Long-term results after endoscopic VUR-treatment using dextranomer / hyaluronic acid copolymer - 5-year experience in a single-center

Giant foreign body granuloma after endoscopic management of vesicoureteric reflux: a case report

Background

Deflux®, a dextranomer/hyaluronic acid copolymer, is extensively used as an endoscopic bulking agent for management of vesicoureteric reflux (VUR). The complications following Deflux® treatment as described in the literature are clinically insignificant transient obstruction and infections of the urinary tract. We report a rare case of a giant Deflux® granuloma presenting as an intraoperative surprise while undergoing open ureteric reimplantation for the failure of prior endoscopic management.

Case presentation

A 2.5-year-old boy with a primary VUR needed Anderson Hyne’s pyeloplasty of the affected side for concomitant pelviureteric junction obstruction. During removal of the double “J “stent in the postoperative period, subureteric Deflux® was injected, hoping that a more invasive procedure could be avoided. At a later date, as VUR persisted, an open ureteric reimplantation, was performed. Intraoperatively, a large Deflux® granuloma was noted at the site of previously injected site.

Conclusions

Giant Deflux® granuloma is a rare complication of this modality of VUR management. A focussed radiological assessment in such pateints during follow-up is required, especially those planned for surgical intervention in the vesicoureteric region later.

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

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

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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