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

OBJECTIVE: To summarize the long-term outcome of endoscopic surgery to correct vesico-ureteric reflux (VUR) using different injected substances, i.e. autologous blood, hyaluronan/dextranomer copolymer (HDC), PTFE and glutaraldehyde cross-linked bovine dermal (GAX) collagen. PATIENTS AND METHODS: Treatment results on 270 ureters of 185 patients followed for >5 years (mean 8.5) were summarized according to the injected substances. The substances were injected into the 6 o'clock position of the ureteric orifice endoscopically. "Success" was defined as the absence of VUR for >5 years after a single injection. RESULTS: The treatment was successful in two of 24 patients (8%) with autologous blood, 17 of 32 (53%) with HDC, 108 of 171 (63%) with PTFE and 24 of 43 (56%) with GAX collagen. The success rate was lower in patients with higher grades of VUR. CONCLUSIONS: Autologous blood is unsuitable for clinical application because of its poor durability. We will no longer use PTFE because its safety is not well established. The overall success rates of endoscopic surgery with GAX collagen and HDC were insufficient compared with surgical reimplantation, but it is advantageous that this procedure is less invasive and can be repeated. The cure rate could be improved by excluding high-grade VUR from the indications for endoscopic surgery.     

The role of endoscopic treatment in the management of grade v primary vesicoureteral reflux

OBJECTIVES: Although endoscopic treatment provides a high rate of success in children with grades II-IV vesicoureteral reflux (VUR), its role in the management of grade V reflux has been questioned. In this study we reviewed our 21-yr experience of endoscopic treatment in children with grade V primary VUR. METHODS: We retrospectively reviewed the medical records of 132 children who underwent endoscopic treatment for primary grade V reflux from 1984 to 2004. VUR was unilateral in 39 patients and bilateral in 34, and 59 patients had ipsilateral grade V reflux with a lower grade of VUR on the contralateral side. Endoscopic treatment was performed in a total of 166 grade V ureters; polytetrafluoroethylene was used from 1984 to 2000 and dextranomer/hyaluronic acid from 2001 to 2004. Median follow-up was 12.2 yr and mean follow-up was 13.4 yr. RESULTS: VUR was completely resolved after first injection in 88 (53%) ureters and downgraded to grade I or II in 26 (15.7%). VUR resolved after a second and third injection in 36 (21.7%) and 10 (6%) of ureters, respectively. Endoscopic treatment failed to correct VUR in 6 (3.6%) ureters, requiring ureteral reimplantation in 5 and nephrectomy in 1. Thirteen patients developed urinary tract infections during the follow-up period, and on investigation 9 ureters (5.4%) had recurrence of VUR. No injection or morbidity related to tissue-augmenting substances was noted in any patient. CONCLUSION: Endoscopic treatment should be the first-line of treatment in management of grade V vesicoureteral reflux.     

Endoscopic correction of vesicoureteric reflux in children with spina bifida

Twenty patients with vesicoureteric reflux (VUR) secondary to a neuropathic bladder and associated spina bifida were treated with the endoscopic injection of subureteric polytetrafluoroethylene (Teflon) paste. Of the 19 patients (29 ureters) followed up, 13 have persistent reflux, although only 3 of these ureters have needed a second injection. Twelve of the 16, where reflux resolved, required only 1 injection.     

Vesico-ureteric reflux in adults with neuropathic bladders treated with Polydimethylsiloxane (Macroplastique)

OBJECTIVE: To establish the efficacy of Macroplastique in treating vesico-ureteric reflux (VUR) in adults with neuropathic bladder dysfunction. PATIENTS AND METHODS: Fifteen patients (12 male and three female), age range 19 to 80 years (mean age 38) were included in this study. Diagnosis was confirmed by videourodynamics. In seven patients reflux was present bilaterally. Twenty-two refluxing ureters were treated. Twelve patients had detrusor hyper-reflexia, two had areflexic bladders and one had loss of bladder wall compliance. According to the International Grading System, 10 ureters had grade IV reflux, five had grade III reflux, five had grade II reflux, and two had grade I reflux. Macroplastique (0.5-1.5 ml) was injected submucosally under each ureteric orifice to convert the opening to a slit like shape. The patients were followed up from 9 to 68 months. RESULTS: VUR was completely resolved in 72.7% (16) ureters following a single injection and in a further 4.5% (1) ureter following a second injection. 9.1% (2) ureters were improved and treatment failed in 13.7% (3) ureters. Two patients showed a recurrence of reflux 1 and 4 years after primary injection and subsequently had a curative second injection. Most of the patients in whom VUR was cured or improved showed a reduction in laboratory proven urinary infection rates. CONCLUSION: Macroplastique produced an excellent result (86% with complete resolution or improvement of reflux) in treating VUR in adult neuropathic bladders. This is comparable to larger studies carried out on the paediatric population. This is an easy procedure, which avoids major surgery and can be performed as a day case. In cases of failure or recurrence, repeat injection or open surgery can be undertaken without any added complications.     

Open ureteroneocystostomy after failed endoscopic injection with three different bulking agents for the treatment of vesicoureteral reflux

Background/PurposeTo evaluate the success rate of open ureteroneocystostomy (UNC) after failed endoscopic treatment of vesicoureteral reflux (VUR) in children and to discuss the reasons for failure under the light of histopathological findings.MethodsThe clinical data of 371 patients who underwent endoscopic injection for VUR at our institution for the treatment of VUR between January 2008 and January 2014 were reviewed. Patients who were submitted to open ureteral reimplantation following failed endoscopic injection were included in the study.ResultsAmong 371 patients, 34 (49 ureters) were submitted to open UNC (9.1%). There were 22 female and 12 male patients. Three different injection materials were used; dextranomer/hyaluronic acid in 29, carbon-coated beans in 7 and polyacrylate polyalchohol copolymer in 13. Histological study revealed that the injected material was identified in 34 ureters as malpositioned. Control VCUG 6 months after UNC showed complete resolution in 46 of 47 ureters (97.87%).ConclusionsPrevious endoscopic injection, although causing difficulty in dissection to some degree, does not alter the success rate of UNC. According to the histopathological findings, the cause of failure of injection seems to be attributable to incorrect plane of injection or leakage of the agent after injection.     

Endoscopic application of dextranomer/hyaluronic acid copolymer in the treatment of vesico-ureteric reflux after renal transplantation

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Vesicoureteral reflux (VUR) after renal transplantation may cause recurrent urinary tract infections (UTIs) and loss of renal function with consecutive risk of progressive graft damage. There are only a few series on the therapeutic success of dextranomer/hyaluronic acid copolymer treatment by transurethral injection. We assessed whether transurethral endoscopic therapy is an alternative strategy treating VUR in this special patient collective and we found out that this surgical method is a minimally invasive and efficient procedure with reflux resolution rate of approximately 60% after one and 79% after two injections with significant reduction of postoperative UTIs on short‐term follow up.

OBJECTIVE

? To evaluate the success of endoscopic dextranomer/hyaluronic acid copolymer (DHAC) application in the treatment of patients with recurrent urinary tract infections (UTIs) and vesico‐ureteric reflux (VUR) into the transplanted graft after renal transplantation.

PATIENTS AND METHODS

? Between January 2008 and April 2009, 19 patients with recurrent UTIs presented VUR proven by voiding cystourethrography. ? To correct VUR of the transplanted ureter, DHAC was injected endoscopically using hydrodistention technique. ? Pre‐ and postoperative serum creatinine levels, the number of pre‐ and postoperative UTIs, postoperative complications and reflux resolution rate were recorded. The mean follow‐up was 6.5 months.

RESULTS

? The average number of UTIs was reduced significantly from 4.89 (range 2–14) to 1.31 (range 0–4) on pre‐ and postoperative follow‐up, respectively, of 6 months (P < 0.001). The success rate increased from 57.9% after the first injection to 78.9% after the second injection. ? The remaining four patients with residual VUR received long‐term low dose antibiotic prophylaxis. In total, two (10.5%) patients developed increasing creatinine levels postoperatively as a result of distal ureteral obstruction, and temporary urinary drainage was necessary in both patients.

CONCLUSIONS

? DHAC appears to be an efficient and minimal invasive method for treating VUR after renal transplantation with respect to short‐term success. ? Further investigation with a larger group of patients and longer follow‐up is needed to evaluate the prolonged effect, as well as any potential side effects.     

Endoscopic treatment of vesicoureteral reflux with polydimethylsiloxane in adult women

OBJECTIVES: Subureteral injection of bulking agents to a refluxing ureteral orifice is an attractive alternative to open repair. We record our experience of the endoscopic subureteral injection of polydimethylsiloxane in women for vesicoureteral reflux (VUR). METHODS: From January 1997 to December 2001, 30 women (mean age 34.9 years) with 43 refluxing ureters underwent endoscopic treatment. The grade of VUR was I, II, III, and IV in 10, 16, 13, and 4 ureters, respectively. The indication for the procedure was VUR with a history of pyelonephritis in women of childbearing age or in whom antibiotic prophylaxis had been unsuccessful. All women underwent voiding cystourethrogram at 3 months and then yearly after the procedures. Follow-up ranged from 12 to 60 months (mean 26.5 months). RESULTS: Reflux was corrected in 34 ureters after a single injection; only 3 ureters needed a 2nd injection. The overall success rate was 86.0%: for grades I, II, III, and IV was 90.0%, 87.5%, 76.9%, and 100% respectively. The mean hospital stay was 1.31 days (range 1-8 days), and no remarkable surgical complications occurred. Most of the patients in whom VUR was cured or improved showed a reduction in laboratory-proven urinary infection rates. CONCLUSIONS: The endoscopic subureteral injection of polydimethylsiloxane in women with vesicoureteral reflux is an effective therapy with no associated morbidity.     

Multivariate analysis of factors predicting success with dextranomer/hyaluronic acid injection for vesicoureteral reflux

PURPOSE: Factors influencing outcomes of dextranomer/hyaluronic acid injection for vesicoureteral reflux remain poorly defined. We performed multivariate analysis of the experience of 1 surgeon (WS). MATERIALS AND METHODS: The study group contained 168 patients and 259 refluxing units. Goal of injection was coaptation of the orifice with creation of a volcanic mound. Outcomes were determined by cystography obtained 12 weeks following injection. Intraoperative photographs of mounds were independently reviewed by 2 authors (WS, SY) without knowledge of results, and classified as "satisfactory" or "other." Univariate and multivariate logistic regression analysis was done evaluating influence of gender, age, voiding dysfunction, reflux grade, unilateral vs bilateral reflux, ureteral duplication, orifice laterality, subureteral vs intraureteral injection, volume injected and mound appearance. RESULTS: A single injection resolved reflux in 70% of patients and 78% of ureters. Additional injection resulted in overall success in 82% of patients and 86% of ureters. Multivariate analysis demonstrated that reflux grade, volume of dextranomer/hyaluronic acid injected and mound appearance correlated with outcomes. A satisfactory mound was achieved in 81% of ureters, of which 87% no longer refluxed. CONCLUSIONS: The ability to create a satisfactory mound was the most important factor determining success of dextranomer/hyaluronic acid injection. Increasing reflux grade was associated with a decreased likelihood of achieving a volcanic mound, and increasing volume injected suggested difficulty in creating a mound.     

Ultrasonic ureteric jet study: A comparison with the voiding cystourethrogram for the detection of vesico-ureteric reflux in children

Summary: The ultrasonic ureteric jet study is a non-invasive method of measuring the distance between the midline of the bladder and the ureteric orifice (MOD). Statistical comparison with the results of single cycle voiding cystourethrograms (VCU) indicates that a normal MOD measurement on the ureteric jet study is a good predictor of the absence of vesico-ureteric reflux (VUR). For ureters of children less than 4 years of age, a MOD ≤8mm has a negative predictive value of 83% (95% confidence interval; 74-93%). For ureters of children aged 4-10 years, a MOD ≤9mm has a negative predictive value of 91% (95% confidence interval; 86–97%). the ureteric jet study has the potential to identify children who do not have reflux, thus sparing them an unpleasant, invasive procedure.     

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.     

Primary vesicoureteric reflux: treatment with subureteric injection of Polytef paste

A series of 34 children with 40 primary refluxing ureters were treated endoscopically with a subureteric injection of polytetrafluoroethylene paste (Polytef). The amount injected ranged between 0.1 and 0.8 ml (mean 0.3). A single injection cured the reflux in 26 ureters (65%) and the grade of reflux improved in a further 9 ureters. Seven ureters required a second injection and reflux was cured in 6 of these. The overall cure rate was therefore 80% after the second injection. There was one complication due to self-limiting ureteric obstruction following injection. The procedure is quick, easy to perform and effective. We have some reservations about the long-term efficiency and safety of subureteric Polytef injection in children.     

Efficiency of endoscopic treatment for vesico‐ureteric reflux in adults

OBJECTIVE

To evaluate the results of our experience with endoscopic management of vesico‐ureteric reflux (VUR) in adults, and to describe factors and complications that might contribute to the failure of the technique.

PATIENTS AND METHODS

Between 1992 and 2006, 21 patients (17 women and four men; mean age 32.1 years, sd 15.6) had endoscopic treatment for VUR (14 unilateral and seven bilateral ureteric units, UU). Patients previously operated for VUR were excluded. The VUR grades were II, III, IV and V in 10, 12, five and one UUs, respectively. The main indication for treatment was a history of repeated episodes of acute pyelonephritis (61%). Complications after surgery were evaluated.

RESULTS

The success rate of the first endoscopic treatment was 69%, and was 81% after the second. Two UUs with grade IV VUR were endoscopically managed for a third time with complete resolution. Only one UU with grade V VUR required open surgery. The success rate for VUR grades II, III and IV after the first treatment was five of eight, 12/12 and one of five, respectively. After the second treatment the success rate increased to seven of eight and two of five for grades II and IV, respectively. There were no complications related to the intervention. Factors related to a failure of technique were duplex ureter and dysfunctional voiding in eight UUs (seven patients).

CONCLUSIONS

The endoscopic management of VUR in previously untreated adult patients is a simple and efficient technique, with low comorbidity.     

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.     

Subureteral injection of dextranomer/hyaluronic acid copolymer for persistent vesicoureteral reflux following ureteroneocystostomy

PURPOSE: We sought to evaluate the use of subureteral dextranomer/hyaluronic acid copolymer injection for persistent vesicoureteral reflux following ureteroneocystostomy. MATERIALS AND METHODS: We performed a retrospective review of patients who had undergone dextranomer/hyaluronic acid injection between 2002 and 2005 for persistent vesicoureteral reflux following ureteroneocystostomy. Analysis included evaluation of patient demographics, reflux grades, voiding dysfunction, reflux resolution rates and operative complications. Success was defined as no reflux on voiding cystourethrogram at 1 to 6 months postoperatively. RESULTS: A total of 12 cases with 14 refluxing ureters were reviewed. Of the 12 patients treated 9 (10 ureters) had adequate followup. Mean followup was 10 months. Seven of 10 ureters (70%) demonstrated resolution of reflux after the initial injection. A second dextranomer/hyaluronic acid injection resulted in complete resolution in 2 of the 3 failed ureters (67%). Resolution in the remaining failed ureter could not be assessed due to insufficient patient followup. In children with adequate followup success was ultimately achieved in 9 of 9 ureters (100%) using up to 2 injections. A comparison of clinical factors between patients with success after the initial injection and those requiring 2 injections showed that the presence of persistent voiding dysfunction was the only parameter that was statistically significant. All patients tolerated the procedure without complications. CONCLUSIONS: Considering the difficulties inherent in repeat surgery and the high success rate of dextranomer/hyaluronic acid injection in this series, this treatment is an appealing and reasonable option for patients with persistent vesicoureteral reflux following open ureteroneocystostomy.     

Endoscopic correction of grades IV and V primary vesicoureteric reflux: six to 30 month follow-up in 42 ureters

Between March 1984 and March 1986, 31 children with 42 ureters with grades IV and V primary vesicoureteric reflux were treated by endoscopic subureteric injection of Polytef paste. Reflux ceased after a single injection in 28 ureters, after the second in six, after the third in three and after the fourth injection in one. Two ureters showed improvement to grade II reflux after two injections and no further treatment was given. Two ureters showed no change in grade of reflux after three and four injections, respectively. Twenty-seven children with successfully treated ureters have now been followed up for periods ranging from 6 to 30 months. All 38 ureters had a negative micturating cystogram following endoscopic correction. At follow-up there was no reflux in 32 (84%) ureters and recurrence in six (16%). The procedure is simple to perform and without significant complications. The follow-up results show that the endoscopic treatment is reliable and effective in correcting higher grades of vesicoureteric reflux.     

Factores implicados en el fracaso tardío del tratamiento endoscópico del reflujo vesicoureteral

Introduction

The short-term results of endoscopic treatment of vesicoureteral reflux (VUR) are excellent. Over time, however, a number of patients have been identified for whom VUR reappeared after being resolved with this technique. The aim of this study was to analyse the factors related to this event.

Vesico-ureteric reflux in Down's syndrome: poor prognosis

Four patients with Down's syndrome and vesico-ureteric reflux (VUR) are reported. VUR was diagnosed in six renal units and three primary nephrectomies were necessary. Three ureters were reimplanted unsuccessfully in two patients. The 50% nephrectomy rate for reflux nephropathy and the 100% failure rate for ureteric reimplantation in Down's syndrome patients are compared with a nephrectomy rate and ureteric reimplantation failure rate of around 1% for primary VUR in other children.     

Endoscopic correction of vesicoureteric reflux: 10-year experience of a tertiary care center

Endoscopic treatment (ET) of vesicoureteric reflux (VUR) is becoming the new gold standard for surgical correction. ET for VUR using newly available bulking agents is a reliable and safe alternative procedure to open ureteral reimplantation for the treatment of VUR in children. We retrospectively reviewed our experience over 10 years of patients with primary VUR who underwent ET and had at least one year of follow-up at our center from 1998 to 2008. We looked at laterality, success rate, need for a second procedure and complication rate. We observed 321 patients with ET for VUR during this period; 115 (35.8%) of them were males and the total intervened ureters were 480. Correction of VUR was defined as either the resolution of reflux or a downgrading to grade 1 revealed with a follow-up voiding cystourethrogram and no ipsilateral renal or ureteric dilatation detected on renal ultrasound. At two to three months of follow-up, VUR was corrected in 393/480 (81.8%) refluxing ureters after a single endoscopic injection. With a second, repeated injection in the failed cases, VUR was corrected in a total of 418 (87.1%) refluxing ureters. Only three patients had post-operative complications (<1%). We conclude that our study suggests that the majority of patients will be cured after undergoing, as out-patients, this endoscopic procedure. We believe that the widely reported safety of bulking agents and the short learning curve will make ET the standard treatment for VUR once surgical correction is warranted.     

A review of failures of endoscopic treatment of vesicoureteral reflux with dextranomer microspheres

PURPOSE: We evaluated the appearance of the mound of failed endoscopic dextranomer microsphere injections at the time of reinjection or open ureteral reimplantation. MATERIALS AND METHODS: We performed a multi-institutional study of 80 patients (97 ureters) who were diagnosed with vesicoureteral reflux and had failed endoscopic treatment with dextranomer microspheres. Observations of injected mound characteristics were made during the time of reinjection or at open ureteral reimplantation. Correlations were made with the pre-injection grade of reflux, volume of initial injection, number of punctures used for the initial injection and presence of symptoms of dysfunctional voiding. RESULTS: Examination of the failed injection sites before subsequent injections or open surgery revealed mound abnormalities in all but 13 of the 97 ureters. Of the cases 49% demonstrated a shifted mound, 22% an absent mound and 10% a loss of volume in the mound. Of the 13 patients with normal appearing mounds 7 had improved reflux grade, 3 had worsened grade and 3 had no change. Patients with dysfunctional voiding symptoms had a second injection failure rate of 44%, compared to a 13% rate in those without symptoms of voiding dysfunction. CONCLUSIONS: Most failures of endoscopic correction are associated with mound shifting. The presence of a perfect mound does not predict success. Dysfunctional voiding predicts a lower success rate after a second injection.     

Late onset ureteric obstruction after endoscopic subureteric injection of calcium hydroxyapatite for primary vesicoureteric reflux

Ureteric obstruction occurs in about 1% of cases undergoing endoscopic treatment of vesicoureteric reflux (VUR). It usually develops shortly after treatment. We report on a case of obstruction occurring 1 year after subureteric injection of calcium hydroxyapatite. Obstruction was progressive and eventually required open ureteric reimplantation. Ureteric obstruction can occur also in the long-term after endoscopic treatment of VUR and even in the absence of symptoms. Although it is so rare as to make long-term follow-up of all treated cases cost ineffective, physicians should be aware of such complications, especially while testing new bulking agents.