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.     

Enuresis and the voiding cystourethrogram: a re-evaluation

Eighty-three children with a chief complaint of nocturnal enuresis and no history of urinary tract infection (UTI) were prospectively evaluated with a contrast voiding cystourethrogram (VCUG). The following four historical details of presentation were noted: primary vs. secondary enuresis, daytime wetting, urgency, and frequency. Each of these four symptoms were treated as a dichotomous variable, and the prognostic value with respect to vesicoureteral (VUR) reflux was assessed using a linear logistic regression model. Nineteen ureters in 13 patients (16%) demonstrated VUR: grade I, 7 ureters; grade II, 5 ureters; grade III, 3 ureters; grade IV, 4 ureters; and grade V, 0 ureters. Three patients demonstrated renal scarring (16%) and 2 patients underwent surgery. The linear regression analysis revealed that no one symptom, group of symptoms, or absence of all four symptoms segregated those patients likely to have reflux with statistical validity. One of 6 children, therefore, who present with nocturnal enuresis and sterile urine will have reflux. Screening these children with a VCUG should be considered.     

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.     

Management of vesicoureteral reflux in patients with neurogenic bladder dysfunction

We studied 20 cases of neurogenic bladder with vesico-ureteral reflux retrospectively. Seven patients voided with Valsalva's maneuver and 12 patients were managed with clean intermittent catheterization, but one patient required permanent urinary diversion because of uncontrollable urinary tract infection. The patients were followed by intravenous pyelography, radioisotope renogram, voiding cystourethrography, determination of serum creatinine level and urodynamic study. Anti-reflux surgery was performed in 22 ureters and reflux resolved in 19 ureters. Among 12 ureters not treated by anti-reflux surgery, reflux disappeared in 5 ureters and improved in 2 ureters. Of 5 ureters, reflux resolved after clean intermittent catheterization in 2 ureters, and remained stable without recurrent infection or renal deterioration in the remaining 5 ureters. Regardless whether antireflux surgery was done or not, most of the patients who had high grade reflux and obstructive renal damage on radioisotope examinations had marked low compliance bladders. Our experience suggested the necessity of a suitable treatment to improve bladder compliance before considering anti-reflux surgery.     

Endoscopic treatment of vesicoureteric reflux with bovine collagen

A submucosal injection with bovine collagen (Zyplast) was performed in 45 female patients with 70 refluxing ureters. 4 ureters showed reflux grade IV, while the others had reflux grade I-III. All patients suffered from recurrent urinary tract infections. In 18 ureters, a second injection was given. As a result of this treatment, reflux was cured in 85.8% of the ureters. Only 13 patients had urinary tract infections during the follow-up period (6-24 months). 5 patients had antireflux surgery and collagen was excised. The histology of the specimen did not show an inflammatory reaction. Collagen injections could gain great importance in the management of vesicoureteral reflux.     

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.     

Urethral controlled bladder substitution: a comparison between the intussuscepted nipple valve and the technique of Le Duc as antireflux procedures.

A urethral controlled bladder substitute was constructed from a detubularized, double folded ileal segment in 40 male patients following cystoprostatectomy for bladder cancer. For reflux prevention patients were prospectively randomized to receive either an intussuscepted nipple valve or the ureters were implanted by the Le Duc mucosal trough technique. All patients had normal upper tracts preoperatively. Mean patient age, performance status and stage of cancer were comparable in both groups. Patients were evaluated 6 to 18 months postoperatively. In addition to history taking, assessment included excretory urography, ascending cystography and voiding cystourethrography. During the observation period all patients with nipple valves had normal radiographic appearance of the upper tracts without evidence of reflux. On the other hand, following the Le Duc procedure 12 of 38 renal units (31%) showed evidence of radiographic dilatation. Of the 12 units 11 had stenotic ureters and 1 had reflux. We conclude that nipple valves are more effective in reflux prevention and protection of the upper urinary tract in patients for whom an ileal neobladder is indicated.     

The hydraulic antireflux valve: a new technique for reimplanting dilated ureters

PURPOSE: Wide ureters have a high risk of urinary reflux if they are implanted in the intestinal segment. Since 1978, we used the continence hydraulic valve as an antireflux device without staples. MATERIALS AND METHODS: A total of 40 patients, 20-65 years old (mean age 50), 36 with bilaterally severely dilated ureters and 4 with unilaterally dilated ureters underwent reconstructive surgery by intestinal segments with a hydraulic antireflux valve (HAV). RESULTS: Mean follow-up was 62 months (range 14-110); upper tract dilatation had improved or stabilized in all patients but one in whom bilateral dilatation occurred with HAV stenosis. All patients underwent follow-up loopogram studies which revealed 2 cases of reflux (4 ureterorenal units). In 1 of the 2 patients the urinary reflux occurred after dessusception (disinvagination) of the nipple. CONCLUSIONS: The HAV is a safe and reliable procedure in preventing reflux when implanting wide ureters into intestinal segments. This technique can be used in continent urinary diversions with intestinal pouches, and can also be used at the proximal level of an ileoureteroplasty. There is no need for staples.     

Laparoscopic extravesical transperitoneal approach for vesicoureteral reflux

INTRODUCTION: Laparoscopy may have a place in the treatment of vesicoureteral reflux. In this study, we present the results of laparoscopic extravesical transperitoneal treatment in 15 children (19 ureters) of vesicoureteral reflux. MATERIALS AND METHODS: Between January 2001 and February 2004, 15 children (11 with unilateral and 4 with bilateral vesicoureteral reflux) were treated with extravesical reimplantation (Lich- Gregoir technique) via a transperitoneal laparoscopic approach. The mean age was 48.2 months (range 12-62), and there were 14 females and 1 male. Two patients had a double total collector system associated with reflux without ureterocele. RESULTS: The mean surgical time was 110 minutes in unilateral and 180 in bilateral vesicoureteral reflux. All procedures were successfully completed laparoscopically and the reflux was corrected in all but one patient, whose grade III vesicoureteral reflux changed to grade I. We had 3 mucosal perforations without leakage. The longest hospital stay was 72 hours. After follow-up ranging 15-49 months, only one patient had urinary tract infection. CONCLUSION: Laparoscopic extravesical transperitoneal reimplantation for vesicoureteral reflux is a safe and effective approach even in bilateral simultaneous and duplex ureters, with success rates similar to the open technique, and a dramatic reduction in postoperative stay. Mucosal perforation was treated by maintaining a Foley catheter for 3-4 days postoperatively.     

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.     

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.     

Outcome of ureteral reimplantation in children with the urge syndrome

PURPOSE: While bladder dysfunction, particularly detrusor-sphincter incoordination, appears to be associated with a higher ureteral reimplantation failure rate, the potential effect of the urge syndrome or detrusor instability alone on surgical outcome remains unclear. We assessed the effect of the underlying urge syndrome on the outcome of ureteral implantation in cases of primary vesicoureteral reflux. MATERIALS AND METHODS: We retrospectively reviewed the charts of all patients who underwent ureteral reimplantation for primary vesicoureteral reflux at our institution in an 11-year period. The urge syndrome was considered frequency, urgency or urge incontinence with absent urinary tract infection. Patients with and without the urge syndrome were compared with respect to the rate of urinary tract infection and renal scarring as well as postoperative outcome. RESULTS: We identified 25 patients (40 ureters) with and 67 (113 ureters) without the urge syndrome. Reimplantation was successful in all except 1 ureter in a patient without the urge syndrome. Postoperatively 2 patients without the syndrome had transient contralateral reflux and 1 in each group had transient ipsilateral reflux. No case required reoperation. Postoperatively patients with the syndrome had a significantly higher incidence of febrile (16% versus 1.5%, p <0.05) and afebrile (52% versus 12%, p <0.05) urinary tract infection. CONCLUSIONS: The results of ureteral reimplantation are excellent with 99.3% success irrespective of the presence or absence of the urge syndrome. Thus, when clinically indicated, reimplantation may be performed safely in such cases. The higher incidence of postoperative urinary tract infection in patients with the urge syndrome may require continuing antibiotic prophylaxis in addition to anticholinergics until voiding symptoms resolve.     

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.     

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.     

Anti-reflux surgery by injection of Teflon paste.

Over a 3-year period, 55 refluxing ureters in 36 patients were treated by the endoscopic injection of Teflon paste. Although reflux was corrected immediately in 54 ureters (98%), reflux recurred 3 to 4 months later in 18 ureters. Reinjection was carried out once in 5 ureters and twice in 1. The success rate was 71% in primary reflux and 53% in secondary reflux. Significant side effects were encountered post-operatively in 3 patients: vesicoureteric junction obstruction in 2 and urethral stricture in 1. We recommend that the results of surgery should not be evaluated until at least 3 to 4 months after operation. A review of the literature shows that the overall success rate was 92% in 367 ureters with primary reflux and 70% in 181 ureters with secondary reflux. Because of the uncertain outcome of surgery and the possibility of adverse side effects, one should be cautious when considering this form of treatment in young children.     

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.     

Clinical evaluation of vesicoureteroneostomy. I. Efficacy of surgery in 65 cases (100 ureters) of primary vesicoureteral reflux

We have experienced 72 patients with primary vesicoureteral reflux (VUR) during the past 16 years. Sixty-five of them (100 ureters) were treated surgically to prevent reflux. Among the surgical methods employed, the Politano-Leadbetter method was the most frequent, being used in 56 patients (87 ureters). Other methods were the combined method in 2 patients (three ureters), the Glenn-Anderson method in 1 (2 ureters), the Cohen method in 1 (1 ureter) and the Lich-Gregoir method in 5 patients (7 ureters). As postoperative complications in the early stage (within 1 month after surgery), remaining VUR in 1 ureter in 1 of the patients who underwent surgery by the Politano-Leadbetter method and occurrence of VUR on the contralateral side in 3 patients with unilateral VUR were encountered. These conditions disappeared during the follow-up period. On the other hand, in the late postoperative stage, ureteral stenosis requiring further surgery occurred in 1 ureter in the transitional region to the urinary bladder in 1 patient 2 months after surgery by the Lich-Gregoir method. The rate of success was all 87 ureters (100%) for the Politano-Leadbetter method and 6 out of 7 ureters (85.7%) for the Lich-Gregoir method. The success rates for the other procedures were also good, resulting in an overall rate of 99 out of 100 ureters (99.0%). Ninety-nine percent of the patients had been treated at least once preoperatively for pyelonephritis or fever of unknown etiology. Among these patients, those who had had 5 or more such episodes accounted for 39%.(ABSTRACT TRUNCATED AT 250 WORDS)     

可控性尿流改道的输尿管肠管吻合术式的比较

目的　比较输尿管肠管的直接吻合和黏膜隧道式、袖口乳头式抗返流吻合术式的并发症发生率 ,为临床术式的选择提供指导。　方法　 6 3例可控性尿流改道术 ,其中 2 4例采用输尿管肠管直接吻合术 (直接吻合组 ) ,39例采用抗返流吻合术 (抗返流吻合组 )。比较直接吻合组和抗返流吻合组术后吻合口狭窄、输尿管返流、肾功能损害及尿路感染等并发症的发生率。术后随访时间 3个月至 6年 ,平均 2 6个月。　结果　 78条输尿管肠管抗返流吻合者 ,术后 12条输尿管出现吻合口狭窄。而直接吻合组 4 8条输尿管仅 1条出现吻合口狭窄 ,两者差异有显著性 (χ2 =4 375 ,P <0 0 5 )。抗返流吻合组和直接吻合组术后输尿管返流、肾功能损害及急性尿路感染发生率差异无显著性。结论　黏膜隧道式、袖口乳头式抗返流吻合术后输尿管吻合口狭窄发生率较直接吻合术高。对可控性尿流改道的输尿管肠管吻合宜选择直接吻合术。     

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.     

Endoscopic injection of glutaraldehyde cross-linked bovine dermal collagen for correction of vesicoureteral reflux

From November 1986 through May 1989, a Food and Drug Administration approved investigational study was done to assess the safety and efficacy of glutaraldehyde cross-linked bovine dermal collagen in the endoscopic treatment of vesicoureteral reflux. Over-all, 57 patients (92 ureters) were treated. The majority of ureters (68.5%) had grade II to III/V vesicoureteral reflux (international classification). One treatment was given in 61.4% of the patients, while 33.3% required 2 and 5.3% required 3 treatments. Nonduplicated/primarily refluxing ureters comprised 68.5% of the total, while 13% were duplex/primarily refluxing and 18.5% were surgical failures. The procedures were performed on an outpatient basis in all but 3 patients. Patients were evaluated by voiding cystourethrogram and renal/bladder sonography before and after treatment at 1 month and 1 year. Cure at 1 month after the last treatment was achieved in 75% of the ureters. Among the ureters cured at 1 month the cure persisted in 79% at 1 year after treatment. Cure at 1 year was achieved in 65% of all ureters evaluated, regardless of the status at 1 month. Procedure-related morbidity was minimal and there were no adverse reactions to the implant substance. Thus, glutaraldehyde cross-linked bovine dermal collagen appears to be safe and effective in the endoscopic treatment of vesicoureteral reflux.