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

Bladder Dysfunction and Re-Absorbable Bulking Agent Affect Success Rate in Children Underwent Endoscopic Treatment for Vesicoureteral Reflux: A Long-Term Follow-Up Study

This paper is designed to evaluate the results (at long-term follow-up of) children affected by dilating VUR. Our attention was focused on how VUR grade, laterality, bladder dysfunction (BD), the double renal system, and the type of bulking substance may affect VUR resolution in the long-term period. The charts of 93 children with dilating VUR who underwent endoscopic treatment (ET) and with a minimum post-operative follow-up of 7 years were reviewed (mean follow-up time was 9.6 + 1.4). The majority of patients had severe and bilateral VUR. Polydimetilsiloxane or hyaluronic acid/dextranomer (PDS or Ha/Dx) were used as bulking agents. VUR persistence following endoscopic injection was independent with respect to grade, laterality, duplex renal system, and BD. However, the rate of VUR persistence was significantly higher in children with BD. Children treated with Ha/Dx had a higher rate of VUR persistence. This research demonstrated that ET of VUR is also effective at very long term follow up (and without the development of significant complications). We also showed that patients treated with absorbable bulking agents such as Ha/Dx may experience a higher recurrence rate at the long-term follow-up). We also confirm that the only preoperative condition affecting VUR recurrence was bladder dysfunction.

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

CONTEXT/OBJECTIVE

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

DESIGN

Retrospective comparative study.

PARTICIPANTS

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

INTERVENTIONS

Macroplastique and BTX-A injections, VUDS.

OUTCOME MEASURES

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

RESULTS

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

CONCLUSION

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

The effect of prior endoscopic correction of vesicoureteral reflux on open ureteral reimplantation: Surgical outcomes and costs

INTRODUCTION

Endoscopic injection of a bulking agent is a common first-line approach to the treatment of vesicoureteral reflux (VUR). While early outcomes are comparable to open ureteroneocystotomy, 5-25% of children will eventually develop recurrent reflux necessitating repeat injections or open ureteral reimplantation.

OBJECTIVE

To determine whether prior endoscopic injection of a bulking agent impacts outcomes of subsequent open ureteral reimplantation.

STUDY DESIGN

Using a retrospective cohort design, radiographic and clinical outcomes of open ureteral reimplantation were compared between patients with and without prior endoscopic correction of reflux. Surgical and hospitalization data were also compared between groups and a cost comparison was performed to assess differences in healthcare costs between the two cohorts. Units of analysis included total ureters or total patients. For certain variables, subanalysis of unilateral versus bilateral reimplantation was included.

RESULTS

A total of 258 patients underwent open reimplantation for VUR between 2007 and 2016 by five pediatric urologists. Final analysis (see Summary Table) included 192 patients with pre-operative and postoperative voiding cystourethrogram (VCUG) and follow-up data at a median 4.95 months. Among 317 reimplanted refluxing ureters, radiographic resolution was reached in 26/27 (96.3%) patients with and 279/290 (96.2%) without prior endoscopic treatment (P = 0.981). Clinical success was achieved in 17/17 (100%) patients with and 174/175 (99.4%) without prior endoscopic treatment (P = 0.755). There were no statistically significant differences between duration of surgery or length of hospital stay. There were no statistically significant differences between total charges, total costs, and operating room (OR) costs between groups.

DISCUSSION

This study indicated that prior endoscopic injection of a bulking agent did not impact the outcomes or costs of subsequent open ureteroneocystotomy. While prior studies have demonstrated tissue changes associated with injection of a bulking agent, these did not seem to significantly impact the difficulty of later open surgery or the success rates compared to patients who proceeded directly to open correction of reflux.

CONCLUSION

Open ureteral reimplantation for recurrent VUR after failed endoscopic injection of a bulking agent was safe and effective, with comparable outcomes and costs to open surgery in patients without prior endoscopic correction.

Polydimethylsiloxane (macroplastique®) injection for vesicoureteral reflux in duplex ureters: a comparison with single renal systems

OBJECTIVE

VUR in patients with a duplex system (DS) is often treated by open surgery. The aim of this study was to evaluate the efficacy of subureteric polydimethylsiloxane (Macroplastique(®)) injection (SMING) in the management of VUR in duplex and single (SS) renal systems.

PATIENTS AND METHODS

Fifteen children (24 refluxing renal units) with VUR in DS underwent SMING. VUR was more frequent in the lower moiety. VUR was graded moderate/severe in 88% of renal units. There was a history of urinary tract infections in 40% of cases. The outcome for DS patients was compared with 44 children (60 refluxing renal units) with moderate/severe VUR in SS.

RESULTS

The VUR resolution/improvement rate was 88% in DS and 95% in SS patients. Ureteric reimplantation was required because of recurrent VUR in 13% and 7% of DS and SS groups, respectively. Transient ureteral obstruction was observed in 1/15 and 5/44 patients. Two required double-J ureteric stenting for 3 months.

CONCLUSION

SMING seems an effective treatment for VUR in both DS and SS patients, even in severe cases. The complication rate does not significantly differ between the two groups.

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

PURPOSE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Endoscopic bulking materials for the treatment of vesicoureteral reflux: a review of our 20 years of experience and review of the literature

Purpose. We reviewed our 20 years of experience and the current literature regarding the long-term outcome of endoscopic treatment of vesicoureteric reflux (VUR) using the different tissue bulking substances with a special emphasis on the long-term efficacy. Material and Methods. Our own experience and the current literature on the long-term results after endoscopic treatment using various bulking agents were reviewed. Results. Short-term data following endoscopic treatment of VUR is similar to the various substances and comparable in the majority of the series to the success rate following open surgery. Recently, a relatively high recurrence rate was noticed especially with the use of dextranomer hyaluronic acid (Dx/HA) as a tissue augmenting material which raises the need for further search for alternative substances. Conclusions. Unfortunately, there is a significant shortage of evidence-based literature on the long-term followup after endoscopic correction of reflux with various substances. No doubt, there is a high recurrence rate during long-term followup after Dx/HA injection, and there is probably lack of proper evaluation regarding the long-term efficacy of other bulking materials. These facts demand long-term close observation and long-term studies beyond the routine protocols following endoscopic treatment of VUR and the correct parental counseling upon the endoscopic correction.

Long-term results of endoscopic treatment of vesicoureteric reflux with different tissue-augmenting substances

OBJECTIVE

To review the current literature regarding the outcome of endoscopic treatment of vesicoureteric reflux (VUR) using different tissue-augmenting substances, with special emphasis on long-term efficacy.

MATERIAL AND METHODS

The current literature, including our own experience, on long-term results after endoscopic treatment was reviewed by MEDLINE/PubMed search.

RESULTS

The short-term results are similar in the majority of series to those of open surgery, but there is a high recurrence rate with use of dextranomer/hyaluronic acid (Deflux) as a tissue-augmenting material.

CONCLUSIONS

There is a significant shortage of evidence-based literature on long-term follow-up after endoscopic correction of VUR utilizing dextranomer/hyaluronic acid. The high recurrence rate that has been reported after Deflux injection highlights a need for close observation beyond routine protocols and appropriate parental counseling upon endoscopic correction, and also the need to search further for alternative tissue-augmenting substances. The algorithm for treating VUR is yet to be finally determined.

[Vesico-ureteric reflux treatment by implant of polydimethylsiloxane (Macroplastique): Review of the literature]

PURPOSE

During the last 25years, endoscopic correction of vesicoureteral reflux (VUR) has become a well-recognized procedure. However, the nature of the bulking agent used has led to many controversies. The objective of this work was to perform a literature review on the use of polydimethylsiloxane (PDMS or Macroplastique) in VUR.

METHOD

A PubMed review of the literature since 1996 resulted in the selection of 24 studies of sufficient level of evidence to assess the efficacy and tolerance of Macroplastique in the VUR in adults and children.

RESULTS

The overall success rate at 1 year, 2 years and 9-years follow-up was respectively 86-93 %, 80-92 %, and 77-100 %, which confirms the maintenance of good results over time, notably in VUR grade III and above. The success rate was similar for primary and secondary VUR except for total duplicity. Predictive criterias of success were the surgeon's experience, the low grade of VUR, and the absence of previous injection. In comparison with other bulking agents, the higher viscosity and absence of shrinkage of the product increase its reliability. After more than 12years of use, no serious complication has been reported in the literature, reflecting the good tolerance of Macroplastique on the long term.

CONCLUSION

The studies published on the use of Macroplastique in VUR confirmed its efficacy, around 85 % of success for all grades, in children and adults as well. The interest of PDMS is linked to its higher viscosity promoting a better reliability and reproducibility of the technique and its non-resorbable nature providing a permanent result, especially valuable in high-grade VUR with anatomical anomaly of the vesicoureteral junction or in VUR secondary to permanent lower urinary tract dysfunction.