Opioid utilization is minimal after outpatient pediatric urologic surgery.

INTRODUCTION: There are no guidelines for opioid use after pediatric urologic surgery, and it is unknown to what extent prescriptions written for these patients may be contributing to the opioid epidemic in the United States. We sought to characterize opioid utilization in a prospective fashion following outpatient pediatric urologic surgery at our institution. MATERIALS AND METHODS: After obtainingapproval from the Institutional Review Board, we prospectively recruited pediatric patients undergoing outpatient urologic surgery. All patients and families were counseled regarding appropriate use of over-the-counter pain medications as first-line agents, with opioids for breakthrough pain only. All patients received an opioid prescription (ORx), which we attempted to standardize to 10 doses. Parents were provided with a log for keeping track of pain medication administration. Postoperative surveys were sent at various time points after surgery to assess utilization of pain medications at home. We quantified unused opioids prescribed and evaluated factors potentially associated with opioid use. RESULTS: Two hundred and two patients were recruited. All patients were male, with a median age of 2.7 years (interquartile range (IQR) 5.5, range 0.5-17.9 years). One hundred and fifty-four children underwent penile surgery, 22 underwent scrotal surgery, and 27 underwent inguinal surgery. Nearly half of our study patients were black, 33.2% were white, 12.9% were Latino, and 4.0% were Asian. The median number of doses prescribed was 10 (IQR 0, range 4.0-20.8). Postoperative surveys were completed by 80.7% of study patients. The median number of opioid doses used was 0 (IQR 2), whereas the mean was 1.28 (standard deviation (SD) 1.98). None of the factors evaluated (including patient age, surgery type, perioperative pain management techniques, length of surgery, and insurance type) were associated with the amount of opioid used at home after surgery, as utilization was equally low across all groups. DISCUSSION AND CONCLUSIONS: Ensuring adequate postoperative pain control for children is critical, yet it is also important to minimize excess ORx. We found that the majority of pediatric patients used 0-2 doses of prescription pain medication after discharge following outpatient urologic surgery, representing a small percentage of the total prescribed amount. Low utilization was seen irrespective of patient age, procedure, and perioperative factors. These data can be used to guide perioperative patient and family counseling and to guide future efforts to standardize ORx following outpatient pediatric urologic surgery.

Abdominoplasty in prune belly syndrome: Modifications in Monfort technique to address variable patterns of abdominal wall weakness.

INTRODUCTION: Abdominoplasty is an important component of the management of children with prune belly syndrome (PBS). While there are features of the abdominal defect in PBS which are common to all patients, there will be differences unique to each patient that should be taken into consideration in surgical planning. Specifically, we have come to realize that although the Monfort procedure assumes a symmetric pattern of abdominal wall laxity, this symmetry is rarely present. OBJECTIVE: The aim of this report is to describe our modifications and review our outcomes for the Monfort procedure which more completely address correction of the abdominal wall laxity including both common and uncommon features while positioning the umbilicus to a more anatomically correct position (Figure). STUDY DESIGN: Sixteen male patients with PBS and one female pseudoprune belly syndrome patient, aged 2-9 years, were treated at our institution between 2003 and 2014. Modifications incorporated into the abdominoplasty procedure for PBS applied to this study group included: 1) use of diagnostic laparoscopy to define the topography of the abdominal wall defect, 2) initial midline rather than elliptical skin incision to defer retailoring of the skin coverage until the final step of the procedure, 3) varying the width of the central plate to correct side to side asymmetry in redundancy, 4) plication of the central plate to reduce vertical redundancy and reposition the umbilicus, and 5) plication of focal areas of fascial weakness, most often in the flank region. RESULTS: All patients have improved abdominal wall contour with a more uniform correction of areas of weakness at a mean follow-up of 5.5 years (range 18 months-11.5 years). All patients and parents indicate that they are very satisfied with the outcome of their procedures without any revisions being performed. This study is descriptive in nature and retrospective, with the patient population treated in a relatively uniform fashion that does not allow direct comparison with other techniques. CONCLUSIONS: The modified Monfort procedure recognizes the pattern of abdominal muscular deficiency unique to each patient and incorporates this information into the surgical design.

Is routine voiding cystourethrogram necessary following double hit for primary vesicoureteral reflux?

INTRODUCTION AND OBJECTIVE: Current AUA guidelines recommend voiding cystourethrogram (VCUG) following endoscopic treatment of vesicoureteral reflux (VUR). We evaluated the clinical and radiographic outcomes of children undergoing Double HIT (hydrodistention implantation technique) for primary VUR to determine success rates and the necessity of postoperative VCUG. STUDY DESIGN: Children with a history of febrile urinary tract infection (fUTI) undergoing Double HIT for primary VUR between 2009 and 2012 were identified. Patients were prospectively classified as high or low clinical and radiographic risk. Children were categorized as high clinical risk if they had ≥ 3 fUTIs or documented bladder bowel dysfunction (BBD). High radiographic risk included those <2 years of age or with grade 4-5 VUR. Initially, all children underwent postoperative VCUG ("routine" group), while only those with an indication (high radiographic risk or clinical failure) did so during the latter portion of the study ("indicated" group). Clinical success was defined as no postoperative fUTI and radiographic success as negative postoperative VCUG. Average clinical follow-up was 34.7 ± 17.2 months. RESULTS: Two hundred and twenty-two children (198 girls, 24 boys) underwent Double HIT at a mean age of 4.1 ± 2.7 years. Mean maximum VUR grade was 3 ± 0.8. Sixty-eight children (30.6%) had documented BBD. Fourteen children (6.3%) experienced postoperative fUTI, for a clinical success rate of 93.7%. One hundred and fourteen patients (51.4%) underwent postoperative VCUG; 76 were "routine" and 38 were "indicated" [Figure]. Of children classified as low clinical/radiographic risk, 96.6% did not have a postoperative fUTI, compared to 91.1% for high risk patients (P = 0.771). Odds of clinical success for routine VCUG group were 9.9 times higher than for the indicated VCUG group (95% CI, 2-50). Odds of radiographic success for the routine cohort were 13 times higher than for the indicated group (95% CI, 4.2-40). Nine children (4.1%) underwent additional procedures. DISCUSSION: We found no difference in clinical success among the different risk groups; the number of children with postoperative fUTI was relatively few so there was not statistical power to discern any differences between patients who experienced clinical success versus clinical failure. However, children with an "indicated" VCUG (i.e. those less than 2 years of age, grade 4-5 VUR or those with a fUTI) were 13 times more likely to experience a radiographic failure. This cohort of 38 patients had a 50% radiographic cure rate and a 78.9% clinical cure rate, compared to the overall long-term clinical success rate of 93.7%. Our data demonstrates that we can predict failures with relatively high sensitivity, and it may therefore be prudent to selectively obtain postoperative VCUG rather than recommend it for all children undergoing dextranomer hyaluronic acid co-polymer (Dx/HA) injection. Our study has several limitations that warrant consideration. Not all children underwent a postoperative VCUG, so the true radiographic success rate is unknown. Incidence of fUTI may also be artificially low, as some radiographic failures proceeded directly to another injection or reimplantation. While we were able to demonstrate that children undergoing an "indicated" VCUG were more likely to experience radiographic failure, a larger patient cohort is necessary to determine whether age or VUR grade is more predictive of failure. Finally all patients underwent endoscopic Dx/HA injection, therefore the incidence "spontaneous resolution" is unknown. CONCLUSION: Long-term clinical success following Double HIT for the endoscopic correction of primary VUR is high, and the majority of children avoid additional procedures. Unless indicated by high-grade, young age, clinical failure, or family/surgeon preference, consideration should be given to making postoperative VCUG an option rather than a recommendation in children undergoing endoscopic treatment of primary VUR using the Double HIT method.

Early effect of American Academy of Pediatrics Urinary Tract Infection Guidelines on radiographic imaging and diagnosis of vesicoureteral reflux in the emergency room setting.

PURPOSE: In 2011 the AAP revised practice parameters on febrile urinary tract infection in infants and children 2 to 24 months old. New imaging recommendations invigorated the ongoing debate regarding the diagnosis and management of vesicoureteral reflux. We compared evaluations in these patients with febrile urinary tract infection before and after guideline publication. MATERIALS AND METHODS: During 2 separate 6-month periods 350 patients 2 to 24 months old were evaluated in the emergency room setting. Demographics, urine culture, renal-bladder ultrasound, voiding cystourethrogram and admission status were assessed. RESULTS: A total of 172 patients presented with initial febrile urinary tract infection in 2011, of whom 47 (27.3%) required hospitalization, while 42 of 178 (23.6%) were admitted in 2012. Admission by year did not significantly differ (p = 0.423). After guideline revision 41.2% fewer voiding cystourethrograms were done (72.1% of cases in 2011 vs 30.9% in 2012, p <0.001). A 17.2% decrease in renal-bladder ultrasound was noted (75.6% in 2011 vs 58.4% in 2012, p <0.001). Of 55 voiding cystourethrograms 21 (38.2%) were positive in 2012 compared to 36.3% in 2011 (p = 0.809). Mean ± SD maximum vesicoureteral reflux grade was unchanged in 2011 and 2012 (2.9 ± 1.2 and 2.5 ± 0.93, respectively, p = 0.109). There was no association between abnormal renal-bladder ultrasound and voiding cystourethrogram positivity (p = 0.116). CONCLUSIONS: AAP guidelines impacted the treatment of infants and young children with febrile urinary tract infection. We found no relationship between renal-bladder ultrasound and abnormal voiding cystourethrogram, consistent with previous findings that call ultrasound into question as the determinant for additional imaging. Whether forgoing routine voiding cystourethrogram results in increased morbidity is the subject of ongoing study.

Vesicoureteral reflux index (VURx): a novel tool to predict primary reflux improvement and resolution in children less than 2 years of age.

PURPOSE: Surgical correction of vesicoureteral reflux (VUR) is influenced by recurrent urinary tract infection (UTI) risk and the likelihood of spontaneous resolution. We aimed to identify factors associated with VUR resolution in children less than 2 years of age and to design a simple scoring tool to predict improvement and resolution. MATERIALS AND METHODS: Children less than 2 years old with primary VUR were identified. Patient demographics, voiding cystourethrogram (VCUG) findings and clinical outcomes over time were assessed. Multivariate analysis with time to resolution was performed to identify factors predictive of VUR improvement and resolution. A random forest model was used to confirm the VUR index (VURx) with normalized importance. RESULTS: Two-hundred and twenty-nine children met all inclusion criteria. Mean age at initial VCUG was 0.46±0.43 years. Median clinical follow-up was 1.6 years (range 0.5-4.4 years). Children with grade 4-5 reflux, complete ureteral duplication or periureteral diverticula, and filling phase VUR, as well as female gender, had significantly (p<0.01) longer time to improvement or resolution on multivariate survival analysis. VURx 1 to 5-6 had improvement/resolution rates of 89%, 69%, 53%, 16% and 11%, respectively. CONCLUSIONS: Female gender, high-grade VUR, ureteral anomalies, and filling reflux are associated with longer time to improvement and non-resolution. VURx reliably predicts resolution of primary reflux in children less than 2 years of age.

Temporal pattern of vesicoureteral reflux on voiding cystourethrogram correlates with dynamic endoscopic hydrodistention grade of ureteral orifice.

PURPOSE: The double hydrodistention implantation technique uses ureteral hydrodistention to visualize injection site(s) and determine required bulking agent volume. Along with grade, early vesicoureteral reflux on voiding cystourethrogram provides prognostic information regarding spontaneous resolution of reflux. We hypothesized that reflux timing is predictive of endoscopic hydrodistention grade. MATERIALS AND METHODS: We identified children undergoing the double hydrodistention implantation technique for primary vesicoureteral reflux between 2009 and 2012. Hydrodistention grade (0 to 3) was assigned prospectively, and compared to vesicoureteral reflux grade and timing on voiding cystourethrogram. RESULTS: A total of 196 children with a mean ± SD age of 3.94 ± 2.58 years underwent injection of 332 ureters. Mean ± SD vesicoureteral reflux grade was 2.8 ± 0.9. Of the ureters 52.4% demonstrated early to mid filling, 39.2% late filling and 8.4% voiding only reflux. Mean ± SD reflux grade was 3.1 ± 0.81 for early filling, 2.6 ± 0.81 for late filling and 2.1 ± 1.1 for voiding only (p <0.0001). Vesicoureteral reflux and hydrodistention grades correlated, with higher reflux grades associated with grade 3 hydrodistention (p <0.001). There was a significant relationship between reflux timing and hydrodistention grade (p <0.001), with a high percentage of ureters with grade 3 hydrodistention displaying early reflux compared to those with grade 1 disease. Significantly increased mean injected volume for ureters with grade 3 hydrodistention (1.6 ml) was observed compared to those with grade 1 or 2 disease (1.25 ml, p <0.001). CONCLUSIONS: Hydrodistention grade correlates with vesicoureteral reflux grade, timing of reflux and injected volume. Early to mid filling vesicoureteral reflux is associated with abnormal hydrodistention (grade 2 to 3). Temporal pattern of vesicoureteral reflux on voiding cystourethrogram may be used to predict ureteral orifice competency and thus aid in predicting resolution of reflux.

Emergency room visits and readmissions after pediatric urologic surgery.

OBJECTIVE: Reducing readmissions has become a focal point to increase quality of care while reducing costs. We report all-cause unplanned return visits following urologic surgery in children at our institution. MATERIALS AND METHODS: Children undergoing urology procedures with returns within 30 days of surgery were identified. Patient demographics, insurance status, type of surgery, and reason for return were assessed. RESULTS: Four thousand and ninety-seven pediatric urology surgeries were performed at our institution during 2012, with 106 documented unplanned returns (2.59%). Mean time from discharge to return was 5.9 ± 4.9 days (range, 0.3-24.8 days). Returns were classified by chief complaint, including pain (32), infection (30), volume status (14), bleeding (11), catheter concern (8), and other (11). Circumcision, hypospadias repair, and inguinal/scrotal procedures led to the majority of return visits, accounting for 21.7%, 20.7%, and 18.9% of returns, respectively. Twenty-two returns (20.75%) resulted in hospital readmission and five (4.72%) required a secondary procedure. Overall readmission rate was 0.54%, with a reoperation rate of 0.12%. CONCLUSIONS: The rate of unplanned postoperative returns in the pediatric population undergoing urologic surgery is low, further strengthening the argument that readmission rates in children are not necessarily a productive focal point for financial savings or quality control.

Intermediate to long-term follow-up indicates low risk of recurrence after Double HIT endoscopic treatment for primary vesico-ureteral reflux.

PURPOSE: Follow-up of patients undergoing dextranomer/hyaluronic acid injection for vesico-ureteral reflux (VUR) is controversial. The purpose of our study was to test the hypothesis that patients undergoing the double hydrodistention-implantation technique (Double HIT) have a higher clinical and radiographic success rate. MATERIALS AND METHODS: Patients undergoing Double HIT endoscopic injection for VUR were prospectively identified. Patients underwent an ultrasound at 6 weeks to assess the implants, and, if visible, prophylactic antibiotics were discontinued and patients were scheduled for a 1-year voiding cystourethrogram (VCUG). Radiographic success was defined as a negative VCUG and clinical success as no febrile urinary tract infections at 1 year. RESULTS: A total of 54 patients underwent endoscopic injection for VUR. Twenty-five (51%) were compliant with the 1 year follow-up; 18 non-compliant patients were contacted and their clinical status assessed. Thirty patients eventually completed the 1-year VCUG at a mean of 12.2 months (range 10-20). Among the 60% of patients with 1-year radiographic follow-up, 2 had persistent VUR for a radiologic success rate of 93%. All radiographic failures were infection-free. Of the 80% (43/54) of patients with available clinical data, 3 (7%) had afebrile UTI for a clinical success rate of 93%. CONCLUSIONS: The Double HIT leads to a 93% clinical and 93% radiographic intermediate/long-term success rate. With this technique, better outcomes were achieved with fewer recurrences than previously reported. These favorable results challenge the need for postoperative VCUG in asymptomatic patients after the Double HIT.

Clinical and radiographic results of endoscopic injection for vesicoureteral reflux: defining measures of success.

OBJECTIVE: Criteria for success following endoscopic vesicoureteral reflux (VUR) surgery vary greatly. We sought to define outcomes based on radiographic and long-term clinical follow up. METHODS: We reviewed the charts and interviewed parents of children who underwent endoscopic treatment for primary VUR (grades I-IV). All patients had a postoperative voiding cystourethrogram (VCUG) at mean of 3 months (1-21 months) and all cases of postoperative febrile urinary tract infection (FUTI) prompted repeat VCUG. Radiographic success was defined as no VUR on postoperative VCUG and clinical success as no FUTIs during follow up of 12-36 months. To demonstrate how criteria for success can affect outcomes, we calculated the success rates using different definitions. RESULTS: In 2004-2008, 336 patients (296 female and 40 male, mean age 4 years) were treated with dextranomer/hyaluronic acid via the Double-HIT method. Initial radiographic success was 90% (302/336). Of these, 19 (6%) developed FUTIs, 12 (4%) of whom had recurrent VUR, and 5 (2%) went on to open surgery. Of the radiographic failures, 18% were observed with no further treatment. Success defined clinically was 94% (281/300), and as 'radiographic cure and no clinical evidence of FUTIs' it was 82% (275/336). CONCLUSIONS: It is important to agree on a universal definition of success for VUR interventions to compare across studies and across therapies. Clinical success is more meaningful to the patient, and initial radiographic success could be followed by UTI necessitating further intervention. We question the need for routine postoperative VCUG.

Does compliance status predict clinical status in patients undergoing endoscopic management of vesico-ureteral reflux?

OBJECTIVE: Previous studies of endoscopic management of vesico-ureteral reflux (VUR) have had non-compliance rates around 50%. We examined success rates of patients non-compliant with a delayed follow up protocol after endoscopic injection for VUR. MATERIALS AND METHODS: Patients undergoing Double HIT, dextranomer/hyaluronic acid copolymer endoscopic injection for VUR were enrolled in a 1-year, delayed voiding cysto-urethrogram (VCUG) study. All patients non-compliant with the VCUG were contacted and information on their clinical status was collected. Non-compliant patients were re-scheduled for a VCUG. RESULTS: 49/54 (91%) patients underwent endoscopic injection for VUR and completed the 6-week ultrasound. At 1-year 49% (24/49) were non-compliant with a VCUG; 75% (18/24) were contacted and provided clinical information. All but one patient agreed to the VCUG. Patients compliant with the 1-year VCUG showed 96% (24/25) clinical and 92% (23/25) radiologic success rates. Non-compliant patients had an 89% (16/18) clinical success rate; 5 (21%) non-compliant patients underwent VCUGs with a 100% success rate. CONCLUSIONS: Long-term compliance remains an issue for patients treated endoscopically for VUR, but compliance does not predict clinical status as both groups have favorable clinical outcomes. The repeat VCUG is a barrier to long-term follow up as only 21% of patients underwent the study.

Is endoscopic injection therapy a reasonable treatment option for low-grade vesicoureteral reflux in association with overactive bladder?

OBJECTIVE: To assess the clinical outcome of endoscopic injection in children with vesicoureteral reflux (VUR) and concomittant overactive bladder (OAB). METHODS: A total of 41 patients with VUR and OAB underwent endoscopic injection of dextranomer/hyaluronic acid. At surgery, 13 patients had been successfully treated for their OAB (urgency with or without wetting) with behavior modification with or without anticholinergic therapy, and 28 had persistent OAB despite treatment. Voiding cystourethrogram was obtained 6-12 weeks postoperatively, and patients were followed up clinically for 1-5 years. RESULTS: Negative voiding cystourethrogram findings after a single treatment were seen in 34 (82.9%) of 41 patients. The radiographic success rate in patients with well-controlled OAB was 76.9% (10 of 13) compared with 85.7% (24 of 28) of those with poorly controlled OAB. The overall clinical success rate, defined as no evidence of urinary tract infection in the setting of negative voiding cystourethrogram findings, reached 78.0% (32 of 41). After successful endoscopic treatment, an unanticipated return to normal voiding patterns without the need for postoperative anticholinergic therapy was seen in 4 of the children with well-controlled OAB (40.0%) and in 4 with poorly controlled OAB (16.7%). CONCLUSION: Our data suggest that endoscopic injection is a viable treatment option for VUR in those with OAB, with postoperative rates of resolution comparable to those found in patients without OAB. Furthermore, 40.0% of children with well-controlled OAB no longer required therapy for OAB after resolution of their VUR.

Partial ureteral quadruplication with contralateral multicystic dysplastic kidney.

Ureteral quadruplication is a rare congenital anomaly of the urinary tract that is associated with other genitourinary malformations. Few cases have been reported worldwide, the majority being described in children. We report the first known case associated with contralateral multicystic dysplastic kidney.

Dynamic hydrodistention of the ureteral orifice: a novel grading system with high interobserver concordance and correlation with vesicoureteral reflux grade.

PURPOSE: We evaluated the usefulness and interobserver concordance of a novel grading system for dynamic ureteral hydrodistention. MATERIALS AND METHODS: Between May 1, 2002 and July 1, 2008 the hydrodistention grade in 697 ureters was prospectively assigned and recorded, including H0-no hydrodistention, H1-ureteral orifice open but tunnel not evident, H2-tunnel seen only and H3-extravesical ureter visualized. Specifically 489 refluxing ureters (vesicoureteral reflux group) were compared to 100 normal control ureters (normal control group). Additionally, the posttreatment hydrodistention grade in 56 ureters in which surgery for reflux failed was compared to that in 52 ureters with successful surgery. Hydrodistention grades assigned to an additional 77 ureters by 3 blinded observers were compared to assess the interobserver concordance of this system. RESULTS: Vesicoureteral reflux and hydrodistention grades correlated significantly (p <0.001). Ureters with a higher reflux grade also showed a higher hydrodistention grade. The normal control group (mean +/- SEM hydrodistention grade 0.62 +/- 0.07) showed a statistically lower hydrodistention grade than the reflux groups (overall mean hydrodistention grade 2.26 +/- 0.01). Mean posttreatment hydrodistention grade in the failed reflux surgery group was statistically higher than that in the mean successful reflux surgery group (2.03 +/- 0.09 vs 1.33 +/- 0.08). By defining the degree of hydrodistention as normal (H0-H1) and abnormal (H2-H3) the concordance between observers was 95% and 96%. CONCLUSIONS: The dynamic hydrodistention classification is a reliable method of evaluating the presence or absence of vesicoureteral reflux as it correlates significantly with radiographic reflux grade. It has high interobserver concordance.

Appearance of dextranomer/hyaluronic Acid copolymer implants on computerized tomography after endoscopic treatment of vesicoureteral reflux in children.

PURPOSE: With the increasing popularity of endoscopic treatment for vesicoureteral reflux in children, dextranomer/hyaluronic acid copolymer implants are more frequently detected on computerized tomography, which may lead to misinterpretation and unnecessary intervention. The objective of this study was to characterize the long-term appearance of dextranomer/hyaluronic acid copolymer implants on computerized tomography. MATERIALS AND METHODS: We evaluated the hospital charts of 893 patients who had undergone dextranomer/hyaluronic acid copolymer injection for vesicoureteral reflux between July 2001 and November 2007 to identify those who underwent subsequent computerized tomography of the abdomen and pelvis. A total of 30 patients with ureterovesical junction stones served as the control group. Seven patients who proceeded to extravesical reimplantation after failed endoscopic treatment had dextranomer/hyaluronic acid copolymer implants explanted and microscopically evaluated. RESULTS: Of 893 patients who had undergone endoscopic treatment for vesicoureteral reflux 17 (1.9%) underwent subsequent computerized tomography. A total of 33 dextranomer/hyaluronic acid copolymer implants were detected on computerized tomography, and were classified as low density (21) or high density (12). Median density was 22 HU (range 15 to 27) for low density implants and 193 HU (126 to 367) for high density implants. Radiograph of the kidneys, ureters and bladder, and fluoroscopy did not visualize high density implants. Neither gender, age at endoscopic treatment, vesicoureteral reflux grade, hydrodistention grade, injection volume, success nor second injection was associated with a high density implant. Only elapsed time between surgery and computerized tomography was associated with increased implant density (p = 0.02). CONCLUSIONS: Dextranomer/hyaluronic acid copolymer implants may be encountered on computerized tomography as low or high density lesions. History of vesicoureteral reflux and absence of hydronephrosis as well as hematuria should provide reassurance and prevent inappropriate intervention for misdiagnosed ureteral stones.

Appearance of Deflux implants with magnetic resonance imaging after endoscopic treatment of vesicoureteral reflux in children.

OBJECTIVE: With the increasing popularity of endoscopic treatment for vesicoureteral reflux (VUR) in children, dextranomer/hyaluronic acid copolymer (Deflux) implants are more frequently detected by magnetic resonance imaging (MRI). Such findings on MRI may be misinterpreted and lead to unnecessary intervention. The objective of this study was to characterize the appearance of Deflux implants on MRI. MATERIALS AND METHODS: Between July 2001 and November 2007, hospital charts of patients with a history of Deflux injection for VUR were evaluated to identify those who had subsequent MRI studies. The indications were determined, and the appearance of Deflux implants analyzed and compared to findings on ultrasound, voiding cystourethrography and kidney ureter bladder radiography. RESULTS: Of 893 patients who underwent endoscopic treatment for VUR, subsequently 16 patients (1.8%) had MRI scans. Twenty-seven Deflux implants were identified on MRI as bright structures on T2-weighted sequences only. Neither T1-weighted images nor excretory MR urography visualized the Deflux implants, which did not enhance with gadolinium. Deflux was not detected by kidney ureter bladder radiography; however, voiding cystourethrography and more reliably ultrasound could identify implants. CONCLUSIONS: Deflux implants appear on MRI as bright structures on T2-weighted sequences. History of VUR/VUR treatment and the presence of a single urinary system should provide reassurance and prevent inappropriate intervention for misdiagnosed ureteroceles.

Endoscopic injection of dextranomer hyaluronic acid copolymer for the treatment of vesicoureteral reflux in duplex ureters.

PURPOSE: Endoscopic injection of dextranomer hyaluronic acid copolymer (DxHA) has been increasingly utilized for the treatment of complex cases of vesicoureteral reflux (VUR). We present our 6-year experience with the use of DxHA for the treatment of VUR in duplex ureters. MATERIALS AND METHODS: Between July 2001 and April 2007, 52 children were identified retrospectively who had been treated by endoscopic injection of DxHA for VUR into duplex ureters. Mean age was 3 years (range 9 months-10 years) with a mean maximum grade of reflux of III (range 2-5). The refluxing lower pole ureter was injected using a subureteric injection technique (STING) or intraureteric injection technique (utilizing the hydrodistention implantation technique). The endpoint in all cases was the loss of hydrodistention of the ureteral orifice. Voiding cystourethrograms was obtained at 6 weeks-3 months to evaluate for the presence of VUR. Cure was defined as complete resolution of reflux in the treated moiety. RESULTS: After initial treatment, 38/52 (73%) patients were cured. Of the 14 failures, nine children underwent repeat endoscopic treatment with a 67% (6/9) resolution rate for repeat injection. Seven of the initial failures failed to grade I VUR. Overall, 85% (44/52) were cured after one or two treatments, 98% (51/52) were improved and only one (1.9%) with grade V VUR required open surgery. The treatment was well tolerated and there were no associated complications. CONCLUSION: Endoscopic injection of DxHA copolymer corrected VUR in 85% of children with VUR into duplex ureters. This minimally invasive approach should be considered as a viable alternative to open surgery or antibiotic prophylaxis for the treatment of VUR associated with duplex ureters.

Endoscopic treatment of vesicoureteral reflux using dextranomer hyaluronic acid copolymer.

Vesicoureteral reflux (VUR) is a common urinary tract anomaly. Treatment is performed to minimize the risk of febrile urinary UTIs that may result in renal scarring. The endoscopic use of dextranomer hyaluronic acid copolymer has been gaining popularity as an alternative to the traditional methods of open surgery and chronic antibiotic prophylaxis. The aim of this educational review was to present the trends, latest perspectives and surgical techniques regarding this newer method of treatment of VUR. Evolving techniques are described that have resulted in VUR cure rates that rival that of open ureteral reimplantation with minimal associated morbidity. These have proven to be effective in complex cases that were previously considered as contraindications for endoscopic treatment, including voiding dysfunction, duplex ureters, high-grade VUR and paraureteral diverticuli. It is recommended that open reimplantation be reserved for those children with ectopic ureters, megaureters that require tapering or secondary grade V VUR, and those who have failed two endoscopic injections. Future advances promise to standardize the injection technique, ensuring optimum needle placement for consistently successful injections.

Endoscopic treatment of vesicoureteral reflux with dextranomer/hyaluronic acid in children.

PURPOSE: The goal of this review is to present current indications, injectable agents, techniques, success rates, complications, and potential future applications of endoscopic treatment for vesicoureteral reflux (VUR) in children. MATERIALS AND METHODS: The endoscopic method currently achieving one of the highest success rates is the double hydrodistention-implantation technique (HIT). This method employs dextranomer/hyaluronic acid copolymer, which has been used in pediatric urology for over 10 years and may be at present the first choice injectable agent due to its safety and efficacy. RESULTS: While most contemporary series report cure rates of greater than 85% for primary VUR, success rates of complicated cases of VUR may be, depending on the case, significantly lower. Endoscopic treatment offers major advantages to patients while avoiding potentially complicated open surgery. As the HIT method continues to be applied to complex cases of VUR and more outcome data become available, the indication for endoscopic treatment may exceed the scope of primary VUR. CONCLUSIONS: Endoscopic injection is emerging as the treatment of choice for VUR in children.

Incidence of urinary tract infections in children after successful ureteral reimplantation versus endoscopic dextranomer/hyaluronic acid implantation.

PURPOSE: Endoscopic implantation of dextranomer/hyaluronic acid has proved to be an effective minimally invasive technique for correcting vesicoureteral reflux in children. There is some evidence suggesting that in addition to being less invasive, successful dextranomer/hyaluronic acid implantation compared to successful antireflux surgery is associated with fewer febrile and nonfebrile urinary tract infections. We review the clinical outcomes of 2 groups of children cured of reflux with open surgery and dextranomer/hyaluronic acid implantation to determine if a difference in clinical outcomes exists. MATERIALS AND METHODS: We reviewed the charts of 43 patients who underwent dextranomer/hyaluronic acid implantation and 33 who underwent open surgery for vesicoureteral reflux. Data collected included age, gender, preoperative and postoperative grades of reflux, and urinalysis and urine culture results. Urinary tract infection was defined as any culture that grew more than 10(5) colonies of a single organism, with symptoms typical of cystitis (urgency, frequency, dysuria). A febrile urinary tract infection was defined as an infection accompanied by a temperature greater than 101.5F. Any hospitalizations for febrile episodes were also recorded. RESULTS: The incidence of urinary tract infection after successful open surgery (38%) was significantly higher than that observed following successful dextranomer/hyaluronic acid treatment (15%, p = 0.03). Febrile urinary tract infections occurred in 24% of the children who underwent open surgery and in 5% of those who underwent dextranomer/hyaluronic acid implantation (p = 0.02). Hospital readmissions occurred only in the group undergoing open surgery. CONCLUSIONS: Children successfully cured of vesicoureteral reflux with dextranomer/hyaluronic acid implantation have a lower incidence of febrile and nonfebrile urinary tract infections compared to those cured with open surgery. These findings suggest that dextranomer/hyaluronic acid implantation, when successful, may result in more favorable clinical outcomes.

Endoscopic treatment of vesicoureteral reflux associated with paraureteral diverticula in children.

PURPOSE: Paraureteral or Hutch diverticula are congenital bladder diverticula that occur at or adjacent to the ureteral hiatus and are associated with vesicoureteral reflux in the majority of cases. Surgical treatment has traditionally been ureteral reimplantation with or without diverticulectomy. We present our experience with endoscopic treatment of vesicoureteral reflux associated with paraureteral diverticula. MATERIALS AND METHODS: Of 745 patients undergoing endoscopic treatment for vesicoureteral reflux between 2002 and 2006, 17 (2.3%) had paraureteral diverticula located at the refluxing ureter. The hydrodistention implantation technique was used and dextranomer/hyaluronic acid copolymer was used as bulking material. Success was defined as vesicoureteral reflux grade 0 on postoperative voiding cystourethrogram at 1 to 3 months after a single treatment. RESULTS: A total of 20 refluxing ureters with associated paraureteral diverticula were treated in 17 patients. Of the cases 14 were unilateral and 3 were bilateral. Reflux was grade I in 6 patients, grade II in 4, grade III in 8, grade IV in 1 and grade V in 1. A mean of 1.2 ml bulking agent was injected per ureter. Overall success was 81% (13 of 16 patients) after a single injection. Success per vesicoureteral reflux grade was 100% (6 of 6 patients) for grade I, 100% (3 of 3) for grade II, 63% (5 of 8) for grade III, 100% (1 of 1) for grade IV and 100% (1 of 1) for grade V. Endoscopic treatment failed in 3 patients. Multivariate analysis identified large diverticular size and high bulking agent volume as predictors of treatment failure. Age, reflux grade and the presence of unilateral vs bilateral paraureteral diverticula did not impact outcome. CONCLUSIONS: Endoscopic injection of dextranomer/hyaluronic acid copolymer is an excellent choice for the treatment of vesicoureteral reflux associated with paraureteral diverticula because it has a high success rate and avoids open surgery.