Surgical Reimplantation for the Correction of Vesicoureteral Reflux following Failed Endoscopic Injection

Long term results of non-refluxing ureteral reimplantation in the pediatric population

PURPOSE

To evaluate the long-term results of UR and to determine the difference between patients with VUR and OMU in terms of re-obstruction rate, complications associated with pregnancy, and de novo reflux.

METHODS

Two-site retrospective study with 69 patients (36 females and 33 males) with a mean age of 5 ± 3.4 years. Fifty-nine (85.5%) underwent UR due to VUR and 10 (14.5%) due to OMU. Mean length of surgery and hospitalization was 90 ± 29.2 min and 9 ± 2.4 days, respectively.

RESULTS

Eight (13.5%) patients with VUR suffered from febrile UTI with a mean of 2.1 ± 1.3 events. In the OMU group, 1 (10%) patient suffered from febrile UTI. None of the patients showed recurrence, obstruction or de novo VUR. Two patients (20%) with OMU suffered from CKD. In the VUR group, 3 (5.1%) patients suffered from CKD. Three women suffered from UTIs during pregnancy. Mean follow-up was 17.5 ± 4.6 years.

CONCLUSIONS

Successful UR is associated with a decreased rate of febrile UTI in patients with VUR. Patients with OMU maintained and improved renal function in the long term. None demonstrated technical failures in the long term. Patients who presented with bilateral VUR are more prone to developing major complications.

Transvesicoscopic Ureteral Reimplantation for Primary Vesicoureteral Reflux in Children: Does Prior Failed Endoscopic Injection Impact Outcome?

Purpose: Transvesicoscopic ureteral reimplantation (TVUR) for vesicoureteral reflux (VUR) is a technically demanding operation. The technical difficulty is further increased by previous failed endoscopic injection, which causes intense fibrosis around the ureter. In this study, we compared primary TVUR with TVUR after previous failed endoscopic injection for VUR. Materials and Methods: The records of all children undergoing TVUR by a single surgeon over a 4-year period were analyzed. The children were divided into group 1 (primary TVUR, n = 50) and group 2 (TVUR after previous failed endoscopic treatment of Dextranomer/Hyaluronic Acid, n = 7). Demographic, clinical, radiologic, operative and follow-up data were compared between the two groups. The results were analyzed by statistical software; Mann-Whitney test and Fisher's exact test were used where appropriate, and P < .05 was considered significant. Results: Both the groups were comparable with respect to age and mean VUR grade. The mean VUR grade was significantly higher in group 1 and mean operative time per ureter was significantly more for group 2 than group 1. The postoperative hospital stay, success of TVUR, and complications were not significantly different between the groups. Conclusions: To our knowledge, this is the first report of its kind. TVUR after previous failed endoscopic injection could be done safely with good success, but with longer operative time than primary TVUR even in expert hands. Hence, previous failed endoscopic injection is not a contraindication to TVUR.

Factors affecting endoscopic treatment’s failure for primary vesicoureteral reflux in the paediatric population

Objective:

The purpose of this study is to identify which factors could determine endoscopic therapy’s failure in the paediatric patients with primary vesicoureteral reflux (VUR).

Methods:

We reviewed data from patients who underwent endoscopic surgery for primary reflux. We performed a multivariate logistic regression analysis considering factors conditioning therapeutic failure. All the tests were performed considering significant values of p < 0.05. Statistical analysis was performed with the SPSS 19.0 program. Study sample was homogenised by just including patients with primary reflux and excluding both patients with secondary reflux and patients with functional lower urinary conditions.

Results:

A total of 96 patients were included for review. Median age at surgery was 28 months. The overall success rate of endoscopic surgery for vesicoureteral reflux was 57%. Female sex, age under 24 months at the time of surgical intervention and having suffered a urinary tract infection (UTI) despite antibiotic prophylaxis are statistically significant risk factors for therapy failure.

Conclusions:

Nonetheless, differences between series could explain these differences in success rates. The lack of standardisation of the definition of ‘success’, the heterogeneity of patients included, and variables such as the degree of reflux, the presence of dysfunctional voiding, age or follow-up make it difficult to compare the success rate between series. Therefore, homogenisation of study samples assessing the evolution of primary reflux and response to endoscopic therapy is warranted.

Level of evidence:

Not applicable

Outcome of salvage ureteral reimplantation after endoscopic treatment failure for high-grade vesicoureteral reflux compared to primary ureteral reimplantation

Introduction

Surgical treatment of vesicoureteral reflux is required after conservative treatment has failed. However, there is a controversy if fibrosis related to previous attempts of dextranomer/hyaluronic acid (Dx/Ha) injection increases the risk of surgical difficulty and postoperative complications. Therefore, the purpose of our study was to compare the outcome of salvage ureteral reimplantation (SUR), after failed endoscopic therapy, to that of primary ureteral reimplantation in patients with high-grade primary vesicoureteral reflux (VUR).

Materials and Methods

We conducted a retrospective analysis of children, <14 years old, treated for Grade IV or V VUR, between 1998 and 2014. Cases were classified into the SUR or the PUR group. Cases of secondary VUR were excluded. All patients were treated using a cross-trigonal ureteral reimplantation technique by two surgeons. The following demographic and clinical variables were included in the analysis: presentation, reflux severity, scarring on imaging, age at endoscopic injection, total amount of Dx/Ha injected, operative time, postoperative hospital stay, operative complications, incidence of febrile urinary tract infections (UTIs) after surgery, and persistent VUR. Between the groups, differences were evaluated using Fisher's exact test.

Results

Twenty-six patients were included, 19 in the SUR and 7 in the primary ureteral reimplantation (PUR) group. In the SUR group, 12 cases had a bilateral VUR and 7 had a unilateral VUR, with 4 bilateral and 3 unilateral VUR cases in the PUR group. In the SUR group, 13 patients had received one Dx/Ha injections, with the other 6 receiving two injections, of 0.5 ml of Dx/Ha (range, 0.5-2.0 ml). A bilateral reimplantation was performed in 14/19 patients in the SUR group and 4/7 in the PUR group. The median age at surgery was 4 years in the SUR group and 3 years in the PUR group (P < 0.02). The median operative time was comparable between the groups (120 and 140 min for the SUR and PUR groups, respectively, P = 0.73), with a comparable length of hospital stay (5 and 6 days, respectively, P = 0.061). Blood loss was generally <10 ml, except in three cases in the SUR group, due to difficult dissection. Over the median follow-up of 1 year, persistent Grade III SUR was identified in only one patient in the SUR group, with no occurrence of febrile UTIs postoperatively.

Conclusion

SUR for high-grade primary VUR after failed Dx/Ha injection has the same success rate as PUR, with no significant complication rate, although the necessary dissection may be more difficult.

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.

Comparison of results of endoscopic correction of vesicoureteral reflux in children using two bulking substances: Dextranomer/hyaluronic acid copolymer (Deflux) versus polyacrylate-polyalcohol copolymer (Vantris)

BACKGROUND

Endoscopic correction of vesicoureteral reflux (VUR) in children offers minimally invasive management and is widely used as a first-line procedure for all grades of reflux. However, there is debate about which tissue-augmenting substance is the best to use. The aim of this study was to evaluate the efficacy of two bulking substances, Deflux (Dx/HA) and Vantris (PPC), for endoscopic treatment of VUR in children.

METHODS

From 2009 to 2012, 65 children (50 girls and 15 boys) aged 1.45-9.9 years (mean 4.85 ± 2.52) underwent endoscopic correction of VUR using Deflux. VUR was unilateral in 31 patients and bilateral in 34 patients, comprising 108 renal refluxing units (RRUs) grades: II in 52, III in 47, IV in 7, and V in 2. From 2012, 68 children (43 girls and 25 boys) aged 0.6-17.9 years (mean 4.89 ± 3.46) were treated with Vantris. VUR was unilateral in 33 and bilateral in 35 patients, comprising 109 RRUs grades: II in 48, III in 29, IV in 13, and V in 19. Voiding cystourethrogram was done 3 months after procedure.

RESULTS

All patients completed follow-up (summary Table). With Deflux, reflux resolved in almost 93% of RRUs after two procedures (in 63% after first injection), with Vantris, VUR was corrected in the same percentage after one procedure.

DISCUSSION

The success rate with Deflux ranges between 68% and 92% (only 50-70% after single injection). The reported possibility of reflux recurrence after successful Deflux treatment, and the need for repeated injection led to introduction of the new substance Vantris. The results of a multi-centre survey published in 2014 showed that reflux is corrected in more than 90% of cases after single PPC injection. Our results with PPC confirm a high level of reflux resolution.

CONCLUSIONS

Our data show that Vantris injection is a safe and effective procedure for treating all grades of VUR with good clinical outcome, and provides a higher and almost complete level of reflux resolution after first injection compared with Deflux.

Secondary surgery for vesicoureteral reflux after failed endoscopic injection: Comparison to primary surgery

PURPOSE

As endoscopic treatment for vesicoureteral reflux (VUR) has increased, secondary ureteral reimplantation (UR) after failure of endoscopic treatment has increased. We studied the clinical feature and efficacy of secondary UR after failure of endoscopic treatment compared with primary UR.

MATERIALS AND METHODS

Eighty-one children who had UR for VUR were enrolled. Charts were reviewed retrospectively for age, sex, grade of VUR before surgery, operative time, hospitalization period, postoperative complication, and success rate. Primary UR (group A, n=64) was compared with secondary UR after failed endoscopic treatment (group B, n=17). In group B, telephone survey for the satisfaction of endoscopic treatment and surgery was done.

RESULTS

Mean age of each group was 49.6±37.1 and 56.6±22.5 months (p=0.236). There was no significant difference between each group in sex, mean operative time, postoperative transfusion, complication rate, and success rate. As telephone survey in group B, eleven responders preferred endoscopic treatment as primary treatment of VUR because it was a simple method and no hospitalization.

CONCLUSIONS

Secondary UR after failure of endoscopic treatment was similar to primary UR. Parents preferred endoscopic treatment as first line treatment for VUR in spite of the need for secondary UR after failure of endoscopic treatment.

Postoperative ureteral obstruction after endoscopic treatment for vesicoureteral reflux

Purpose

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

Materials and Methods

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

Results

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

Conclusions

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

Ureteroneocystostomy in primary vesicoureteral reflux: critical retrospective analysis of factors affecting the postoperative urinary tract infection rates

INTRODUCTION

To determine the parameters affecting the outcome of ureteroneocystostomy (UNC) procedure for vesicoureteral reflux (VUR).

MATERIALS AND METHODS

Data of 398 patients who underwent UNC procedure from 2001 to 2012 were analyzed retrospectively. Different UNC techniques were used according to laterality of reflux and ureteral orifice configuration. Effects of several parameters on outcome were examined. Disappearance of reflux on control VCUG or absence of any kind of UTI/symptoms in patients without control VCUG was considered as clinical improvement.

RESULTS

Mean age at operation was 59.2 ± 39.8 months and follow-up was 25.6 ± 23.3 months. Grade of VUR was 1-2, 3 and 4-5 in 17, 79, 302 patients, respectively. Male to female ratio was 163/235. UNC was performed bilaterally in 235 patients and intravesical approach was used in 373 patients. The frequency of voiding dysfunction, scar on preoperative DMSA, breakthrough infection and previous surgery was 28.4%, 70.7%, 49.3% and 22.4%, respectively. Twelve patients (8.9%) with postoperative contralateral reflux were excluded from the analysis. Overall clinical improvement rate for UNC was 92%. Gender, age at diagnosis and operation, laterality and grade of reflux, mode of presentation, breakthrough infections (BTI) under antibiotic prophylaxis, presence of voiding dysfunction and renal scar, and operation technique did not affect the surgical outcome. However, the clinical improvement rate was lower in patients with a history of previous endoscopic intervention (83.9% vs. 94%). Postoperative UTI rate was 27.2% and factors affecting the occurrence of postoperative UTI were previous failed endoscopic injection on univariate analysis and gender, preoperative BTI, postoperative VUR state, voiding dysfunction on multivariate analysis. Surgery related complication rate was 2% (8/398). These were all low grade complications (blood transfusion in 1, hematoma under incision in 3 and prolonged hospitalization secondary to UTI in 4 patients). In long term, 12 patients are under nephrologic follow-up because of hypertension in 5, increased serum creatinine in 5, proteinuria in 1 and hematuria in 1 patient and all these patients had preoperative scarred kidneys.

CONCLUSIONS

Despite its invasive nature, UNC has a very high success rate with a negligible percent of complications. In our cohort, the only factor that negatively affected the clinical improvement rate was the history of previous antireflux interventions where the predictive factors for postoperative UTI were previous failed endoscopic injection, female gender, preoperative BTI, persistent VUR and voiding dysfunction.