Feasibility of total intravesical endoscopic surgery using mini-instruments in a porcine model

BACKGROUND AND OBJECTIVES: The aim of minimally invasive approaches to vesicoureteral reflux, such as endoscopic trigonoplasty, is to lower the morbidity of open procedures without compromising the results. Initial successes have not been sustained, mainly because of trigonal splitting, which results in the ureteral orifices returning to their preoperative positions. This study was designed to address trigonal splitting by mobilizing the ureters before repositioning them and to evaluate the feasibility of accomplishing this intravesically with 2- to 3-mm endoscopic mini-instruments. METHODS: Bilateral vesicoureteral reflux was surgically created in 10 minipigs. After radiologic confirmation of success 4 weeks later, modified trigonoplasty was performed by endoscopic intravesical mobilization of both ureters and incision of the trigonal mucosa using 2-mm instruments. The ureteral orifices were then advanced toward the midline and sutured in place. The initial surgical techniques were modified to permit the entire procedure to be performed endoscopically in the last four minipigs. Cystograms and intravenous urograms were obtained 4 weeks later. RESULTS: Two minipigs died postoperatively. Six of the remaining eight had persistent reflux, including three of the four in the group treated completely by endoscopic means. None of the dissected ureters showed evidence of stricture or necrosis. CONCLUSIONS: Although the procedure was not successful in correcting reflux in this model, this study demonstrates the feasibility of endoscopic ureteral mobilization. With current instrumentation, there is no significant technical obstacle to complete intravesical endoscopic surgery, including ureteral reimplantation.     

A comparative study of endoscopic trigonoplasty for vesicoureteral reflux in children and in adults

BACKGROUND: Endoscopic trigonoplasty is an experimental therapy for vesicoureteral reflux. We investigated differences in surgical results between children and adults. METHODS: Endoscopic trigonoplasty was performed on 51 patients and 15 pediatric and 21 adult patients were included in this study. The children accounted for 27 cases of refluxing ureter (grade II, 8; III, 14; IV, 4; V, 1) and the adults for 28 cases (I, 4; II, 18; III, 4; IV, 2). There was a greater proportion of bilateral disease and a higher average degree of reflux in the children's group. RESULTS: We found no significant differences in operative time, complications, analgesics usage, the duration of the indwelling catheter and hospital stay. Our follow up at 3 months showed that the reflux had ceased in 19 of 27 cases (70%) in the children's group and in 27 of 28 cases (96%) in the adults' group. The next follow up at 12 months showed that there was no reflux in 16 of 27 cases (59%) in 15 children and in 17 of 23 adult cases (74%). Trigonal splitting caused recurrence of reflux greater than grade II, in two children (13%) affecting four ureters and in three adults (14%) affecting four ureters. CONCLUSIONS: Endoscopic trigonoplasty has proved to be equally less invasive in children and in adults, but vesicoureteral reflux was less often resolved in children. This suggests that the greater original distance between the ureteral orifices and the greater thickness of the detrusor muscle favor the adult patient. For children, a new surgical concept is needed to increase cessation rate of vesicoureteral reflux.     

Endoscopic Treatment of Vesicoureteral Reflux in Patients With Myelodysplasia

Purpose

We assessed the usefulness of and indications for endoscopic treatment of vesicoureteral reflux in myelodysplasia patients.

Materials and Methods

A total of 26 patients treated with intermittent catheterization was divided into 11 (16 ureters) with and 15 without vesicoureteral reflux. In 9 patients (13 ureters) endoscopic correction was performed with 3 percent atelo-collagen and without anesthesia at the outpatient clinic. In each ureter we obtained the sum of scores for 4 risk factors for upper urinary tract deterioration: bladder compliance less than 10 ml./cm. water, grade 2 to 3 bladder deformity, detrusor-sphincter dyssynergia and urethral closure pressure 50 cm. water or greater.

Results

No reflux was demonstrated immediately after the initial collagen injection but cystography 3 to 6 months later showed recurrent reflux in 5 ureters (38 percent). Repeat injection cured the reflux, with results persisting for an average of 17 months. Mean risk factor score for patients without vesicoureteral reflux was significantly lower than that for patients with reflux. In patients treated with intermittent catheterization and anticholinergic agents the mean score for ureters with an increased or unchanged reflux grade was significantly greater than for those with a decreased grade.

Conclusions

Endoscopic treatment of reflux appears to be safe and useful in patients with myelodysplasia. This treatment is preferable in those with high risk factor scores due to the possibility of increased reflux grade in such patients.     

Endoscopic treatment of vesicoureteral reflux in children with posterior urethral valves

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.     

Extraperitoneal laparoscopic trigonoplasty for treatment of vesicoureteral reflux: novel technique duplicating its open counterpart

PURPOSE: We describe a novel technique of extraperitoneal laparoscopic trigonoplasty for the treatment of vesicoureteral reflux. MATERIALS AND METHODS: Three boys and 24 girls with 41 refluxing units underwent extraperitoneal laparoscopic trigonoplasty. A 10 mm incision was made below the umbilicus. With sharp, blunt finger dissection and balloon dilation an extraperitoneal space was created. The bladder was opened using a laparoscopic scissors. Two 3Fr ureteral catheters were inserted intracorporeally into the ureters. A transverse superficial incision was made in the epithelium between the ureteral orifices. The medial aspect of the ureters was cleared of the muscles and attachments, and sutured in the midline with 4-zero polyglactin sutures. RESULTS: Operative time ranged from 60 to 240 minutes (mean 147). Blood loss was less than 50 ml. Adequate extraperitoneal space, bladder opening, epithelial incision, ureteral approximation with secure suturing in the midline and bladder closure were carried out in all cases. Peritoneal perforation was noted in 4 patients while creating the extraperitoneal space, with suturing needed for 1 large perforation. Hospital stay was 1 to 6 days (mean 2.7). At 4 to 19 months of followup (mean 8.2) reflux had resolved in 38 units (93%). CONCLUSIONS: Extraperitoneal laparoscopic trigonoplasty is technically feasible. Results are comparable to open techniques. The major advantage of this procedure is the avoidance of peritoneum. Other advantages include a shorter hospital stay and good cosmesis. More followup is necessary to establish the long-term results.     

Endoskopische Unterspritzung des vesikoureteralen Refluxes mit Dextranomer/Hyaluronsäure

Background

A number of bulking agents have been used for the endoscopic correction of vesicoureteral reflux in children. We present the long-term results of endoscopic use of dextranomer/hyaluronic acid copolymer (Deflux®) for VUR grade I–IV in children.

Patients and methods

Between 2004 and 2008, 21 children underwent endoscopic subureteral injection of Deflux® in 30 ureters as an outpatient procedure. Twelve children had a unilateral reflux (two duplicated systems) and nine had a bilateral reflux. The median age was 5 years (6 months to 14.9 years). Six weeks postoperatively a voiding cystourethrogram (VCUG) was performed. This study examined the disappearance of VUR and urinary tract infection (UTI) as well as the quality of life (parents’ questionnaire) during long-term follow-up.

Results

No intra- and postoperative complications were noticed. In 25 ureters (83%) VCUG showed no VUR 6 weeks postoperatively. In three children a second injection was done (two were successful). After a median follow-up of 2.5 years 27 ureters in 17 children (90%) had no UTI and VUR. The results of the questionnaire regarding quality of life were very good in the successfully treated children and the parents would choose the same treatment option again.

Conclusion

Subureteral injection of Deflux® for children with VUR is an effective treatment option for VUR with a low complication rate.     

Durability of a single successful endoscopic polytetrafluoroethylene injection for primary vesicoureteral reflux: 14-year followup results

PURPOSE: We reviewed our 14-year experience with successful single endoscopic subureteral polytetrafluoroethylene injection for the treatment of primary vesicoureteral reflux in children. MATERIALS AND METHODS: We retrospectively reviewed the charts of 42 patients with primary vesicoureteral reflux who were treated with a single successful subureteral polytetrafluoroethylene injection between 1989 and 1993 and followed with routine 1, 3 and 10-year voiding cystourethrography. RESULTS: The study included 30 girls and 12 boys 2 to 14 years old (median age 6 years). Four patients were lost to followup. Of the 38 remaining patients 28 had unilateral and 10 had bilateral primary vesicoureteral reflux. Endoscopic treatment with subureteral polytetrafluoroethylene injection was performed in 48 ureters. Followup ranged from 10 to 14 years (mean 12.5+/-2.1). Voiding cystourethrography in 38 patients and 48 ureters revealed that 35 ureters (73%) remained free of reflux, whereas reflux recurred in 13 (27%) at a median of 2 years. Of these 13 ureters recurring reflux was grade I to II in 5 and grade III to V in 8. Reflux recurred in 11 of 24 ureters with grade IV to V reflux. Of the 13 recurrences 10 presented as febrile urinary tract infections and only 3 grade I recurrences were detected on voiding cystourethrography alone. No untoward effects were seen in any of these patients with injection of polytetrafluoroethylene. CONCLUSIONS: Long-term followup may be warranted after a single successful endoscopic injection for vesicoureteral reflux, particularly high grade reflux. However, followup voiding cystourethrography is unnecessary in patients presenting with febrile urinary tract infection.     

Endoscopic Treatment of Vesicoureteral Reflux with Collagen: Preliminary Report and Cost Analysis

Purpose

We determined therapeutic and operative cost efficacy of endoscopic collagen injection for vesicoureteral reflux.

Materials and Methods

We performed a multicenter study of 10 male and 23 female sequential patients (45 renal units) with vesicoureteral reflux and a surgical indication. Patients were skin tested with collagen and when negative, they underwent endoscopic injection. Renal ultrasound/ cystography was done 3 months after treatment. Cost analysis was performed at 1 institution.

Results

Reflux was grade I in 2 renal units, II in 18, III in 15 and IV in 10. The majority of cases were single systems with primary reflux. We performed 1 treatment in 32 renal units, 2 in 6, 3 in 6 and 4 in 1. Cure was evident in 31 of 38 renal units (81.6 percent) and 21 of 27 patients (78 percent) 3 months after the last injection. Patient morbidity was minimal. Operative cost per renal unit was $1,599.68 for collagen injection and $9,144.47 for reimplantation.

Conclusions

Endoscopic injection of collagen is effective treatment for vesicoureteral reflux. Furthermore, it causes minimal morbidity and may effect cost savings in health care management.     

Trigonoplasty to treat secondary vesicoureteral reflux in neurogenic bladders

OBJECTIVES: The effectiveness of Gil-Vernet's trigonoplasty, with technical modifications, was studied in treating vesicoureteral reflux (VUR) in neurogenic bladders. METHODS: Modified Gil-Vernet's trigonoplasty, making the transmural ureters advance over the midline and cross each other in the trigone, was applied in patients with neurogenic bladder dysfunction and VUR, diagnosed by voiding cystourethrogram. Most of the patients were sufficiently followed up by cystourethrogram. RESULTS: 26 patients with neurogenic bladder dysfunction were diagnosed as having 43 refluxing units and underwent modified Gil-Vernet's trigonoplasty. Reflux was grade I in 5 units, grade II in 7, grade III in 5, grade IV in 18, and grade V in 8, with unilateral reflux in 9 patients and bilateral reflux in 17. Surgery was successful in 95.3% of 43 refluxing units. 22 patients were followed 3-6 months after the operation, and the cure rate was 90.9% (no reflux under voiding cystourethrogram). 18 patients were followed up for more than 2 years without recurrence of VUR. CONCLUSIONS: Modified Gil-Vernet's trigonoplasty might be a useful technique in the management of patients with VUR secondary to neurogenic bladder dysfunction.     

Surgical Versus Endoscopic Correction of Vesicoureteral Reflux in Children with Neurogenic Bladder Dysfunction

Purpose

We attempted to compare the efficacy of subureteral polytetrafluoroethylene injection and ureteral reimplantation for treating vesicoureteral reflux in children with neurogenic bladder dysfunction.

Materials and Methods

We retrospectively studied the records of all children with neurogenic bladder dysfunction and reflux into single collecting systems treated with cross-trigonal ureteroneocystostomy or subureteral polytetrafluoroethylene injection. Followup cystography was performed 2 months postoperatively and ultrasound was done twice yearly thereafter. Urodynamic data were evaluated when available. Success was defined as complete eradication of reflux. Data were stratified by procedure, patient sex, grade and laterality of reflux, and the presence of unilateral or bilateral reflux, and then compared using chi-square analysis.

Results

Of 85 patients (118 ureters) identified followup data were available in 95%. Subureteral polytetrafluoroethylene injection and ureteroneocystostomy were done on 60 and 47 ureters, respectively. Both groups were similar in mean patient age, followup and preoperative degree of reflux. Success rates after ureteroneocystostomy and a single injection were 84.3 versus 56.7%. The cumulative success rate of subureteral polytetrafluoroethylene injection was 61% after a second injection. The success rate of ureteroneocystostomy was significantly greater than that of injection (p = 0.02). Reflux resolved in all patients in whom injection failed and who underwent secondary reimplantation. Successful ureteroneocystostomy was unrelated to patient sex, reflux grade or laterality, or bilateral versus unilateral reflux. Subureteral polytetrafluoroethylene injection was more likely to fail in higher grades of reflux (p = 0.03) but success was otherwise unrelated to other parameters. Failure to correct reflux was unrelated to urodynamic findings.

Conclusions

Primary open ureteral reimplantation is more effective than subureteral polytetrafluoroethylene injection for correcting reflux in children with neurogenic bladder dysfunction. Despite controversy related to the appropriate injectable substance, the relative technical simplicity, outpatient nature, rapid recovery and potential for successful secondary reimplantation support a role for subureteral polytetrafluoroethylene injection in managing reflux in these difficult cases.     

FURTHER EXPERIENCE WITH SPLIT-CUFF NIPPLE URETERAL REIMPLANTATION IN URINARY DIVERSION

Purpose

The intermediate followup results with split-cuff nipple ureteral reimplantation in larger numbers of urinary diversion patients are reviewed.

Materials and Methods

Split-cuff nipple ureteroenteric anastomosis was performed in 98 ureters of 51 adult patients. Mean duration of followup was 23 months (range 3 to 62). Two minor variations in technique compared to the original report are presented.

Results

Urinary reflux was prevented in 97.6 and 96.8% of cases at 1 and 2-year followup, respectively. Ureteroenteric anastomotic obstruction occurred in 3.1% of ureters by 3 months postoperatively. No cases of anastomotic leak or later obstruction occurred. Four episodes of acute pyelonephritis occurred in the early postoperative period.

Conclusions

The split-cuff nipple ureteral reimplant technique in urinary diversion continues to provide excellent results with low rates of reflux or obstruction. The 2 described minor technical modifications further simplify the procedure.     

Outcome of endoscopic treatment for vesicoureteral reflux in children using polydimethylsiloxane

PURPOSE: We reviewed the outcome of subureteral injection of polydimethylsiloxane as a bulking agent for endoscopic treatment for vesicoureteral reflux in patients younger than 12 years. MATERIALS AND METHODS: A total of 40 children (59 ureters) with primary grades II to IV vesicoureteral reflux were treated with a single subureteral injection from 1997 to 2001 and followed an average of 26 months (range 4 to 45). Results in 38 patients (55 ureteral units) were available for review. Each child underwent preoperative voiding cystourethrography, renal ultrasound, dimercapto-succinic acid scan and urine culture. Treatment was done on an outpatient basis. With the patient general anesthesia polydimethylsiloxane implant was injected transurethrally below the ureteral opening of the affected renal unit. Renal ultrasound at 1 week and voiding cystourethrography at 2 months were done to rule out obstruction at the injection site and/or persistent reflux, respectively. Cure was defined as absent vesicoureteral reflux on voiding cystourethrography 2 months after injection. RESULTS: After a single injection polydimethylsiloxane cured vesicoureteral reflux in 45 ureteral units (81.8%), while in 5 (9.1%) the condition was improved. The remaining 5 ureteral units (9.1%) showed no change in reflux grade. In 1 patient (1.9%) with unilateral grade IV vesicoureteral reflux contralateral reflux developed. None of the cured patients had recurrent reflux during followup. In 1 patient ureteral obstruction was successfully treated with ureteral reimplantation. CONCLUSIONS: Endoscopic subureteral injection of polydimethylsiloxane implant in children with primary grades II to IV vesicoureteral reflux appears to be an effective, safe and minimally invasive technique.     

Surgical Management of Grades III and IV Primary Vesicoureteral Reflux in Children With and Without Acute Pyelonephritis as Breakthrough Infections: A Comparative Analysis

Purpose

Although high grade vesicoureteral reflux associated with breakthrough infection may be an indication for surgical intervention, it remains uncertain whether acute pyelonephritis as breakthrough infection is a risk for renal scar formation and whether surgery performed without it has any advantage. We assessed the results of antireflux surgery for high grade vesicoureteral reflux in children with and without acute pyelonephritis as breakthrough infections.

Materials and Methods

A total of 33 boys and 27 girls (102 refluxing units) less than 3 years old with grades III and IV vesicoureteral reflux who underwent surgical management because of breakthrough infections were retrospectively studied in a 3-year period. Of the 60 patients 30 (group 1) presented with breakthrough infections of acute pyelonephritis, although they were maintained on prophylactic antibacterials. The remaining 30 patients (group 2) underwent surgery without acute pyelonephritis as the breakthrough infections. There was no renal scar formation at the diagnosis of vesicoureteral reflux in either group. Patients with renal scars were excluded from study. There was no significant difference in patient gender (p = 0.795) or distribution of bilateral vesicoureteral reflux (p = 0.781) in the groups. Group 1 patients were significantly younger at the diagnosis of vesicoureteral reflux (p = 0.006).

Results

Although 55 patients presented with a febrile urinary tract infection at the diagnosis of vesicoureteral reflux, the infection was not significantly related to the development of renal scars (p = 0.066). Of the 55 patients 12 presented with acute pyelonephritis as the initial episode of urinary tract infection. The presence of acute pyelonephritis at the diagnosis of vesicoureteral reflux was also not significantly related to renal scar formation (p = 0.207). Postoperative urinary tract infections developed in 34 patients but there was no significant correlation between postoperative urinary tract infections and renal scar formation (p = 0.235). At followup 17 group 1 and 7 group 2 patients (29 renal units) were found to have renal scars.

Conclusions

Renal scars were significantly more common in younger children with than without acute pyelonephritis as breakthrough infections (p = 0.010). Although breakthrough infections in high grade reflux may be an indication for antireflux surgery, the most appropriate results were achieved when acute pyelonephritis was not a breakthrough infection.     

Subureteral polydimethylsiloxane injection versus extravesical reimplantation for primary low grade vesicoureteral reflux in children: a comparative study

PURPOSE: We compare the outcome of extravesical ureteral reimplantation to endoscopic polydimethylsiloxane (Macroplastique, Uroplasty, Inc., Minneapolis, Minnesota) subureteral injection for primary low grade vesicoureteral reflux in children. MATERIALS AND METHODS: Between 1997 and 2000, 180 patients underwent polydimethylsiloxane injection (74, 108 ureters) or extravesical ureteral reimplantation (106, 166 ureters) for low grade vesicoureteral reflux. Low grade reflux was defined as grades I to III. Outcome analysis included success rates, de novo hydronephrosis, voiding efficiency, urinary tract infections and complications. RESULTS: Mean patient age at surgery for the injection and surgery groups was 60 and 77 months, and mean followup was 12 and 15 months, respectively. Of the patients who underwent single injection 80.6% were cured of reflux at 3 months and 91.6% were cured at last followup. Success rate after reimplantation was 95.8% at 3 months which improved to 98.8% 1 year later. The success rate was significantly different between the injection and reimplantation groups at 3 and 12 months (p <0.01). Postoperative complications in the reimplantation group included transient urinary retention after bilateral surgery in 2 patients (3.3%), suprapubic fluid collections in 2 and wound seroma in 1. No complications occurred in the polydimethylsiloxane group. CONCLUSIONS: Extravesical ureteral reimplantation has near perfect success with a low but definite complication rate. Polydimethylsiloxane offers high success rates for reflux in an ambulatory setting with no short-term complications. Currently, endoscopic polydimethylsiloxane injection is our preferred mode of therapy for low grade vesicoureteral reflux in children when surgical correction is indicated.     

Endoscopic treatment of vesicoureteral reflux in children with subureteral dextranomer/hyaluronic acid injection: a single-centre, 7-year experience

Background

The goals of medical intervention in patients with vesicoureteral reflux are to allow normal renal growth, prevent infections and pyelonephritis, and prevent renal failure. We present our experience with endoscopic treatment of vesicoureteral reflux in children by subureteral dextranomer/hyaluronic acid copolymer injection.

Methods

Under cystoscopic guidance, dextranomer/hyaluronic acid copolymer underneath the intravesical portion of the ureter in a subureteral or submucosal location was injected in patients undergoing endoscopic correction of vesicoureteral reflux.

Results

A total of 282 patients (120 boys and 162 girls) underwent the procedure. There were 396 refluxed ureters altogether. The mean age of patients was 4.9 years. The mean overall follow-up period was 44 months. Among the 396 ureters treated, 76% were cured with a single injection. A second and third injection raised the cure rate to 93% and 94%, respectively. Twenty-two (6%) ureters failed all 3 injections, and were converted to open surgery.

Conclusion

Endoscopic treatment of vesicoureteral reflux can be recommended as a first-line therapy for most cases of vesicoureteral reflux, because of the short hospital stay, absence of complications and the high success rate.     

Long-term followup of children treated with dextranomer/hyaluronic acid copolymer for vesicoureteral reflux

PURPOSE: Dextranomer/hyaluronic acid copolymer is a novel substance that has favorable properties for endoscopic treatment of vesicoureteral reflux. We assess the long-term efficacy and safety of this treatment of children. MATERIALS AND METHODS: Children 1 to 15 years old with grade III or greater vesicoureteral reflux were eligible for enrollment in our study. All patients received endoscopic treatment with dextranomer/hyaluronic acid copolymer and were scheduled to have a voiding cystourethrogram 3 and 12 months after implantation. Children with reflux grade III or greater after treatment received up to 2 more implantations, and those with persistent reflux were referred for open surgery. In some cases long-term clinical followup was accompanied by a late voiding cystourethrogram. RESULTS: A total of 228 patients received endoscopic treatment. The efficacy population was comprised of 221 children, including 67 who received 2 and 8 who received 3 implantations. Endoscopic treatment was performed without complications in all cases. Patients were followed clinically for 2 to 7.5 years (mean 5). On the last voiding cystourethrogram 68% of patients had a positive response (grade I or less) and 81% had no dilating reflux. The corresponding results for treated ureters were 75% and 85%, respectively. Only 27 (12%) patients were referred for open surgery. A late voiding cystourethrogram was performed in 49 patients 2 to 5 years after treatment. Of the ureters free of reflux (grade 0) 3 to 12 months after treatment 96% remained free of dilating reflux. Adverse events occurred in association with implantation in only 2% of patients, although urinary tract infection subsequently developed in 8%. CONCLUSIONS: Endoscopic treatment with dextranomer/hyaluronic acid copolymer was effective and well tolerated in children with vesicoureteral reflux. Long-term followup indicated that there was no deterioration in patients responding positively to treatment.     

The Cohen cross-trigonal technic for vesicoureteral reflux with contracted bladder in children

A 8-year-old girl was referred with both vesicoureteral reflux and repeated urinary infection since she was 30 months old. At 5 years old, she had had cystoscopy. Her excretory urogram (IVP) was almost normal; her voiding cystogram showed both vesicoureteral reflux of grade III and a maximum bladder capacity of 75 ml. At cystoscopy the ureteral orifices were in normal position of the trigone and the orifices were dilated like a golf-hole. Both ureters were reimplanted without ureter stents by the Cohen cross-trigonal advancement technique. Her IVP and a renograms postoperatively have shown normal kidney function and no urinary retention in either kidney. Her voiding cystograms have shown no vesicoureteral reflux. For 15 months after operation she has had no urinary infection. The Cohen cross-trigonal technique is a simple, safe and more applicable method than other anti-vesicoureteral reflux operations in cases of vesicoureteral reflux with contracted bladder.     

Endoscopic treatment of vesicoureteral reflux: 11 to 17 years of followup

PURPOSE: We review our 17-experience with endoscopic subureteral polytetrafluoroethylene injection for the treatment of primary vesicoureteral reflux in children. MATERIALS AND METHODS: We retrospectively reviewed the charts of 258 patients with primary vesicoureteral reflux who were treated with subureteral polytetrafluoroethylene injection from 1984 to 1990. RESULTS: The study included 205 girls and 53 boys between 3 months and 14 years old (median age 6 years). Of the patients 92 had unilateral vesicoureteral reflux, 129 had bilateral reflux and 37 had a refluxing duplex system including 6 with bilateral duplex systems. Endoscopic treatment by subureteral polytetrafluoroethylene injection was performed in 393 ureters. Reflux was corrected in 302 ureters (76.8%) after a single injection. Injection failed to stop reflux in 7 ureters (7 patients) and reimplantation was required. Patients were followed from 11 to 17 years with a mean followup plus or minus standard deviation of 13.5 +/- 3.4 years. Four patients were either lost to followup or parents refused to let them undergo voiding cystourethrography. Voiding cystourethrography in 247 patients with 379 ureters revealed that 360 ureters (95%) remain free of reflux whereas reflux recurred in 19 ureters (5%). Of these 19 ureters reflux was grade I or II in 13 for which no treatment was given and reflux was grade III or IV in 6, which required repeat injection. No untoward effects were seen in any of these patients with use of polytetrafluoroethylene as an injectable biomaterial. CONCLUSIONS: Endoscopic subureteral polytetrafluoroethylene injection is a simple and effective outpatient procedure for in the treatment of vesicoureteral reflux. No long-term morbidity was observed in our patients with small amounts of injectable polytetrafluoroethylene.     

Common Sheath Reimplantation Yields Excellent Results in the Treatment of Vesicoureteral Reflux in Duplicated Collecting Systems

Purpose

We evaluated our 10-year experience with the surgical treatment of vesicoureteral reflux in uncomplicated duplicated collecting systems.

Materials and Methods

Between 1984 and 1994, 54 refluxing renal units (8 bilateral) in 37 female and 9 male patients required surgery. Patient age ranged from 7 months to 17 years (average 4.9 at surgery). Postoperative followup (average 14.2 months) included voiding cystourethrography and renal sonography or excretory urography.

Results

Common sheath ureteral reimplantation via an intravesical approach was performed in 48 of the 54 refluxing renal units. Of the remaining 6 renal units detrussorrhaphy was performed in 4, and ureteroureterostomy combined with ureteral reimplantation and partial lower pole nephrectomy were done in 1 each. Two treated renal units had persistent postoperative vesicoureteral reflux, which resolved after subureteral polytetrafluoroethylene (Teflon) injection. No renal unit had postoperative hydronephrosis. Contralateral reflux was identified in 1 patient who underwent unilateral reimplantation. Our overall success rate was 96 percent for the surgical correction of vesicoureteral reflux in uncomplicated duplicated collecting systems. Common sheath reimplantation had a 98 percent success rate.

Conclusions

Although a duplicated collecting system increases the risk for surgical treatment, the presence of a duplication anomaly does not adversely affect surgical outcome. Modifications of procedures commonly performed in the surgical treatment of single system reflux to accommodate common sheath reimplantation have excellent surgical results with minimal morbidity.