Long-term outcome of the endoscopic correction of vesico-ureteric reflux: a comparison of injected substances

Vesicoureteral reflux: From prophylaxis to surgery

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.

Endoscopic treatment of vesicoureteral reflux with non-simultaneous involuntary detrusor contraction in chronic spinal cord injury patients with neurogenic detrusor overactivity

OBJECTIVE

To analyze whether it is correct to use endoscopic treatment via bulking agents of vesicoureteral reflux (VUR) seen on video urodynamics with non-simultaneous involuntary detrusor contraction in chronic spinal cord injury (SCI) patients with neurogenic detrusor overactivity (NDO).

METHODS

A retrospective study was performed with a cohort of 76 patients (age 48.9 ± 14.4 years) (mean ± standard deviation) of both sexes with chronic SCI who underwent endoscopic treatment of VUR during the years 2008 to 2011. Patients were subjected to clinical examinations and video urodynamic studies preoperatively and 22 ± 11.4 months after the intervention.

RESULTS

Resolution of VUR was achieved in 46 cases (61%). Cured patients had a statistically significant younger age and showed stress urinary incontinence more frequently. On the contrary, a greater grade of VUR, presence of bilateral reflux and presence of NDO were positively associated with treatment failure. The variables that independently influenced the cure of the reflux were NDO and reflux grade.

CONCLUSIONS

The failure rate was high in patients with NDO, even though the reflux was not synchronous with involuntary detrusor contraction, and therefore these patients should have NDO eradicated before doing any anti-reflux procedures.

Prognostic factors of endoscopic treatment of vesicoureteral reflux in spinal cord injured patients

INTRODUCTION

Vesicoureteral reflux (VUR) is an important complication in patients with spinal cord injury due to its frequency and morbidity. One of the most extended therapeutic options is endoscopic injection of obliteration substances in the urethral meatus.

OBJECTIVE

To analyze the prognostic factors of VUR treatment using obliterative substances in patients with spinal cord injury.

MATERIAL AND METHODS

A prospective study was performed in a cohort of 76 patients (age 48.9±14.4 years), of both genders, with spinal cord injuries, who underwent endoscopic treatment of the VUR during the years 2008 to 2011. In all the patients, a clinical history was obtained and a pre-operative videourodynamic study was performed. Another study was carried out at 7.32 months (standard deviation: 6.28 months) of the intervention. Treatment consisted in endoscopic injection of dextranomer/hyaluronic acid copolymer (62 cases) and polydimethylsiloxane (14). The statistical tests applied were the Fisher's exact test and the Student's T test comparing the means. Bilateral significance level was established at 95%.

RESULTS

Resolution of VUR was achieved in 46 cases (61%). The statistically significant prognostic factors were age (younger aging cured patients), bilaterality and reflects great (greater grade in bilaterality in the cases with persistence of reflux) and presence of neurogenic detrusor overactivity (greater percentage in the cases of reflux persistence). Stress urinary incontinence (greater percentage in cured patients), contractile potency (lower percentage in cured patients) and urethral resistance (greater percentage in cured patients) were also statistically significant prognostic factors.

CONCLUSIONS

Among the prognostic factors that affected the endoscopic treatment results of the VUR in patients with neurogenic lower urinary tract dysfunction (NLUTD), anatomical as well as functional factors were found.

Autologous fibroblast transplantation at the vesico-ureteral junction as potential reconstructive cell replacement in an animal model

PURPOSE

To evaluate the cellular survival of donor fibroblasts after transplantation at the vesico-ureteral junction (VUJ) and to analyse their potential for reconstructive cell replacement in an animal model as autologous fibroblasts have been used as soft tissue augmentation material for scared and damaged tissue.

METHODS

Muscles biopsies were procured from the lower limb muscles of 4 pigs; cytoplasm of fibroblasts was labelled with nano-sized iron oxide particles. Six weeks after taking of the muscle biopsies, fibroblast transplantation was performed, 3 × 10(6) cells suspended in transplantation medium (in 1-ml syringes) were injected at the VUJ using the modified STING technique. Animals were killed 8 weeks later; seeded fibroblasts were identified using prussian blue staining protocol; histological evaluation and morphological analysis were performed by light microscopy (Mayer's haematoxylin-eosin staining); and bladders were scanned by MRI for visualization and localization of the iron-labelled donor cells.

RESULTS

Donor fibroblast cell colonization and cellular viability at the VUJ was demonstrated by MRI and histochemically indicating cellular uptake of iron particles at the VUJ. It was also evident that transplanted fibroblasts integrate into the extracellular matrix of the distal ureter augmenting ureteral host tissue.

CONCLUSIONS

Labelled implanted autologous fibroblasts were visualized by staining procedure as well as MRI scan demonstrating persistence at the VUJ, suggesting that in vitro expanded fibroblasts survived in vivo after transplantation.

Implantation of autologous urine derived stem cells expressing vascular endothelial growth factor for potential use in genitourinary reconstruction

PURPOSE

We evaluated the effects of vascular endothelial growth factor overexpression on urine derived stem cell survival and myogenic differentiation to determine whether these cells could be used as a novel cell source for genitourinary reconstruction.

MATERIALS AND METHODS

Urine derived stem cells were isolated from 31 urine samples of 6 healthy individuals 3 to 27 years old. Urine derived stem cells were infected with an adenoviral vector containing the mouse VEGF gene. These cells were then mixed with human umbilical vein endothelial cells (total 5×10(6)) in a collagen-I gel. These cell containing gels were subcutaneously implanted along with 6 other controls into 18 athymic mice. The grafts were assessed up to 28 days after injection for gross appearance and immunocytochemistry.

RESULTS

Vascular endothelial growth factor levels in the media from infected urine derived stem cell cultures reached a peak value on day 10 after infection. Grafts composed of urine derived stem cell/adenoviral vector containing the mouse VEGF gene and human umbilical vein endothelial cells were larger and better vascularized compared to uninfected urine derived stem cell control grafts. Additionally more implanted cells expressed human nuclear markers in the vascular endothelial growth factor expressing grafts. Vascular endothelial growth factor expressing grafts also contained more cells expressing the endothelial markers CD-31 and von Willebrand factor, and smooth muscle markers (α-smooth muscle actin, desmin and myosin). Also, more nerve fibers were present in urine derived stem cell/adenoviral vector containing mouse VEGF gene plus human umbilical vein endothelial cell grafts than in controls.

CONCLUSIONS

Vascular endothelial growth factor overexpression combined with human umbilical vein endothelial cells enhanced in vivo survival and myogenic differentiation of urine derived stem cells. Neovascularization and nerve regeneration were also enhanced within the implanted grafts.

[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.

Are there predictive factors for the outcome of endoscopic treatment of grade III-V vesicoureteral reflux with dextranomer/hyaluronic acid in children?

Dextranomer/hyaluronic acid (Dx/HA) copolymer has been used widely for the treatment of vesicoureteral reflux (VUR) in children since 2001. However, the factors that influence the outcome of injection therapy with Dx/HA have remained unclear. In this study, we retrospectively evaluated the outcomes in 101 consecutive children to determine the cure and to identify the factors that can impact treatment outcomes of Dx/HA injection. Endoscopic treatment with Dx/HA was performed in 133 ureters, in 101 patients with grade III-V VUR. Of the patients, 68 (67.3%) were girls and the mean age was 6.5 years. Before and after the treatment, the presence and grades of VUR were determined by voiding cystourethrograms. The patients' age, gender, laterality, preoperative reflux grade, ureteral duplication, morphology of ureteral orifice, renal hypoplasia and experience with surgery were assessed as predictive factors related to the success rates of Dx/HA injection therapy. The cure rates were 54.8% after the first injection, 66.9% after the second and 73.6% after the third injection. Patients with a high grade (grade IV or V), duplicated system, golf hole-shaped orifice and renal hypoplasia had significantly lower cure rates (P<0.05). Experience with the technique also correlated with the positive outcome of the procedure. New contralateral vesicoureteral reflux developed in five (7.2%) patients with unilateral VUR, and all of them resolved spontaneously during the first year of followup. No treatment-related significant complication was encountered. Although, endoscopic treatment of VUR with Dx/HA provides a high rate of success in children with medium or high grade VUR, treatment failure may be seen in some patients. However, we showed that endoscopic treatment with Dx/HA was effective in selected patients with grade V VUR, and we emphasize the need for further large-scale studies to confirm our findings.

Endoscopic Management of Vesicoureteral Reflux in Women Presenting With Pyelonephritis

PURPOSE

Vesicoureteral reflux is not usually considered a major cofactor in acute pyelonephritis in women. However, there is a subset of individuals in whom reflux must be considered in the evaluation of acute pyelonephritis. We sought to evaluate the effectiveness of endoscopic treatment for vesicoureteral reflux in this subset of patients.

MATERIALS AND METHODS

We retrospectively reviewed the records of 13 female patients presenting with clinical pyelonephritis between 2001 and 2005. All of these patients had either a history of vesicoureteral reflux in childhood or a family history of reflux, or had previously undergone surgery for reflux. All patients underwent voiding cystourethrogram and dimercapto-succinic acid renal scan as part of the evaluation.

RESULTS

Of the 13 individuals evaluated 9 had vesicoureteral reflux. Of these patients 5 had been operated on previously for vesicoureteral reflux, 2 had a strong family history of reflux and 2 had reflux as a child with documented resolution. Six of the 9 patients with reflux exhibited renal scarring on dimercapto-succinic acid renal scintigraphy. Endoscopic correction of reflux was done in all 9 patients and was successful in 8, as shown on voiding cystourethrogram at 3 months postoperatively. One patient required a second procedure, which was successful. Only 1 patient has had a subsequent episode of clinical pyelonephritis, and voiding cystourethrogram following treatment again revealed resolution of reflux.

CONCLUSIONS

There is a subset of women presenting with acute pyelonephritis in whom vesicoureteral reflux is a risk factor. When documented, vesicoureteral reflux can be managed effectively with endoscopic treatment.

Complicaciones del tratamiento endoscópico del reflujo vesicoureteral en la infancia

INTRODUCTION

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

OBJECTIVE

To establish the complications of childhood VUR endoscopic treatment.

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Endoscopic treatment of vesicoureteral reflux

PURPOSE OF REVIEW

The treatment of vesicoureteral reflux in children has seen a shift from invasive surgery to endoscopic management in recent years. Early studies demonstrate favorable outcomes but do not reach the success of surgery. Subspecialization also may play a role in the successful outcomes of all reflux management. This review focuses on the recent literature regarding endoscopic treatment of reflux and the role of subspecialization in treatment of children.

RECENT FINDINGS

Dextranomer/hyaluronic acid copolymer has emerged as the favored bulking agent since its Food and Drug Administration approval in the United States. Although success is defined somewhat differently than surgery, overall success rates range from 82-89% with initial injection of dextranomer/hyaluronic acid. The outpatient nature of the procedure and its high success rate have led to a shift in treatment strategies especially in Europe, where endoscopic management is often considered first-line therapy. Extravesical reimplants can be performed on an outpatient basis safely. Subspecialization leads to improved outcomes with no difference in cost.

SUMMARY

Endoscopic treatment of reflux is promising, but long-term results are not available to ascertain the efficacy of treatment into adulthood. Open surgery remains the gold standard.