Long-term efficacy of subureteral collagen injection for endoscopic treatment of vesicoureteral reflux in neurogenic bladder cases

PURPOSE: We evaluated the long-term efficacy of subureteral glutaraldehyde cross-linked collagen injection (GAX 35) for endoscopic treatment of vesicoureteral reflux in patients with neurogenic bladder dysfunction due to meningomyelocele. MATERIALS AND METHODS: We prospectively studied 12 women and 8 men (26 ureteral renal units) with a median age of 8 years (range 1 to 51) who had neurogenic bladder due to meningomyelocele. Reflux into single collecting systems was treated with subureteral collagen injection (GAX 35). Followup with video urodynamics included voiding cystography. RESULTS: All patients performed intermittent catheterization to control the bladder. During the study all bladders were areflexic with normal compliance. Preoperative reflux according to the International Reflux Study Classification was grade I in 1, II in 9, III in 10, IV in 4 and V in 2 ureteral renal units. All patients were treated with subureteral collagen injection (mean volume 1.9 ml., range 0.7 to 3.5). Reflux resolved initially in all but 2 cases. Mean followup was 16 months (range 1 to 71). Reflux was still absent in only 15% of treated units after 24 months. CONCLUSIONS: Our data suggest that endoscopic subureteral collagen injection in neurogenic bladder cases is not effective with long-term followup. New biocompatible and biodegradable materials should be tested to control vesicoureteral reflux.     

Pitfalls of repeat subureteral bovine collagen injections for the endoscopic treatment of vesicoureteral reflux

PURPOSE: Collagen has been used for the endoscopic subureteral treatment of vesicoureteral reflux since the late 1980s. We evaluated the long-term efficacy of repeat subureteral glutaraldehyde bovine cross-linked collagen injections for the endoscopic management of vesicoureteral reflux. MATERIALS AND METHODS: We prospectively evaluated 14 girls and 2 boys (21 ureteral units) 6 months to 16 years old (median age 6 years). In all patients initial treatment failed or reflux recurred after a single subureteral collagen injection and injection was repeated. Patients were followed with voiding cystography. Reflux-free periods after each injection and reflux grade were documented. RESULTS: All patients were treated twice with subureteral bovine collagen injection. Mean injected collagen volume of injections 1 and 2 was 1. 5 ml. (range 0.7 to 3.0) and 1.6 ml. (range 1.0 to 2.3), respectively, at a concentration of 35 mg./ml. In all but 4 cases reflux disappeared after injection 2. Mean followup was 11 months (range 1 to 41) after treatment 2. However in 10 patients (13 ureteral units) treatment failed or reflux recurred a mean of 10 months after injection 2. The reflux-free period after injection 2 was prolonged compared to that after injection 1 (p <0.05). CONCLUSIONS: Our results suggest that repeat endoscopic subureteral bovine collagen injections prolong the reflux-free period but remain ineffective at long-term followup for correcting vesicoureteral reflux.     

Use of collagen for endoscopic correction in complicated vesicoureteral reflux

OBJECTIVE: Endoscopic treatment of children with primary vesicoureteral reflux (VUR) has become an alternative to long-term antibiotic prophylaxis and open surgery. The purpose of this study was to assess the efficiency and safety of endoscopic subureteral injections of collagen (STING) as a treatment for complicated VUR in children. MATERIAL AND METHODS: Twenty-five patients (41 ureteral units) underwent a modified STING procedure for the correction of complicated VUR. Of these patients, five (nine refluxing units) had Hutch's diverticulum, 10 (17 refluxing units) had a duplex system, eight (10 refluxing units) had ureterocele, one (three refluxing units) had a unilateral triple ureter and one (two refluxing units) had a bilateral single ectopic ureter. Of these 41 ureteral units, 14 had grade III VUR, 17 grade IV and 10 grade V. Fourteen refluxing units (30%) received one session of STING, which was successful, and 27 (70%) needed a second session. A follow-up voiding cystourethrogram was performed 3 months after each session of STING. RESULTS: The mean follow-up period was 24 months (range 3-36 months). Of these 41 refluxing units, 34 were treated successfully and regression or downgrading occurred in seven. Follow-up i.v. pyelography or sonography did not reveal any urinary tract obstruction. CONCLUSIONS: The results of this study showed that endoscopic correction of these complicated refluxing ureters may be the first choice of treatment, but the technique must be modified to suit each individual case.     

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.     

Endoscopic subureteral injection treatment with calcium hydroxylapatite in primary vesicoureteral reflux

Introduction In this study, we aimed to evaluate efficiency of subureteral injection of calcium hydroxylapatite treatment for primary vesicoureteral reflux (VUR). Materials and methods A total of 25 children (mean age 6.9 ± 2.7 years) underwent subureteral injection of calcium hydroxylapatite for primary VUR. Reflux was present in 39 ureteral units that were unilateral in 11 cases and bilateral in 14 cases. According to “International Reflux Classification”; grade II in 12 (30.8%), grade III in 18 (46.2%) and grade IV in 9 (23.1%) ureteral units were found. Results The refluxes were resolved in 23 (59.0%) ureteral units after a single injection and 5 ureteral units (12.8%) after a second injection. Overall success rate of reflux treatment with calcium hydroxylapatite was 71.8% in all ureteral units. Conclusion Endoscopic subureteral injection of calcium hydroxylapatite in children with primary low-grade VUR appears to be an effective, safe and minimally invasive technique.     

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.     

Possible causes of unsuccessful endoscopic collagen treatment of vesicoureteric reflux in children

OBJECTIVE: The purpose of this prospective study was to identify possible causes of unsuccessful treatment of vesicoureteric reflux (VUR) in children by endoscopic collagen injection. Patients and METHODS: Between February 1994 and September 1996, 130 primary VURs in 94 children aged 3-16 years were treated by endoscopic injection of collagen. Grade 2 VUR was found in 46 ureteric units, grade 3 in 55, and grade 4 in 11 ureteric units. Seventy-seven children had normal micturition, and 17 showed signs of an unstable bladder. The collagen injection was performed under general anaesthesia. All children had a follow-up assessment on average 5.1 months after the first injection of collagen. They were evaluated by micturition cystography and ultrasound examination of the urinary tract. RESULTS: A single injection of collagen eliminated VUR in 74 (56.9%) cases. There was a statistically significant correlation between the grade of VUR and the success rate of collagen therapy (p < 0.01). The average amount of collagen used in cured and in noncured children was 0.55 and 0.76 ml, respectively (p < 0.01). Children with normal appearance of the ureteric orifice had significantly better results as compared with other children (p < 0.01). There was no statistically significant correlation between the success rate of treatment and the place of collagen injection or the shape of ureteric orifice following the injection. A statistically significant association, however, was found between the function of the lower urinary tract and the results of endoscopic collagen treatment for VUR (p < 0.05). Ultrasound showed no obstruction of the upper urinary tract. CONCLUSION: High-grade VUR, incorrect technique of injection, and voiding dysfunction seem to be some of the possible causes of an unsuccessful endoscopic collagen treatment of VUR in children.     

Consideraciones técnicas en el tratamiento endoscópico del reflujo vesicoureteral tras reimplante tipo Cohen

IntroductionThe range of indications for endoscopic treatment of vesicoureteral reflux opens more and more until including correction of secondary reflux (VUR) after ureteral reimplantation. However these cases suppose a technical challenge due to postoperative changes.The aim of this work is to present our experience on endoscopic treatment for VUR in ureteral units with Cohen reimplantation surgery, with special interest in the technical peculiarities of the procedure.Material and methodsA retrospective study of cases of secondary VUR after reimplantation surgery treated by subureteral injection.TechniqueWe put the needle perpendicular to submucous tunnel and inject medially to hole forming a wheal on the anterior face that occludes the meatusResultsDuring the 1993-2016 period 21 injections were performed in 15 ureteral units. The ureteral pathology included primary VUR (4), duplex system with lower pole reflux (4), megaureter (3) and ureterocele (2). Average patient age was 5.7 years old (2-12). Succesful outcome had been got in 10 ureteral units (66.67%), a decrease of VUR grade in 4 (26.67%) and perseverance/no resolution of grade IV VUR in 1 (6.67%)DiscussionThe anti-reflux mechanism of reimplantation depends on optimizing the submucosous tunnel. This subgroup of pacients is small and there are few studies, hindering the agreement on the most appropiate technique.ConclusionEndoscopic treatment of secondary reflux after reimplantation surgery is a procedure with certain technical feature, but safe and effective offering an alternative prior to surgical reoperation.     

Endoscopic subureteral glutaraldehyde cross-linked collagen injection for the treatment of secondary vesicoureteral reflux: comparison with primary vesicoureteral reflux in adults

PURPOSE: We assessed the effectiveness of endoscopic subureteral glutaraldehyde cross-linked collagen injection for treating vesicoureteral reflux in patients with vesicoureteral disorders. MATERIALS AND METHODS: All 51 ureters studied had grade II or greater vesicoureteral reflux. We treated 18 patients (24 refluxing ureters) with secondary and 17 adults (27 refluxing ureters) with primary vesicoureteral reflux. The primary group served as controls to establish normal urination. A total of 14 patients with secondary vesicoureteral reflux had a low compliant autonomous bladder, including 11 with myelodysplasia and 3 after pelvic surgery and radiotherapy. One patient had an unstable bladder due to cerebral palsy and 3 had anatomical abnormalities of the urinary tract. We evaluated the estimated reflux-free rate in the secondary and adult primary vesicoureteral reflux groups. RESULTS: Repeat injection was required in 24 ureters because of recurrent reflux. Average injected volume in the secondary and primary groups was 2.72 and 2.88 ml. per refluxing unit, respectively. The estimated reflux-free rate after the initial injection decreased gradually to about 35% in each group, while 12 and 24 months after the last injection it remained constant at 70% in the secondary group but decreased from 84.7% to 62.1% in the primary group. The percent of late recurrence was higher in the primary group. CONCLUSIONS: Long-term efficacy of the endoscopic correction of vesicoureteral reflux in the secondary group was similar to that in the primary group. Thus, endoscopic subureteral glutaraldehyde cross-linked collagen injection is useful for treating complicated secondary vesicoureteral reflux as a minimally invasive procedure. It is considered optional treatment of primary vesicoureteral reflux to avoid long-term prophylactic treatment.     

Subureteral dextranomer/hyaluronic acid copolymer injection for vesicoureteral reflux in transplant candidates

BACKGROUND AND PURPOSE: Endoscopic subureteral injection of tissue-augmenting substances has become an alternative to antibiotic prophylaxis and open surgery for the management of vesicoureteral reflux (VUR). Several injectable materials have been tried for this purpose. In this study, we tried to determine the efficacy of dextranomer/hyaluronic acid copolymer (Dx/HA) injection for the treatment of VUR in renal-transplant candidates. PATIENTS AND METHODS: A total of 21 transplant candidates (29 ureteral units; 13 females, 8 males) with a mean age of 20.2 years (range 14-26 years) underwent endoscopic correction of VUR with Dx/HA. Diagnosis of VUR was made by voiding cystourethrography. The efficacy of the treatment was assessed with voiding cystourethrography at 3 months and 1 year postoperatively. Renal transplantation with living related donor organs was performed in 11 of the 21 patients. RESULTS: Endoscopic treatment was performed without complication in all cases. Higher success rates were obtained in patients with low-grade reflux, the overall success rate in the series being 82.7%. The mean follow- up after renal transplantation was 21.8 months (range 5-45 months). In one patient, reflux recurred after renal transplantation and was treated successfully by a repeat Dx/HA injection. The urine cultures of all patients remained sterile. CONCLUSION: Transplant candidates with VUR can be treated with Dx/HA, which cured the majority of our patients after one or two treatments with few low side effects. Endoscopic subureteral injection of Dx/HA has become an alternative treatment for VUR in transplant candidates. Long-term results are needed before making a final statement about its value.     

Long-term outcome of the retained ureteral stump after lower pole heminephrectomy in duplex kidneys

OBJECTIVES: Duplication of the ureter and renal pelvis is the most common upper urinary tract anomaly in childhood. The anatomical and functional divisions between upper and lower moieties of duplex kidney are extremely variable. The underlying pathological condition associated with a lower moiety is usually massive vesicoureteral reflux (VUR) to the lower collecting system and only rare obstruction. The non-functioning upper moiety is usually associated with obstructive ectopic ureter (with or without ureterocele). Most lower pole heminephrectomies are carried out for non-functioning lower moieties. In most cases, the lower defunctionalised segment of the ureter is left in situ. Complete ureterectomy is usually performed if presence of VUR into the lower end of the corresponding ureter is shown. There is little information on the long-term outcome of residual ureteral 'stumps'. The purpose of our study was to review the long-term outcome of retained ureteral stumps in children undergoing heminephrectomy for non-functioning lower pole moieties in duplex kidneys. MATERIALS AND METHODS: The medical records of 19 patients who underwent 20 lower pole heminephrectomies for a non-functioning lower pole moiety of a duplex kidney between January 1990 and December 2000 were reviewed retrospectively. Median age at heminephrectomy was 4.5 years (range: 1 month to 12 years). Indications for heminephrectomy in the 20 renal units was reflux nephropathy in 16 (80%) and obstructive nephropathy in 4 (20%). All corresponding ureters were taken down as low as possible and transfixed through the heminephrectomy incision. Median follow-up was 8.5 years (range: 1-11 years). RESULTS: Eight (40%) showed VUR into the stump after lower pole heminephrectomy. Two of these underwent subureteral endoscopic correction of VUR with polytetrafluoroethylene paste and resection of the stump was carried out in remaining two patients for recurrent urinary tract infections (UTI). Remaining four of the eight patients demonstrated spontaneous resolution of VUR during follow-up. CONCLUSIONS: Our data suggest that the vast majority of patients with residual ureteral stumps after lower pole heminephrectomy do not require stump resection at long-term follow-up.     

Effect of transurethral collagen injection for vesicoureteral reflux in patients with spina bifida]

BACKGROUND: The effect of endoscopic injection of collagen was assessed in spina bifida patients with vesicoureteral reflux (VUR). METHODS: Endoscopic collagen injection was carried out for grade II or worse VUR according to the international classification. Twenty-two ureters were studied in 6 boys and 8 girls (mean: 14.4 years) who were followed up over a period of at least 3 months (mean: 5 months) after surgery they all had a negative preoperative skin test for collagen and were investigated radiologically and urodynamically. Cystograpy was performed 1, 3 and 12 months after surgery and thereafter once a year to detect recurrence of VUR. RESULTS: Anesthesia was not necessary in 4 patients. No adverse reactions occurred to the injection of collagen. VUR disappeared after 1 and 2 collagen injections in 17 (77%) and 2 (9%) ureters, respectively. The therapeutic effect of the single collagen injection showed no relationship to shape of the ureteral orifice, grade of VUR, compliance of the bladder, and presence of detrusor hyperreflexia. CONCLUSIONS: Endoscopic treatment of VUR with collagen injection in spina bifida patients is a simple and less invasive method. We obtained satisfactory short-term results by this method. However, since the risk factor of recurrence remains unclear, sufficient investigation of long-term results is important to determine the role of this method in the treatment of VUR in patients with spina bifida.     

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.     

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.     

Endoscopic treatment of primary grades IV and V vesicoureteral reflux in children with subureteral injection of polytetrafluoroethylene

PURPOSE: We evaluated our experience with endoscopic STING (subureteral polytetrafluoroethylene injection) for grades IV and V vesicoureteral reflux. MATERIALS AND METHODS: We reviewed the records of 221 boys and 305 girls who underwent STING for primary grades IV (430) and V (96) vesicoureteral reflux between 1984 and 2000. Median patient age at STING was 3 years (range 3 months to 14 years). Reflux was unilateral and bilateral in 335 and 191 children, respectively (717 refluxing units). Median followup was 11.6 years (range 1 to 17). RESULTS: Reflux was corrected in 420 of the 717 refluxing units (58%) after a single injection. Reflux resolved after a second and third injection in 185 ureters (26%). High grade reflux was converted to grades I and II in 112 ureters (15%) and did not require any further treatment. STING failed to correct reflux in 7 units (0.9%), which were managed by ureteral reimplantation (5) and nephrectomy (2) due to poor renal function. Voiding cystourethrography showed recurrent vesicoureteral reflux in 9 units (1.2%), including 2 with low grade reflux for which no treatment was given. Seven ureters required repeat injection due to grades III and IV reflux. No untoward effects were noted in any patients in whom polytetrafluoroethylene was used as the injected material. CONCLUSIONS: STING is a simple, safe and effective outpatient procedure for grades IV and V vesicoureteral reflux.     

Tratamiento endoscópico del reflujo vesicoureteral primario en niños con dos materiales diferentes. Tasa de éxito alta y tasa de complicaciones baja: comparación entre Dexell y Vantris

Introduction and ObjectivesTo compare the results in terms of efficacy and safety of the endoscopic management for vesicoureteral reflux (VUR) in two different standardized primary VUR cohorts treated with Dexell and Vantris.Patients128 refluxing renal units (RRU) in 87 patients with primary VUR (64 females, 23 males). Patients with secondary VUR and severe bladder and bowel dysfunction were excluded. A total of 22 continent children with mild bladder-bowel dysfunction underwent bladder-bowel training before the implantation. All procedures were performed in the presence of sterile urine using a conventional subureteral transurethral injection technique.ResultsThere were no statistically significant differences between groups in terms of mean age, sex, RRU side, ^99mTc-DMSA uptake, and reflux grade. The overall resolution rates based on the number of RRUs for up to three endoscopic treatments were 80% (56/70) in Dexell group and 94.8% (55/58) in Vantris group (p = 0.012). No postoperative recurrences or vesicoureteral junction obstructions were seen in any group.ConclusionsDexell and Vantris provided an effective and safe endoscopic VUR treatment in the early and mid-term follow up of children with primary VUR. The effectiveness of these substances, which can produce different mass effects with different particle sizes, in safe VUR resolution, needs further investigations.     

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.     

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.     

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.     

Evaluation of antibody class in response to endoscopic subureteral collagen injection in patients with vesicoureteral reflux

PURPOSE: Clinical problems after glutaraldehyde cross-linked collagen injection for vesicoureteral reflux are the appearance of anticollagen antibodies and a decrease in collagen with time. We evaluated whether antibody production affects reflux recurrence and implanted collagen absorption. MATERIALS AND METHODS: We treated 27 patients (39 ureters) who had vesicoureteral reflux with endoscopic subureteral glutaraldehyde cross-linked collagen injection. The maximum diameter of the elevated ureteral orifice was measured 3-dimensionally and the numerical value calculated by multiplying each diameter by approximately pi/6 was used as the ultrasound estimate of injected collagen volume. The 1-to-6-month collagen volume ratio was used as an index of the decrease in implant collagen volume. The antibody class against bovine collagen was characterized by indirect enzyme-linked immunosorbent assay. RESULTS: Seroconversion in 6 patients was noted a mean 6.8 months after the first injection. In these patients the antibody class was IgG dominant and IgA or IgM was not detected. There was no significant difference in the total injected collagen volume, total number of injections or collagen volume ratio in the seropositive and seronegative groups. Reflux recurred in 4 patients and the curve of the reflux-free rate was similar regardless of antibody appearance. CONCLUSIONS: The immune response to bovine collagen injection for vesicoureteral reflux does not depend on injected collagen volume or an increased number of treatments. Antibody production had no effects on absorption of the implanted collagen or reflux recurrence.