with growth/development or provision of continuous antibiotic prophylaxis based on patient characteristics (age, presence/absence of febrile urinary tract infection, lower urinary tract dysfunction and constipation). Furthermore, there are various surgical procedures with different indications and rationales. These guidelines, formulated and issued by the Japanese Society of Pediatric Urology to assist medical management of pediatric vesicoureteral reflux, cover the following: epidemiology, clinical practice algorithm for vesicoureteral reflux, syndromes (dysuria with vesicoureteral reflux, and bladder and rectal dysfunction with vesicoureteral reflux), diagnosis, treatment (medical and surgical), secondary vesicoureteral reflux, long‐term prognosis and reflux nephropathy. They also provide the definition of bladder and bowel dysfunction, previously unavailable despite their close association with vesicoureteral reflux, and show the usefulness of diagnostic tests, continuous antibiotic prophylaxis and surgical intervention using site markings.
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Affiliation(s)
- Hideshi Miyakita
- Committee for the Formulation of Medical Management Guidelines for Pediatric Vesicoureteral Reflex, Japanese Society of Pediatric Urology, Osaka, Japan.,Department of Urology, Tokai University Oiso Hospital, Oiso, Kanagawa, Japan
| | - Yutaro Hayashi
- Committee for the Formulation of Medical Management Guidelines for Pediatric Vesicoureteral Reflex, Japanese Society of Pediatric Urology, Osaka, Japan.,Department of Pediatric Urology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan
| | - Takahiko Mitsui
- Committee for the Formulation of Medical Management Guidelines for Pediatric Vesicoureteral Reflex, Japanese Society of Pediatric Urology, Osaka, Japan.,Department of Urology, University of Yamanashi Graduate School of Medical Sciences, Chuo, Yamanashi, Japan
| | - Manabu Okawada
- Committee for the Formulation of Medical Management Guidelines for Pediatric Vesicoureteral Reflex, Japanese Society of Pediatric Urology, Osaka, Japan.,Department of Pediatric General and Urogenital Surgery, Juntendo University Hospital, Tokyo, Japan
| | - Yoshiaki Kinoshita
- Committee for the Formulation of Medical Management Guidelines for Pediatric Vesicoureteral Reflex, Japanese Society of Pediatric Urology, Osaka, Japan.,Department of Pediatric Surgery, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Takahisa Kimata
- Committee for the Formulation of Medical Management Guidelines for Pediatric Vesicoureteral Reflex, Japanese Society of Pediatric Urology, Osaka, Japan.,Department of Pediatrics, Kansai Medical University, Hirakata, Osaka, Japan
| | - Yasuhiro Koikawa
- Committee for the Formulation of Medical Management Guidelines for Pediatric Vesicoureteral Reflex, Japanese Society of Pediatric Urology, Osaka, Japan.,Department of Urology, Fukuoka City Medical Center of Sick Children, Fukuoka, Japan
| | - Kiyohide Sakai
- Committee for the Formulation of Medical Management Guidelines for Pediatric Vesicoureteral Reflex, Japanese Society of Pediatric Urology, Osaka, Japan.,Department of Urology, Miyagi Children's Hospital, Sendai, Miyagi, Japan
| | - Hiroyuki Satoh
- Committee for the Formulation of Medical Management Guidelines for Pediatric Vesicoureteral Reflex, Japanese Society of Pediatric Urology, Osaka, Japan.,Department of Urology and Kidney Transplantation, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Masatoshi Tokunaga
- Committee for the Formulation of Medical Management Guidelines for Pediatric Vesicoureteral Reflex, Japanese Society of Pediatric Urology, Osaka, Japan.,Department of Urology, Tokai University Oiso Hospital, Oiso, Kanagawa, Japan
| | - Yasuyuki Naitoh
- Committee for the Formulation of Medical Management Guidelines for Pediatric Vesicoureteral Reflex, Japanese Society of Pediatric Urology, Osaka, Japan.,Department of Urology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Fumio Niimura
- Committee for the Formulation of Medical Management Guidelines for Pediatric Vesicoureteral Reflex, Japanese Society of Pediatric Urology, Osaka, Japan.,Department of Pediatrics, Tokai University School of Medicine, Hiratsuka, Kanagawa, Japan
| | - Hirofumi Matsuoka
- Committee for the Formulation of Medical Management Guidelines for Pediatric Vesicoureteral Reflex, Japanese Society of Pediatric Urology, Osaka, Japan.,Department of Urology, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Kentaro Mizuno
- Committee for the Formulation of Medical Management Guidelines for Pediatric Vesicoureteral Reflex, Japanese Society of Pediatric Urology, Osaka, Japan.,Department of Pediatric Urology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan
| | - Kazunari Kaneko
- Committee for the Formulation of Medical Management Guidelines for Pediatric Vesicoureteral Reflex, Japanese Society of Pediatric Urology, Osaka, Japan.,Department of Pediatrics, Kansai Medical University, Hirakata, Osaka, Japan
| | - Masayuki Kubota
- Committee for the Formulation of Medical Management Guidelines for Pediatric Vesicoureteral Reflex, Japanese Society of Pediatric Urology, Osaka, Japan.,Department of Pediatric Surgery, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
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The Effects of Intradetrusor BoNT-A Injections on Vesicoureteral Reflux in Children With Myelodysplasia. Int Neurourol J 2019; 23:321-326. [PMID: 31905279 PMCID: PMC6944790 DOI: 10.5213/inj.1938100.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 07/30/2019] [Indexed: 11/08/2022] Open
Abstract
PURPOSE We retrospectively evaluated the efficacy of botulinum neurotoxin A (BoNT-A) on vesicoureteral reflux (VUR), continence status, and urodynamic parameters in children with myelodysplasia who were not responsive to standard conservative therapy. METHODS The study included 31 children (13 boys, 18 girls) with a mean age of 9.2±2.3 years (range, 5-14 years) with myelodysplasia, retrospectively. All children were fully compatible with clean intermittent catheterization (CIC) and did not respond to the maximum tolerable anticholinergic dose. All children received an intradetrusor injection of 10 U/kg (maximum, 300 U) of BoNT-A into an infection-free bladder. All patients had VUR (22 unilateral, 9 bilateral) preoperatively. The grade of reflux was mild (grades 1, 2), intermediate (grade 3), and severe (grades 4, 5) in 25, 7, and 8 ureters, respectively. RESULTS The mean maximum bladder capacity increased from 152.9±76.9 mL to 243.7±103 mL (P<0.001), and the maximum detrusor pressure decreased from 57±29.4 cm H2O to 29.6±13.9 cm H2O (P<0.001). After BoNT-A treatment, 16 refluxing ureters (40%) completely resolved, 17 (42.5%) improved, 5 (12.5%) remained unchanged, and 2 (5%) became worse. Of the 31 children with urinary leakage between CICs, 22 (71%) became completely dry, 6 (19%) improved, and 3 (10%) experienced partial improvement. CONCLUSION In children with myelodysplasia, we were able to increase bladder capacity, enhance continence, and prevent VUR by using intradetrusor BoNT-A injections. Although our results are promising, a larger group of long-term prospective studies are warranted to investigate this method of treatment.
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Geljic A, Abdovic S, Stampalija F, Loncar L, Tripalo BA, Cuk M. An Unusual Case of Syringohydromyelia Presenting with Neurogenic Bladder. European J Pediatr Surg Rep 2019; 7:e79-e82. [PMID: 31763129 PMCID: PMC6874505 DOI: 10.1055/s-0039-1697925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 08/19/2019] [Indexed: 11/04/2022] Open
Abstract
We report the case of a 4-year-old boy who first presented with acute pyelonephritis at the age of 6 months. Diagnostic workup revealed high-grade bilateral vesicourethral reflux (VUR). At the age of 18 months, a bulking agent was used to treat bilateral VUR. Since the VUR persisted, an open bilateral Lich-Gregoir procedure was done at the age of 3 years. Immediately after surgery, he developed acute urinary retention with hydronephrosis that resolved with the placement of dwelling urinary catheter. After removal of the catheter urinary retention relapsed so placement of suprapubic urinary catheter was indicated since he did not have sensory loss. He was started with tamsulosin (α − 1-blocker) and prophylactic antibiotics. Urodynamics were performed and suggested bladder outlet obstruction. On the basis of previous urethroscopy and the absence of neurological sequelae, the differential diagnosis of Hinman syndrome was made. After removal of the suprapubic catheter, clean intermittent catheterization was started and α-blocker continued. However, magnetic resonance imaging of the brain and the spinal cord revealed syringohydromyelia extending from thoracic spine (Th5) to conus medullaris with 6 to 7 mm in diameter. Electromyoneurogram was normal. After a follow-up of 3 years, the hydronephrosis has resolved. The patient is on clean intermittent catherization and has no urinary tract infections.
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Affiliation(s)
- Antonella Geljic
- Department of Paediatrics, Klinika za djecje bolesti Zagreb, Zagreb, Croatia
| | - Slaven Abdovic
- Department of Pediatric Nephrology, Klinika za djecje bolesti Zagreb Klinika za pedijatriju, Zagreb, Croatia
| | - Fran Stampalija
- Department of Pediatric Urology, Klinika za djecje bolesti Zagreb, Zagreb, Croatia
| | - Lana Loncar
- Department of Pediatric Neurology, Klinika za djecje bolesti Zagreb Klinika za pedijatriju, Zagreb, Croatia
| | - Batos A Tripalo
- Department of Pediatric Radiology, Klinika za djecje bolesti Zagreb, Zagreb, Croatia
| | - Martin Cuk
- Department of Pediatric Nephrology, Klinika za djecje bolesti Zagreb Klinika za pedijatriju, Zagreb, Croatia
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Carrillo Arroyo I, Fuentes Carretero S, Gómez Fraile A, Morante Valverde R, Tordable Ojeda C, Cabezalí Barbancho D. Technical challenges of endoscopic treatment for vesicoureteral reflux after Cohen reimplantation. Actas Urol Esp 2019; 43:384-388. [PMID: 31103394 DOI: 10.1016/j.acuro.2019.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 02/06/2019] [Accepted: 02/16/2019] [Indexed: 10/26/2022]
Abstract
INTRODUCTION The range of indications for endoscopic treatment of vesicoureteral reflux opens more and more until including correction of secondary reflux (VUR) after ureteral reimplantation. However these cases suppose a technical challenge due to postoperative changes. The aim of this work is to present our experience on endoscopic treatment for VUR in ureteral units with Cohen reimplantation surgery, with special interest in the technical peculiarities of the procedure. MATERIAL AND METHODS A retrospective study of cases of secondary VUR after reimplantation surgery treated by subureteral injection. TECHNIQUE We put the needle perpendicular to submucous tunnel and inject medially to hole forming a wheal on the anterior face that occludes the meatus RESULTS: During the 1993-2016 period 21 injections were performed in 15 ureteral units. The ureteral pathology included primary VUR (4), duplex system with lower pole reflux (4), megaureter (3) and ureterocele (2). Average patient age was 5.7 years old (2-12). Succesful outcome had been got in 10 ureteral units (66.67%), a decrease of VUR grade in 4 (26.67%) and perseverance/no resolution of grade IV VUR in 1 (6.67%) DISCUSSION: The anti-reflux mechanism of reimplantation depends on optimizing the submucosous tunnel. This subgroup of pacients is small and there are few studies, hindering the agreement on the most appropiate technique. CONCLUSION Endoscopic treatment of secondary reflux after reimplantation surgery is a procedure with certain technical feature, but safe and effective offering an alternative prior to surgical reoperation.
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Zambaiti E, Sergio M, Casuccio A, Salerno S, Cimador M. Intraoperative ultrasound-assisted approach for endoscopic treatment of vesicoureteral reflux in children. J Pediatr Surg 2017; 52:1661-1665. [PMID: 28442139 DOI: 10.1016/j.jpedsurg.2017.04.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Revised: 03/06/2017] [Accepted: 04/09/2017] [Indexed: 11/25/2022]
Abstract
PURPOSE Despite minimal invasiveness and high success rate, guidelines still prescribe voiding Cystourethrogram (VCUG) after endoscopic treatment for vesicoureteral reflux (VUR) in children. The aim of this paper was to analyze whether intraoperative ultrasound (IO-US) could improve surgical accuracy and perioperative counseling, thus potentially decreasing the need for postoperative VCUG. METHODS We selected children treated for moderate to high grade VUR, renal scarring or repeated infections under antibiotic prophylaxis from January to December 2015. Endoscopic injection was combined with IO-US to detect optimal needle placement and to guide mound formation. IO-US findings were compared to surgeon opinion and postoperative VCUG, performed 3months after surgery. All patients were followed-up for 1year. RESULTS A significant relationship was found between IO-US mound height (p=0.003) or localization (p<0.0005) and VCUG. Success of endoscopic treatment vs persistence of reflux groups had a mean mound height of 10.62±1.36mm and 8.39±1.08mm respectively (p<0.0005). Height maintained a significant correlation with success in simple and multivariable regression analysis. ROC curve determined ≥9.8mm as predictor of reflux resolution (95% CI 0.825 to 0.998; p<0.0001). CONCLUSIONS IO-US facilitates pediatric urologists to find an optimal location, to reach a volcano mound morphology and height, thus increasing intraoperative accuracy. IO-US also helps evaluating high-risk recurrence and guiding prognostic counseling. TYPE OF STUDY Treatment study. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Elisa Zambaiti
- Pediatric Urological Unit, Department of Sciences for Health Promotion and Mother-Child Care "G. D'Alessandro", AOU Policlinico Paolo Giaccone, Via Giordano 3, 90127 Palermo, Italy.
| | - Maria Sergio
- Pediatric Urological Unit, Department of Sciences for Health Promotion and Mother-Child Care "G. D'Alessandro", AOU Policlinico Paolo Giaccone, Via Giordano 3, 90127 Palermo, Italy
| | - Alessandra Casuccio
- Department of Sciences for Health Promotion and Mother-Child Care "G. D'Alessandro", University of Palermo, Via del Vespro 133, 90133 Palermo, Italy
| | - Sergio Salerno
- Section of Radiological Sciences, Department of Radiology, AOU Policlinico Paolo Giaccone, Via del Vespro 127, 90127 Palermo, Italy
| | - Marcello Cimador
- Pediatric Urological Unit, Department of Sciences for Health Promotion and Mother-Child Care "G. D'Alessandro", AOU Policlinico Paolo Giaccone, Via Giordano 3, 90127 Palermo, Italy
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10
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Endoscopic Treatment of Vesicoureteral Reflux. CURRENT BLADDER DYSFUNCTION REPORTS 2017. [DOI: 10.1007/s11884-017-0431-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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11
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Bawazir O. The treatment of vesicoureteral reflux in children by endoscopic sub-mucosal intra-ureteral injection of dextranomer/hyaluronic acid: A case-series, multi-centre study. Electron Physician 2017; 9:4145-4149. [PMID: 28607648 PMCID: PMC5459285 DOI: 10.19082/4145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 03/28/2017] [Indexed: 11/20/2022] Open
Abstract
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.
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Affiliation(s)
- Osama Bawazir
- MD, Consultant Paediatric Surgeon, Department of Surgery, Faculty of Medicine, Umm Al-qura University, Mecca, Kingdom of Saudi Arabia
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12
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Wu CQ, Franco I. Management of vesicoureteral reflux in neurogenic bladder. Investig Clin Urol 2017; 58:S54-S58. [PMID: 28612061 PMCID: PMC5468266 DOI: 10.4111/icu.2017.58.s1.s54] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 03/06/2017] [Indexed: 11/18/2022] Open
Abstract
Vesicoureteral reflux (VUR) is a significant risk factor for pyelonephritis and renal scarring. VUR can occur through a defective ureterovesical junction (UVJ) or an overwhelmed normal UVJ mechanism such as in bladder dysfunction of congenital, acquired, or behavioral etiology. There are numerous causes for the development of a neurogenic bladder from spinal dysraphisms to spinal cord trauma and even centrally based abnormalities in children with apparently normal motor function (inappropriately termed nonneurogenic neurogenic bladder). The foundation of managing reflux in these neurogenic bladders is to maintain low bladder pressures which will commonly mean that compliance will be normal as well. There have been several publications that have shown that if bladder pressures are lowered simply with clean intermittent catheterization and medications that the reflux can resolve spontaneously. Alternatively, the patients that are in need of bladder augmentation can have spontaneous resolution of their reflux with the resulting increase in capacity. Surgical intervention is called for when bladder capacity is adequate and the reflux persists or if it is part of a larger operation to increase capacity and to manage outlet resistance. In some instances, reimplantation is necessary because the ureters interfere with the bladder neck procedure. Aside from open and robotic surgical intervention the use of endoscopic injectable agents is beginning to become more popular especially when combined with intravesical botulinum toxin A injections. Great strides are being made in the management of patients with neurogenic bladders and we are seeing more choices for the urologist to be able to manage these patients.
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Affiliation(s)
- Charlotte Q Wu
- Department of Urology, Section of Pediatric Urology, Yale School of Medicine, New Haven, CT, USA
| | - Israel Franco
- Department of Urology, Section of Pediatric Urology, Yale School of Medicine, New Haven, CT, USA
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13
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Kim SW, Lee YS, Han SW. Endoscopic injection therapy. Investig Clin Urol 2017; 58:S38-S45. [PMID: 28612059 PMCID: PMC5468263 DOI: 10.4111/icu.2017.58.s1.s38] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 05/18/2017] [Indexed: 11/18/2022] Open
Abstract
Since the U.S. Food and Drug Administration approved dextranomer/hyaluronic acid copolymer (Deflux) for the treatment of vesicoureteral reflux, endoscopic injection therapy using Deflux has become a popular alternative to open surgery and continuous antibiotic prophylaxis. Endoscopic correction with Deflux is minimally invasive, well tolerated, and provides cure rates approaching those of open surgery (i.e., approximately 80% in several studies). However, in recent years a less stringent approach to evaluating urinary tract infections (UTIs) and concerns about long-term efficacy and complications associated with endoscopic injection have limited the use of this therapy. In addition, there is little evidence supporting the efficacy of endoscopic injection therapy in preventing UTIs and vesicoureteral reflux-related renal scarring. In this report, we reviewed the current literature regarding endoscopic injection therapy and provided an updated overview of this topic.
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Affiliation(s)
- Sang Woon Kim
- Department of Urology, Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Seung Lee
- Department of Urology, Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Won Han
- Department of Urology, Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea
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Moriya K, Nakamura M, Nishimura Y, Kanno Y, Kitta T, Kon M, Shinohara N. Prevalence of and risk factors for symptomatic urinary tract infection after endoscopic incision for the treatment of ureterocele in children. BJU Int 2017; 120:409-415. [DOI: 10.1111/bju.13884] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Kimihiko Moriya
- Department of Renal and Genitourinary Surgery; Hokkaido University Graduate School of Medicine; Sapporo Japan
| | - Michiko Nakamura
- Department of Renal and Genitourinary Surgery; Hokkaido University Graduate School of Medicine; Sapporo Japan
| | - Yoko Nishimura
- Department of Renal and Genitourinary Surgery; Hokkaido University Graduate School of Medicine; Sapporo Japan
| | - Yukiko Kanno
- Department of Renal and Genitourinary Surgery; Hokkaido University Graduate School of Medicine; Sapporo Japan
| | - Takeya Kitta
- Department of Renal and Genitourinary Surgery; Hokkaido University Graduate School of Medicine; Sapporo Japan
| | - Masafumi Kon
- Department of Renal and Genitourinary Surgery; Hokkaido University Graduate School of Medicine; Sapporo Japan
| | - Nobuo Shinohara
- Department of Renal and Genitourinary Surgery; Hokkaido University Graduate School of Medicine; Sapporo Japan
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15
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Ellison JS, Lendvay TS. Robot-assisted ureteroureterostomy in pediatric patients: current perspectives. ROBOTIC SURGERY : RESEARCH AND REVIEWS 2017; 4:45-55. [PMID: 30697563 PMCID: PMC6193430 DOI: 10.2147/rsrr.s99536] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Developments in pediatric robotic surgery have increased the feasibility of minimally invasive surgery for complex urinary tract reconstruction. Ureteroureterostomy is a commonly employed strategy for the management of a duplicated ureteral system with either upper pole obstruction or lower pole vesicoureteral reflux, and this approach minimizes the risk to a healthy ureter as might be seen in a common sheath ureteral reimplant and avoids complex dissection around the renal hilum as with a heminephrectomy. The robotic platform enables optimum instrument manipulation for an end-to-side ureteral anastomosis as well as excellent visualization deep into the pelvis for excision of the distal ureteral stump. In this study, the indications and preoperative evaluation for pediatric robotic ureteroureterostomy (RUU) were described and intraoperative considerations for a successful repair were highlighted. In order to assess the outcomes, a PubMed search was performed to find the articles focusing on RUU in the pediatric population. The institutional experience of the authors was also reviewed. As with an open procedure, both minimizing dissection on the recipient ureter and ensuring a tension-free, watertight anastomosis are key principles to minimize complications. Although port placement is similar to that in robotic pyeloplasty, small adjustments may need to be made to ensure access to the pelvis. An assistant port and/or traction sutures is often used to aid in the dissection and anastomosis. RUU was first described in 2008, and several reports have demonstrated positive short-term results. However, median follow-up times are limited with most series reporting outcomes <1 year postoperatively. A future study is required to establish the long-term efficacy of this procedure and define the optimum patient population for a robotic approach.
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Affiliation(s)
- Jonathan S Ellison
- Division of Pediatric Urology, Seattle Children's Hospital, University of Washington, Seattle, WA, USA,
| | - Thomas S Lendvay
- Division of Pediatric Urology, Seattle Children's Hospital, University of Washington, Seattle, WA, USA,
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Blais AS, Bolduc S, Moore K. Vesicoureteral reflux: From prophylaxis to surgery. Can Urol Assoc J 2017; 11:S13-S18. [PMID: 28265309 DOI: 10.5489/cuaj.4342] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Vesicoureteral reflux (VUR) is one of the most common pathologies encountered in pediatric urology. Better understanding of the evolution of VUR and new endoscopic surgical techniques in the last decades have led to major changes in the management of this pathology. However, the treatment algorithm remains complex and is composed of a wide variety of options, from active surveillance to surgical treatment. Herein, we propose to review treatment options for VUR in order to help clinicians make the right treatment decision for the right patient.
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Affiliation(s)
- Anne-Sophie Blais
- Division of Urology, CHU de Québec-Université Laval, Quebec City, QC, Canada
| | - Stéphane Bolduc
- Division of Urology, CHU de Québec-Université Laval, Quebec City, QC, Canada;; CRCHU de Québec-Université Laval, Quebec City, QC, Canada and Axe Médecine Régénératrice
| | - Katherine Moore
- Division of Urology, CHU de Québec-Université Laval, Quebec City, QC, Canada
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17
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Abstract
Vesicoureteral reflux (VUR) is the most common underlying etiology responsible for febrile urinary tract infections (UTIs) or pyelonephritis in children. Along with the morbidity of pyelonephritis, long-term sequelae of recurrent renal infections include renal scarring, proteinuria, and hypertension. Treatment is directed toward the prevention of recurrent infection through use of continuous antibiotic prophylaxis during a period of observation for spontaneous resolution or by surgical correction. In children, bowel and bladder dysfunction (BBD) plays a significant role in the occurrence of UTI and the rate of VUR resolution. Effective treatment of BBD leads to higher rates of spontaneous resolution and decreased risk of UTI.
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Affiliation(s)
- Michael L Garcia-Roig
- Department of Pediatric Urology, Children's Healthcare of Atlanta and Emory University, Atlanta, GA, USA
| | - Andrew J Kirsch
- Department of Pediatric Urology, Children's Healthcare of Atlanta and Emory University, Atlanta, GA, USA
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18
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Arlen AM, Broderick KM, Travers C, Smith EA, Elmore JM, Kirsch AJ. Outcomes of complex robot-assisted extravesical ureteral reimplantation in the pediatric population. J Pediatr Urol 2016; 12:169.e1-6. [PMID: 26747012 DOI: 10.1016/j.jpurol.2015.11.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 11/24/2015] [Indexed: 12/14/2022]
Abstract
INTRODUCTION AND OBJECTIVE While open ureteral reimplantation remains the gold standard for surgical treatment of vesicoureteral reflux (VUR), minimally invasive approaches offer potential benefits. This study evaluated the outcomes of children undergoing complex robot-assisted laparoscopic ureteral reimplantation (RALUR) for failed previous anti-reflux surgery, complex anatomy, or ureterovesical junction obstruction (UVJO), and compared them with patients undergoing open extravesical repair. STUDY DESIGN Children undergoing complex RALUR or open extravesical ureteral reimplantation (OUR) were identified. Reimplantation was classified as complex if ureters: 1) had previous anti-reflux surgery, 2) required tapering and/or dismembering, or 3) had associated duplication or diverticulum. RESULTS Seventeen children underwent complex RALUR during a 24-month period, compared with 41 OUR. The mean follow-up was 16.6 ± 6.5 months. The RALUR children were significantly older (9.3 ± 3.7 years) than the OUR patients (3.1 ± 2.7 years; P < 0.001). All RALUR patients were discharged on postoperative day one, while 24.4% of children in the open group required longer hospitalization (mean 1.3 ± 0.7 days; P = 0.03). Adjusting for age, there was no significant difference in inpatient analgesic usage between the two cohorts. Three OUR patients (7.3%) developed postoperative febrile urinary tract infection compared with a single child (5.9%) undergoing RALUR (P = 1.00). There was no significant difference in complication rate between the two groups (12.2% OUR versus 11.8% RALUR; P = 1.00). A postoperative cystogram was performed in the majority of RALUR patients, with no persistent VUR detected, and one child (6.7%) was diagnosed with contralateral reflux. DISCUSSION Reported VUR resolution rates following robot-assisted ureteral reimplantation are varied. In the present series, children undergoing RALUR following failed previous anti-reflux surgery, with complex anatomy, or UVJO experienced a shorter length of stay but had similar analgesic requirements to those undergoing open repair. Radiographic, clinical success rates and complication risk were comparable. This study had several limitations, aside from lack of randomization. Analgesic use was limited to an inpatient setting, and pain scores were not assessed. Not all children underwent a postoperative VCUG, so the true radiographic success rate is unknown. A larger patient cohort with longer follow-up is necessary to determine predictors of radiographic and clinical failure. CONCLUSION Older children with a previous history of anti-reflux surgery were more likely to undergo RALUR. These children had success and complication rates comparable to younger patients following complex open extravesical reimplantation, which underscores the expanding role of robot-assisted lower urinary tract reconstructive surgery in the pediatric population.
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Affiliation(s)
- Angela M Arlen
- Department of Pediatric Urology, Children's Healthcare of Atlanta and Emory University School of Medicine, 5730 Glenridge Drive, Atlanta, GA 30328, USA
| | - Kristin M Broderick
- Department of Pediatric Urology, Children's Healthcare of Atlanta and Emory University School of Medicine, 5730 Glenridge Drive, Atlanta, GA 30328, USA
| | - Curtis Travers
- Department of Pediatrics, Division of Biostatistics, Emory University School of Medicine, 2015 Uppergate Dr, Atlanta, GA 30322, USA
| | - Edwin A Smith
- Department of Pediatric Urology, Children's Healthcare of Atlanta and Emory University School of Medicine, 5730 Glenridge Drive, Atlanta, GA 30328, USA
| | - James M Elmore
- Department of Pediatric Urology, Children's Healthcare of Atlanta and Emory University School of Medicine, 5730 Glenridge Drive, Atlanta, GA 30328, USA
| | - Andrew J Kirsch
- Department of Pediatric Urology, Children's Healthcare of Atlanta and Emory University School of Medicine, 5730 Glenridge Drive, Atlanta, GA 30328, USA.
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Abstract
OBJECTIVE The aim was to highlight the advantages and the feasibility of treating ureteral stump syndrome (USS) by different minimally invasive procedures. MATERIALS AND METHODS Four patients with USS who were treated by different minimally invasive surgery approaches depending on their presentation and findings on radiologic investigations. RESULTS Three patients had complete resolution of their symptoms, whereas the fourth patient had persistence of urinary tract infection. CONCLUSION Minimally invasive surgery is a valid treatment option for patients with USS with possible less morbidity than conventional open surgical excision.
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Affiliation(s)
- Husain Alenezi
- Department of Surgery, Division of Urology, Adan Hospital, Hadiya, Kuwait, Kuwait
| | - Abdelmoniem E Eltiraifi
- Department of Surgery, King Khalid University Hospital and College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Mohammad Alomar
- Department of Surgery, King Khalid University Hospital and College of Medicine, King Saud University, Riyadh, Saudi Arabia
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20
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Endoscopic correction of complex cases of vesicoureteral reflux utilizing Vantris as a new non-biodegradable tissue-augmenting substance. Pediatr Surg Int 2014; 30:445-8. [PMID: 24448911 DOI: 10.1007/s00383-014-3468-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
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.
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21
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Randomized clinical trial comparing endoscopic treatment with dextranomer hyaluronic acid copolymer and Cohen's ureteral reimplantation for vesicoureteral reflux: long-term results. J Pediatr Urol 2013; 9:483-7. [PMID: 23602843 DOI: 10.1016/j.jpurol.2013.03.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2012] [Accepted: 03/02/2013] [Indexed: 11/20/2022]
Abstract
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.
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Hunziker M, Mohanan N, Puri P. Dextranomer/hyaluronic acid endoscopic injection is effective in the treatment of intermediate and high grade vesicoureteral reflux in patients with complete duplex systems. J Urol 2012; 189:1876-81. [PMID: 23159268 DOI: 10.1016/j.juro.2012.11.048] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2012] [Indexed: 10/27/2022]
Abstract
PURPOSE Endoscopic subureteral injection of dextranomer/hyaluronic acid has become an established alternative to long-term antibiotic prophylaxis or surgical treatment for vesicoureteral reflux. We evaluated the effectiveness of endoscopic injection of dextranomer/hyaluronic acid in intermediate and high grade vesicoureteral reflux in patients with complete duplex collecting systems. MATERIALS AND METHODS A total of 123 children underwent endoscopic correction of intermediate or high grade vesicoureteral reflux using injection of dextranomer/hyaluronic acid into complete duplex systems between 2001 and 2010. Vesicoureteral reflux was diagnosed by voiding cystourethrogram, and dimercapto-succinic acid scan was performed to evaluate the presence of renal scarring. Followup ultrasound and voiding cystourethrogram were performed 3 months after the outpatient procedure and renal ultrasound thereafter every 2 years. Mean followup was 6.7 years. RESULTS Complete duplex systems were unilateral in 110 patients and bilateral in 13. Reflux severity in the 136 refluxing units was grade II in 1 (0.7%), III in 52 (38.2%), IV in 61 (44.9%) and V in 22 (16.2%). Dimercapto-succinic acid scan revealed renal functional abnormalities in 63 children (51.2%). Vesicoureteral reflux resolved after the first endoscopic injection of dextranomer/hyaluronic acid in 93 ureters (68.4%), after a second injection in 35 (25.7%) and after a third injection in 8 (5.9%). Febrile urinary tract infection developed in 5 patients (4.1%) during followup. No patient required ureteral reimplantation or experienced significant complications. CONCLUSIONS Our results confirm the safety and efficacy of endoscopic injection of dextranomer/hyaluronic acid in eradicating intermediate and high grade vesicoureteral reflux in patients with complete duplex systems. We recommend this minimally invasive, 15-minute outpatient procedure as a viable option for treating intermediate and high grade vesicoureteral reflux in patients with complete duplex collecting systems.
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Affiliation(s)
- Manuela Hunziker
- National Children's Research Center, Our Lady's Children's Hospital and National Children's Hospital, Dublin, Ireland
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23
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Polackwich A, Skoog S, Austin J. Long-Term Followup After Endoscopic Treatment of Vesicoureteral Reflux with Dextranomer/Hyaluronic Acid Copolymer in Patients with Neurogenic Bladder. J Urol 2012; 188:1511-5. [DOI: 10.1016/j.juro.2012.03.046] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Indexed: 11/30/2022]
Affiliation(s)
- A.S. Polackwich
- Division of Urology, Oregon Health & Science University, Portland, Oregon
| | - S.J. Skoog
- Division of Urology, Oregon Health & Science University, Portland, Oregon
| | - J.C. Austin
- Division of Urology, Oregon Health & Science University, Portland, Oregon
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Oktar T, Acar O, Sancaktutar A, Sanlı O, Tefik T, Ziylan O. Endoscopic treatment of vesicoureteral reflux in children with posterior urethral valves. Int Urol Nephrol 2012; 44:1305-9. [PMID: 22767179 DOI: 10.1007/s11255-012-0240-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2012] [Accepted: 06/22/2012] [Indexed: 11/29/2022]
Abstract
PURPOSE We reviewed the clinical outcome of endoscopic injection therapy in children with vesicoureteral reflux persisting after posterior urethral valve ablation. METHODS We retrospectively reviewed the charts of 16 patients with posterior urethral valves who have undergone endoscopic injection to correct persistent reflux after successful relief of urethral obstruction. Breakthrough urinary tract infections, persistent high-grade reflux and failed ureteroneocystostomy were the indications of endoscopic antireflux surgery. RESULTS Reflux was grade I in 1, grade II in 3, grade III in 11 and grade IV in 4 ureters. Mean age at injection was 6.9 ± 3.8 years and the mean interval from initial intervention to injection was 4.3 ± 2.4 years. Injected material was dextranomer/hyaluronic acid in the majority (87.5 %) of cases. Reflux was resolved or downgraded in 12 ureters (63.1 %) after a single injection. All failed cases had urodynamically documented bladder dysfunction. CONCLUSION More than half of the patients with vesicoureteral reflux, persisting after initial valve ablation, showed complete resolution or significant downgrading in their reflux grade after endoscopic injection. Given the technical difficulties and potential complications of open surgical reimplantation in valve patients, endoscopic subureteral injection can be considered as an effective alternative to cure persistent vesicoureteral reflux.
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Affiliation(s)
- Tayfun Oktar
- Department of Urology, Istanbul Faculty of Medicine, Istanbul University, 34093 Capa, Istanbul, Turkey.
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Phillips GS, Paladin A. Essentials of genitourinary disorders in children: imaging evaluation. Semin Roentgenol 2011; 47:56-65. [PMID: 22166231 DOI: 10.1053/j.ro.2011.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Grace S Phillips
- Department of Radiology, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, WA 98105, USA.
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An all-endo Approach to Complete Ureteral Duplications Complicated by Ureterocele and/or Vesicoureteral Reflux: Feasibility, Limitations, and Results. Int J Pediatr 2011; 2011:103067. [PMID: 22220183 PMCID: PMC3246730 DOI: 10.1155/2011/103067] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2011] [Accepted: 11/01/2011] [Indexed: 11/29/2022] Open
Abstract
Purpose. Totally endoscopic management (all-endo) of patients with a duplicated renal system (DS) associated with severe vesicoureteral reflux (VUR) or obstructive ureterocele (UC) is an attractive alternative to traditional open procedures. The authors discuss feasibility and results of an all-endo approach on a consecutive series of patients. Methods. From 1999 to 2009, all patients with a complete DS associated with UC and/or VUR were proposed for primary all-endo approach. UC puncture was performed using a 3 Fr Bugbee electrode. Deflux (dextranomer/hyaluronic acid copolymer) injection was administered for VUR. The need for secondary surgery was evaluated on followup. Results. Of the 62 patients recruited, 46 were treated using a primary all-endo approach and 16 patients received no treatment. Of the 46 treated patients with 56 affected renal units, 32 (97%) UCs collapsed following puncture and 29 (63%) VURs were resolved or downgraded. Secondary VUR occurred in 13 (39%) renal units. Secondary surgery was performed on 23 (41%) renal units. Conclusion. The all-endo approach for VUR in DS is an effective therapeutic option. UC collapse was achieved by puncture in most of the patients; secondary VUR was the main complication in a small group of extravesical UC.
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27
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Läckgren G, Stenberg A. Endoscopic treatment of vesicoureteral reflux: current practice and the need for multifactorial assessment. Ther Adv Urol 2011; 1:131-41. [PMID: 21789061 DOI: 10.1177/1756287209342731] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
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.
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Affiliation(s)
- Göran Läckgren
- Section of Urology, Uppsala University Children's Hospital, S-751 85 Sweden
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Antonopoulos IM, Piovesan AC, Falci R, Kanashiro H, Saito FJA, Nahas WC. Transurethral injection therapy with carbon-coated beads (Durasphere®) for treatment of recurrent pyelonephritis in kidney transplant patients with vesico-ureteral reflux to the allograft. Clin Transplant 2011; 25:329-33. [PMID: 20331685 DOI: 10.1111/j.1399-0012.2010.01242.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Ioannis M Antonopoulos
- Renal Transplant Unit, Division of Urology, Hospital das Clínicas, University of São Paulo, São Paulo, Brazil.
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Recent advances in the management of ureteroceles in infants and children: why less may be more. Curr Opin Urol 2011; 21:322-7. [DOI: 10.1097/mou.0b013e328346d455] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Salvage Dextranomer-Hyaluronic Acid Copolymer for Persistent Reflux After Ureteral Reimplantation: Early Success Rates. J Urol 2011; 185:2531-4. [DOI: 10.1016/j.juro.2011.01.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2010] [Indexed: 11/21/2022]
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Yucel S, Celik O, Kol A, Baykara M, Guntekin E. Initial Pre-Scrotal Approach for Palpable Cryptorchid Testis: Results During a 3-Year Period. J Urol 2011; 185:669-72. [DOI: 10.1016/j.juro.2010.09.117] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2010] [Indexed: 11/25/2022]
Affiliation(s)
- Selcuk Yucel
- Department of Urology, Akdeniz University School of Medicine, Antalya, Turkey
| | - Orcun Celik
- Department of Urology, Akdeniz University School of Medicine, Antalya, Turkey
| | - Arif Kol
- Department of Urology, Akdeniz University School of Medicine, Antalya, Turkey
| | - Mehmet Baykara
- Department of Urology, Akdeniz University School of Medicine, Antalya, Turkey
| | - Erol Guntekin
- Department of Urology, Akdeniz University School of Medicine, Antalya, Turkey
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Yucel S, Akin Y, Celik O, Erdogru T, Baykara M. Endoscopic vesicoureteral reflux correction in transplanted kidneys: does injection technique matter? J Endourol 2011; 24:1661-4. [PMID: 20626270 DOI: 10.1089/end.2010.0219] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
AIM AND BACKGROUND Posttransplant vesicoureteral reflux (VUR) is a common urologic complication after renal transplantation, although its management is controversial. The treatment of choice is open surgical revision ureteral reimplantation with significant morbidity. Recently, endoscopic correction by using nonanimal dextranomer/hyaluronic acid copolymer (NA Dx/HA) injection has been reported to be effective in the treatment of VUR of transplanted kidneys. Herein, we present our 3-year endoscopic correction results in transplanted kidneys where we used two different injection techniques, subureteral and intraureteral. MATERIALS AND METHODS We retrospectively reviewed all patients who underwent endoscopic VUR correction of posttransplant VUR by NA Dx/HA injection between July 2005 and March 2009. We excluded patients with underlying urologic abnormalities. RESULTS A total of 26 patients (14 women and 12 men) with a mean age of 32.2 years (range: 15–55) were studied. The VUR was also graded as nondilating reflux in 10 (grade I–II) and dilating reflux in 16 (grade III–IV). Seventeen ureters (5 nondilating and 12 dilating VUR) were injected NA Dx/HA intraureterally, and 9 ureters (5 nondilating and 4 dilating VUR) were injected NA Dx/HA subureterally. Overall success rate was 53.8% (14 out of 26). Intraureteral injection technique was successful in nine cases (52.9%), and subureteral injection technique was successful in five cases (55.5%). In nondilating VUR, injection corrected 90% (9 out of 10) of posttransplant patients, whereas in dilating VUR group injection corrected only 31.25% (5 out of 16). We found no statistical significance of injection technique on the success rate. CONCLUSIONS Endoscopic correction by using NA Dx/HA with any injection technique seems to be a plausible alternative to correction of refluxing posttransplant ureters, particularly in nondilating VUR.
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Affiliation(s)
- Selcuk Yucel
- Department of Urology, Akdeniz University School of Medicine, Antalya, Turkey.
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Kim SO, Shin BS, Hwang IS, Hwang EC, Oh KJ, Jung SI, Kang TW, Kwon D, Park K, Ryu SB. Clinical Efficacy and Safety in Children with Vesicoureteral Reflux of a Single Injection of Two Different Bulking Agents – Polydimethylsiloxane (Macroplastique) or Dextranomer/Hyaluronic Acid Copolymer (Deflux): A Short-Term Prospective Comparative Study. Urol Int 2011; 87:299-303. [DOI: 10.1159/000324594] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2010] [Accepted: 01/22/2011] [Indexed: 11/19/2022]
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Romero N, Romo M, Vegas Á, Izquierdo J, Varela J, Arteche A, Moyano Á. Deflux Injections for Vesicoureteral Reflux in Transplanted Kidneys. Transplant Proc 2010; 42:2892-5. [DOI: 10.1016/j.transproceed.2010.07.074] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Bayne AP, Roth DR. Dextranomer/hyaluronic injection for the management of vesicoureteric reflux in complete ureteral duplication: should age and gender be factors in decision making? J Endourol 2010; 24:1013-6. [PMID: 20377431 DOI: 10.1089/end.2009.0412] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND AND PURPOSE The injection of dextranomer/hyaluronic acid (DHA) has become an accepted treatment for children with vesicoureteral reflux (VUR). Complete ureteral duplication has been considered by some practitioners as counterindication for its use. We reviewed the Texas Children's Hospital (TCH) records for children with complete ureteral duplication who were treated with DHA for VUR. METHODS We searched medical records at TCH for patients with a preoperative diagnosis of complete ureteral duplication who had undergone DHA injection between January 1, 2001, and October 15, 2008. Operative notes, imaging studies, and clinic notes were reviewed. RESULTS In this period, 28 kidneys in 24 children were treated. The average grade of reflux before injection was 3.44 (range 1-5). First injection resolution of reflux was 57% with an increase to 73% after a second injection with an average volume of DHA of 1.05 mL. New contralateral VUR developed postinjection in three (15%) children with unilateral VUR. There were no perioperative complications. The average age of the children who were treated was 41.4 months. Mean follow-up was 45.94 months. Success of DHA injection tended to be higher in girls (65%) and older children. CONCLUSIONS High levels of success can be achieved with DHA injection in children with complete ureteral duplication. DHA injection is more likely to be successful for older girls with VUR and complete ureteral duplication. If initial injection does not result in VUR resolution, a second injection offers an opportunity for improved success. For physicians and families who are seeking an alternative to open surgical management, DHA represents an attractive option for selected children with complete ureteral duplication.
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Affiliation(s)
- Aaron P Bayne
- Scott Department of Urology, Baylor College of Medicine, Houston, Texas, USA.
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Routh JC, Inman BA, Reinberg Y. Dextranomer/hyaluronic acid for pediatric vesicoureteral reflux: systematic review. Pediatrics 2010; 125:1010-9. [PMID: 20368325 DOI: 10.1542/peds.2009-2225] [Citation(s) in RCA: 116] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Jonathan C Routh
- Children's Hospital Boston, Department of Urology, Boston, MA 02115, USA.
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Vemulakonda VM, Koyle MA, Lendvay TS, Risk MC, Kirsch AJ, Cheng EY, Cisek LJ, Campbell JB. Endoscopic treatment of symptomatic refluxing renal transplant ureteroneocystostomies in children. Pediatr Transplant 2010; 14:212-5. [PMID: 19515081 DOI: 10.1111/j.1399-3046.2009.01196.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
To present a multi-center experience with the use of Dx/HA copolymer for treatment of symptomatic refluxing renal transplant UNC in children. A multi-center, retrospective chart review was performed. Eleven patients with a mean age of eight yr underwent renal transplantation with an anti-refluxing UNC. Data were collected to determine the safety and effectiveness of the procedure and to identify possible predictors of success. Endoscopic treatment was successful in one of five males and five of six females, for an overall success rate of 54.5%. The etiology of renal failure was associated with success of treatment, with 4/6 (67%) patients with upper tract pathology demonstrating resolution of the VUR, as compared with one of three (33%) patients with lower tract pathology. Male patients had a higher incidence of lower tract pathology. No complications were associated with the endoscopic procedure. Endoscopic injection of Dx/HA remains a safe option for the treatment of symptomatic refluxing transplant UNC in children. Although the success rate is lower than that seen in the treatment of primary VUR, the minimally invasive nature and safety of this technique may offer advantages over open reconstruction of the refluxing transplant ureter.
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The clinical utility and safety of the endoscopic treatment of vesicoureteral reflux in patients with duplex ureters. J Pediatr Urol 2010; 6:15-22. [PMID: 19625219 DOI: 10.1016/j.jpurol.2009.05.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2009] [Accepted: 05/28/2009] [Indexed: 11/20/2022]
Abstract
OBJECTIVE A systemic review of published literature on the use of bulking agents in the treatment of vesicoureteral reflux (VUR) in patients with duplex systems was performed in order to evaluate the diagnostic challenges; determine success rates, and compare with use in single systems; and evaluate safety, in particular of Deflux. METHODS A PubMed/Medline search was conducted for index articles discussing duplex ureters published in 1963-2007. All types of publications were included. A multiple linear regression analysis was performed. RESULTS Overall, 28 different treatment arms originating in 17 separate studies (19 publications) satisfied the inclusion criteria for linear regression efficacy analysis. Data were available on 2879 patients: 2400 with single and 479 with duplex systems. Ten publications provided information on the frequency of failure to diagnose duplex systems using specific techniques. An overall 18% failure rate to detect duplex systems was reported for combined techniques. For patients in whom favorable anatomic location of ureters allowed successful endoscopic injection of a bulking agent, correction of VUR was achieved in 53-100% of cases. A univariant analysis showed no difference in success rate between single and duplex systems with the use of Deflux, or other bulking agent. The predicted probability of success in a single system was 68% and in a duplex system 64%. CONCLUSIONS There is significant potential for failing to detect duplex systems prior to preparing an individual for either open or endoscopic treatment. From the studies available, endoscopic injection of bulking agents is highly successful in correcting mild-to-moderate VUR in duplex systems, with no reports of serious or clinically significant adverse effects. At a minimum, duplex systems would not seem to be a contraindication to the use of Deflux or any other bulking agent.
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New Tissue Bulking Agent (Polyacrylate Polyalcohol) for Treating Vesicoureteral Reflux: Preliminary Results in Children. J Urol 2010; 183:714-7. [DOI: 10.1016/j.juro.2009.10.047] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2009] [Indexed: 11/18/2022]
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Predicting success in the endoscopic management of pediatric vesicoureteral reflux. Urology 2009; 76:195-8. [PMID: 19931896 DOI: 10.1016/j.urology.2009.09.017] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2009] [Revised: 09/02/2009] [Accepted: 09/05/2009] [Indexed: 11/22/2022]
Abstract
Vesicoureteral reflux is a common cause of pediatric morbidity. Though traditionally managed using a limited number of therapeutic modalities, the last decade has witnessed countless surgical innovations for treating reflux. A major force behind this innovation is the increasing use of endoscopic injection, which currently constitutes nearly half of all anti-reflux procedures performed in the United States. However, published success rates for injection vary dramatically. Despite a relative lack of comparative data, multiple studies have attempted to define the most important prognostic factors for injection success. This article is an attempt to summarize these findings.
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Abstract
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. Endoscopic treatment with NASHA/Dx gel (dextranomer microspheres in a stabilized hyaluronic acid-based gel of nonanimal origin) is minimally invasive, well tolerated and provides cure rates approaching those of open surgery: approximately 90% in several studies. It has also been shown to be effective in a variety of 'complicated' cases. Endoscopic treatment is therefore considered preferable to open surgery and long-term antibiotic prophylaxis. Nontreatment of VUR is being discussed as an alternative option, whereby children are treated with antibiotics only when UTIs occur. Considering all the available evidence, however, active intervention with endoscopic treatment remains preferable. A new approach to managing VUR may nevertheless be considered, with treatment decisions based not only on the grade of reflux, but also factors such as age, sex, renal scarring, and bladder dysfunction. Open surgery would be reserved for use only in the ( approximately )10% of children not responding to endoscopic treatment, and patients with refluxing primary megaureter.
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Affiliation(s)
- Göran Läckgren
- Section of Urology, University Children's Hospital, Uppsala, Sweden
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Kang MY, Park DS, Park YH, Lee JW, Baek M, Choi H. Overall Outcomes and Factors Predicting the Success of Endoscopic Dextranomer/Hyaluronic Acid Copolymer Injection for Vesicoureteral Reflux. Korean J Urol 2009. [DOI: 10.4111/kju.2009.50.1.51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Min Yong Kang
- Department of Urology, Seoul National University College of Medicine, Korea
| | - Dong-Soo Park
- Department of Urology, Seoul National University College of Medicine, Korea
| | - Yong Hyun Park
- Department of Urology, Seoul National University College of Medicine, Korea
| | - Jeong-Won Lee
- Department of Nuclear Medicine, Seoul National University College of Medicine, Korea
| | - Minki Baek
- Department of Urology, Konkuk University College of Medicine, Seoul, Korea
| | - Hwang Choi
- Department of Urology, Seoul National University College of Medicine, Korea
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Kurzrock EA. Pediatric enterocystoplasty: long-term complications and controversies. World J Urol 2008; 27:69-73. [DOI: 10.1007/s00345-008-0335-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2008] [Accepted: 09/16/2008] [Indexed: 11/30/2022] Open
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Complete Excision or Marsupialization of Ureteroceles: Does Choice of Surgical Approach Affect Outcome? J Urol 2008; 180:1819-22; discussion 1822-3. [DOI: 10.1016/j.juro.2008.04.078] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2007] [Indexed: 11/17/2022]
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Ashley R, Vandersteen D. Outcome Analysis of Mini-Ureteroneocystostomy Versus Dextranomer/Hyaluronic Acid Copolymer Injection for Unilateral Vesicoureteral Reflux. J Urol 2008; 180:1611-3; discussion 1614. [DOI: 10.1016/j.juro.2008.04.084] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2008] [Indexed: 10/21/2022]
Affiliation(s)
- Richard Ashley
- Department of Urology, Mayo Clinic, Rochester and Pediatric Surgical Associates (DV), Minneapolis, Minnesota
| | - David Vandersteen
- Department of Urology, Mayo Clinic, Rochester and Pediatric Surgical Associates (DV), Minneapolis, Minnesota
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Saperston K, Smith J, Putman S, Matern R, Foot L, Wallis C, deVries C, Snow B, Cartwright P. Endoscopic Subureteral Injection is Not Less Expensive Than Outpatient Open Reimplantation for Unilateral Vesicoureteral Reflux. J Urol 2008; 180:1626-9; discussion 1629-30. [PMID: 18715586 DOI: 10.1016/j.juro.2008.05.124] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2008] [Indexed: 10/21/2022]
Affiliation(s)
| | | | | | | | - Laura Foot
- University of Utah, Salt Lake City, Utah
| | | | | | - Brent Snow
- University of Utah, Salt Lake City, Utah
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Molitierno JA, Scherz HC, Kirsch AJ. Endoscopic injection of dextranomer hyaluronic acid copolymer for the treatment of vesicoureteral reflux in duplex ureters. J Pediatr Urol 2008; 4:372-6. [PMID: 18790423 DOI: 10.1016/j.jpurol.2008.01.216] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2007] [Accepted: 01/29/2008] [Indexed: 11/15/2022]
Abstract
PURPOSE Endoscopic injection of dextranomer hyaluronic acid copolymer (DxHA) has been increasingly utilized for the treatment of complex cases of vesicoureteral reflux (VUR). We present our 6-year experience with the use of DxHA for the treatment of VUR in duplex ureters. MATERIALS AND METHODS Between July 2001 and April 2007, 52 children were identified retrospectively who had been treated by endoscopic injection of DxHA for VUR into duplex ureters. Mean age was 3 years (range 9 months-10 years) with a mean maximum grade of reflux of III (range 2-5). The refluxing lower pole ureter was injected using a subureteric injection technique (STING) or intraureteric injection technique (utilizing the hydrodistention implantation technique). The endpoint in all cases was the loss of hydrodistention of the ureteral orifice. Voiding cystourethrograms was obtained at 6 weeks-3 months to evaluate for the presence of VUR. Cure was defined as complete resolution of reflux in the treated moiety. RESULTS After initial treatment, 38/52 (73%) patients were cured. Of the 14 failures, nine children underwent repeat endoscopic treatment with a 67% (6/9) resolution rate for repeat injection. Seven of the initial failures failed to grade I VUR. Overall, 85% (44/52) were cured after one or two treatments, 98% (51/52) were improved and only one (1.9%) with grade V VUR required open surgery. The treatment was well tolerated and there were no associated complications. CONCLUSION Endoscopic injection of DxHA copolymer corrected VUR in 85% of children with VUR into duplex ureters. This minimally invasive approach should be considered as a viable alternative to open surgery or antibiotic prophylaxis for the treatment of VUR associated with duplex ureters.
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Affiliation(s)
- Joseph A Molitierno
- Children's Healthcare of Atlanta, Atlanta, GA, USA; Emory University School of Medicine, Atlanta, GA, USA
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Diagnosis and management of congenital bladder diverticulum in infancy and childhood: experience with nine cases at a tertiary health center in a developing country. Int Urol Nephrol 2008; 41:237-42. [DOI: 10.1007/s11255-008-9443-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2008] [Accepted: 07/14/2008] [Indexed: 12/13/2022]
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