Role of dexamethasone in controlling the proinflammatory cytokine cascade in the first episode of paediatric acute pyelonephritis.

AIM: Febrile urinary tract infection is a common bacterial infection in childhood. The kidney damage after acute pyelonephritis (APN) could be related to the stimulation of the proinflammatory response. We aimed to investigate the role of inflammatory cytokines and the effect of dexamethasone after a first episode of APN. METHODS: Subanalysis of the DEXCAR RCT in which children with confirmed APN (1 month-14 years) were randomly assigned to receive a 3 days course of either intravenous dexamethasone or placebo. Urinary cytokine levels at diagnosis and after 72 h of treatment were measured. RESULTS: Ninety-two patients were recruited. Younger patients, males and those with abnormalities in the ultrasound study or vesicoureteral reflux showed higher values of urinary cytokines. Patients with severe APN had higher Tumour Necrosis Factor (TNF)α levels (81.0 ± 75.8 vs. 33.6 ± 48.5 pg/mg creatinine, p = 0.015). Both intervention groups showed similar basal clinical characteristics, including urinary cytokine levels. Treatment reduced urinary cytokine levels irrespective of dexamethasone administration. Neither the intervention group nor the urinary cytokine levels modulated the development of kidney scars. CONCLUSION: Basal urinary cytokines were associated with age, abnormal ultrasound and vesicoureteral reflux. Patients with severe APN had higher TNFa urinary levels. Administration of dexamethasone in children with APN does not improve the control of the proinflammatory cytokine cascade.

Efficacy and safety of Hyadex for treatment of vesicoureteral reflux: a multicenter experience.

OBJECTIVE: This study was performed to evaluate the efficacy and safety of dextranomer/cross-linked hyaluronic acid (Hyadex) in patients with a clinical diagnosis of vesicoureteral reflux (VUR). METHODS: In this cross-sectional multicenter observational study, Hyadex was used in four different centers for the endoscopic treatment of VUR from 2020 to 2022. The study involved 74 patients (93 renal units) who were diagnosed with VUR according to voiding cystourethrography (VCUG) findings and were considered suitable for subureteric endoscopic treatment. The follow-up time (control VCUG time) was 3 months. RESULTS: In the VCUG evaluation, grade I VUR was found in 13 renal units, grade II in 23 renal units, grade III in 42 renal units, and grade IV in 12 renal units. The success rates of Hyadex treatment according to the degree of VUR were as follows: 84.6% for grade I, 82.6% for grade II, 71.4% for grade III, and 66.0% for grade IV. No major complications were observed. CONCLUSION: Endoscopic subureteric Hyadex injection had high success rates in appropriately selected patients with VUR and may be used as the first-line treatment for children with VUR.

Intravesical Botulinum toxin-A injection in pediatric overactive neurogenic bladder with Detrusor overactivity: Radiologic and clinical outcomes.

OBJECTIVE: The neurogenic bladder is one of the most serious and painful disorders seen in pediatric urology clinics. The upper urinary tract can be impaired by increased bladder pressure. Botulinum toxin-A (BTX-A) is one of the new therapeutic interventions for this disease. Thus, this research was designed to determine the clinical as well as radiological outcomes intravesical BTX-A injections in patients with overactive neurogenic bladder with Detrusor over activity. PATIENTS AND METHODS: From March 2012 to March 2019, this cohort study was conducted at Shahid Labbafinejad hospital in Tehran, Iran. Thirty-five pediatric patients with a neurogenic bladder and Detrusor overactivity who fulfilled the eligibility criteria received BTX-A injections. Demographic data, including spinal cord lesions or congenital malformations, upper and lower urinary tract nuclear scans, evidence of vesicoureteral reflux (VUR) and its severity, and hydronephrosis and 72 h voiding diary before and after intervention were all recorded. RESULTS: The mean ± standard deviation age of participants was 9.47 ± 4.61 years. After injection, nocturia and urination frequency as general symptoms of the overactive neurogenic bladder improved (p < 0.05). Also, the severity of hydronephrosis was decreased in 33% of patients following injection. In our study, 32 out of 35 patients had vesicoureteral reflux. Of those, there was complete resolution and downgrading of VUR in 17 (53.12%) and 13 (40.62%) respectively. CONCLUSION: In the evaluation of voiding cystourethrography (VCUG) before and after the injection, downgrading of VUR was seen in 53% of the cases. In the 99mTc-DMSA nuclear scan before and after the injection, the appearance of a new parenchymal scar and uptake reduction was not observed, which indicates the cessation of scar formation in all patients. Although Enuresis, Urgency, Frequency, Nocturia, and UUI significantly improved after injection.

Bilateral duplex collecting system with bilateral vesicoureteral reflux: a case report.

BACKGROUND: A bilateral duplex collecting system is an unusual renal tract abnormality. Vesicoureteral reflux may be associated. We describe a rare case of bilateral duplex collecting system with bilateral vesicoureteral reflux in which the refluxing ureter on the left side drains the upper pole moiety contrary to what is often found. CASE PRESENTATION: A 24-year-old married Arab woman presented with ascending left-sided flank pain during micturition. She complained of recurrent urinary tract infections. A physical examination and laboratory tests were normal. Voiding cystourethrography and computed tomography scan detected bilateral duplex collecting system, grade IV vesicoureteral reflux on the left side, and grade I vesicoureteral reflux on the right. She underwent left heminephrectomy and dextranomer/hyaluronic acid injections on the right side. After a year of follow-up, a clinical examination and imaging findings were unremarkable. CONCLUSIONS: A bilateral duplex collecting system with refluxing upper pole moiety ureter is a very rare entity. The diagnosis should be suspected when exploring any flank pain with recurrent urinary tract infections to avoid subsequent renal impairment. Furthermore, this case shows how some common symptoms may lead to finding an unexpected urinary tract abnormality.

Did our current initial treatment practice change after EAU/ESPU vesicoureteral reflux risk grouping?

BACKGROUND/PURPOSE: The "European Association of Urology (EAU) Guidelines on Vesicoureteral Reflux (VUR) in Children (September 2012)" established risk classification by analyzing and defining risk factors for each patient. In this study we aimed to investigate how our initial treatment procedures were affected by EAU/ESPU guideline vesicoureteral reflux risk grouping and to compare the early clinical results of treatments performed before and after the risk classification in our patients with VUR. MATERIALS AND METHODS: 334 renal units with regular clinical follow-up who were treated owing to VUR (vesicoureteral reflux) between years 2009 and 2017 were retrospectively reviewed. Preoperative clinical parameters such as grade and laterality of reflux, presence of renal scar, initial and follow-up treatments, findings of medical treatment and surgical procedures were analyzed. The initial medical and surgical methods were compared by categorizing patients according to risk groups before and after 2013. RESULTS: Mean age and follow-up duration were 71.4(6-216) months and 47(4-141) months, respectively. Among the preoperative parameters, only high EAU risk group (p = 0.01) and treating lower urinary tract symptoms (p < 0.001) were determining the postoperative success rates significantly, while age, sex, and presence of renal scar at DMSA were not affecting the success of treatment significantly. While no significant difference in medical and surgical treatment rates is observed after risk grouping system in low risk group, the percentages of patients who are treated with surgical methods initially were significantly decreased in moderate and high risk groups (p = 0.002 and p = 0.012, respectively). We determined that VUR risk grouping did not change clinical success significantly in all risk groups. CONCLUSIONS: Despite the fact that EAU/ESPU VUR risk classification changed our current practice in terms of initial treatment method, this different approach did not seem to affect early clinical success positively. There is still an absolute need for studies with larger sample size and long-term follow-up to reach more reliable results. TYPE OF STUDY: Therapeutic. LEVEL OF EVIDENCE: Level 4.

Dextranomer-Hyaluronic Acid and Polyacrylate-Polyalcohol Copolymer are Equally Efficient for Endoscopic Treatment of Vesicoureteral Reflux in Children.

PURPOSE: To compare the efficacy of two bulking agents, Dextranomer-Hyaluronic Acid (DxHA) and Polyacrylate-Polyalcohol Copolymer (PPC) used for endoscopic treatment of vesicoureteral reflux (VUR). MATERIALS AND METHODS: We endoscopically treated 125 patients (89 girls and 36 boys) diagnosed with VUR grades I-V, comprising a total of 174 refluxing ureters (RUs). Patients were categorized into two groups, 99 (56,9%) RUs were treated with DxHA (Group 1) and 75 (43,1%) RUs with PPC (Group 2). RUs treated with both bulking agents were excluded. The success of treatment was evaluated with postoperative VCUG at 3- and 12-months after the endoscopic procedure, only complete resolution of VUR was considered as treatment success. Data was collected and analyzed retrospectively. Statistical calculations were performed using the Chi-square test. RESULTS: After a single injection 80,0% (60/75) and 68,7% (68/99 RUs) of RUs resolved completely when treated with PPC and DxHA, respectively (P = .094). A second injection of PPC healed another 10 RUs (total 93,3%), whereas DxHA resolved additional 16 RUs (total 84,8%) (P = .097). A third injection was needed for 1 RU, treated with PPC and another 3 RUs with DxHA. Twelve months post-operatively, we achieved a total resolution rate of 94,7% (71/75 RUs) with PPC, while DxHA successfully treated 87,9% (87/99) of RUs (P = .125). CONCLUSIONS: DxHA and PPC showed no statistically significant differences neither in the number of injections needed nor in the total success rate after 12 months of follow-up.

Durasphere® EXP: a non-biodegradable agent for treatment of primary Vesico-Ureteral reflux in children

ABSTRACT Introduction: Durasphere® EXP (DEXP) is a compound of biocompatible and non--biodegradable particles of zirconium oxide covered with pyrolytic carbon. The aim of this study is to evaluate the durability of off-label use of DEXP in the treatment of primary vesicoureteral reflux in children. Materials and Methods: Patients who underwent subureteric injection of DEXP for the correction of primary VUR were retrospectively reviewed. Patients aged >18 years as well as those who had grade-I or -V VUR, anatomic abnormalities (duplicated system, hutch diverticulum), neurogenic bladder or treatment refractory voiding dysfunction were excluded. Radiologic success was defined as the resolution of VUR at the 3rd month control. Success was radiographically evaluated at the end of the first year. Results: Thirty-eight patients (9 boys, 29 girls; mean age, 6.3±2.7 years) formed the study cohort. Forty-six renal units received DEXP (grade II: 22; grade III: 18; grade IV: 6). Mean volume per ureteric orifice to obtain the mound was 0.70±0.16mL. First con- trol VCUG was done after 3 months in all patients. After the first VCUG, 6 patients had VUR recurrence. Short-term radiologic success of DEXP was 84.2%. Rate of radiologic success at the end of the first year was 69.4% (25/32). Lower age (p:0.006) and lower amount of injected material (p:0.05) were associated with higher success rates at the end of 1 year. Conclusion: This is the first study to assess the outcomes of DEXP for treatment of primary VUR in children. After 1 year of follow-up, DEXP had a 69.4% success rate.

Emerging Landscape of Antibiotic Resistance and Use of Endoscopic Injection in Vesicoureteral Reflux.

Vesicoureteral reflux (VUR) in children is often treated with antimicrobials for prolonged durations, which often leads to antimicrobial resistance. In this context, this review article discusses the use of endoscopic injection in VUR as a safe and efficacious option for these children. The literature pertaining to VUR- its clinical manifestation and management, antibiotic resistance- with special reference to management of VUR, and endoscopic dextranomer/hyaluronic acid gel injection for management of VUR was reviewed by identifying key words in a PubMed search. Vesicoureteral reflux is managed using antibiotic prophylaxis, urotherapy, or surgical correction (open, endoscopic injection therapy, or laparoscopic). Continuous antibiotic prophylaxis for urinary tract infections in VUR can lead to antibiotic resistance. Urotherapy cures about 75% of cases with dysfunctional voiding and the rest have to be managed at specialized centers. While open surgery provides relief of VUR and related complications in majority, it requires hospitalization. Endoscopic injection of dextranomer/hyaluronic acid gel into the submucosa of bladder or ureter near ureteral orifice increases the tissue bulk and creates a valve function. Various studies show the efficacy and safety of endoscopic injection of dextranomer/hyaluronic acid gel in VUR. The use of endoscopic injection being a non-invasive modality, can be performed in children with VUR in the outpatient department, precluding hospitalization. In view of the threat of developing antimicrobial resistance and also realising the need for definitive treatment of VUR, endoscopic injection is an efficacious and safe option in primary VUR.

Surgical Outcome Analysis of Pneumovesicoscopic Ureteral Reimplantation and Endoscopic Dextranomer/Hyaluronic Acid Injection for Primary Vesicoureteral Reflux in Children: A Multicenter 12-Year Review.

OBJECTIVE: Vesicoureteral reflux (VUR) is a common condition associated with childhood urinary tract infection (UTI), which may lead to chronic renal failure and hypertension. Different antireflux approaches were advocated with differences in morbidity and success. The aim of this study is to review and analyze the surgical outcomes of pneumovesicoscopic ureteral reimplantation and endoscopic injection of dextranomer/hyaluronic acid (Dx/HA) in three tertiary centers. MATERIALS AND METHODS: The medical records of 215 patients (159 boys and 56 girls) for a total of 323 ureters underwent surgical interventions for primary VUR from February 2002 to August 2014 were reviewed. Data on baseline demographics, preoperative symptoms, radiological imaging studies, and postoperative outcomes were analyzed. VUR resolution was defined as when no VUR was detected by micturating cystourethrogram at 3 months or later after the intervention. Independent t-test, Mann-Whitney U test, Fisher's Exact test, and Chi-Square test were used for different parameters. All results with P value ≤.05 were regarded as statistically significant. RESULTS: The mean age at operation was 3.33 and 4.63 for reimplantation and Dx/HA injection respectively. A total of 234 ureters underwent Dx/HA injection and 92 ureters underwent pneumovesicoscopic ureteral reimplantation with mean preoperative VUR grading of 3.1 and 4.2 respectively (P = .0001). The overall VUR downgrading and resolution rates were both significantly higher in reimplantation than Dx/HA injection (97.8% versus 78.6% P = .0001 and 84.3% versus 65% P = .0011). Further subgroup analyses across the different VUR gradings showed higher downgrading and resolution rates in reimplantation group than Dx/HA injection for grade 4 (100% versus 81% P = .0147 and 82.4% versus 63% P = .0411) and grade 5 VUR (97.3% versus 50% P = .0022 and 81.6% versus 40% P = .0256). Dx/HA injection was associated with shorter operation time (41.5 minutes versus 147.5 minutes, P < .001), less postoperative analgesic usage (P = .049), and shorter hospital stay (1.06 days versus 4.44 days P < .0001). No major complications were identified in both groups. The mean follow-up time was significantly longer in reimplantation group than Dx/HA group (57.25 months versus 37.85 months, P = .002). There was no significant difference in the rate of subsequent UTI development during follow-up (P = .8). CONCLUSIONS: Both Dx/HA injection and pneumovesicoscopic ureteral reimplantation are safe and effective treatments for VUR. Reimplantation is associated with significantly higher VUR downgrading and resolution rates than Dx/HA injection especially in the higher grade VUR while Dx/HA injection has significantly shorter operation time, lower postoperative analgesic usage, and shorter hospital stay. Dx/HA injection can be considered as the first line surgical treatment especially for lower grade VUR. Pneumovesicoscopic ureteral reimplantation can be used for higher grade reflux or those who failed Dx/HA treatments.

[Vesicoureteral reflux : Watchful waiting, surgery or antibiotic prophylaxis?] / Vesikoureteraler Reflux : Wann konservativ, wann operativ, wann Antibiotikaprophylaxe?

Primary vesicoureteral reflux (VUR) is a dynamic disease with several factors influencing its course. Therapeutic options range from watchful waiting to open surgery. Multiple risk factors for the development of pyelonephritis are identified, which then determine the decision for the appropriate treatment option. They include age, gender, history of pyelonephritis and renal scarring, bladder and bowel dysfunction (BBD), circumcision status and parental preference. The use of continuous antibiotic prophylaxis (CAP) is becoming increasingly controversial with antibiotic resistance being a major concern. Aggressive treatment of BBD and infant circumcision can greatly reduce the risk for pyelonephritis and should always be considered and discussed. This article is soley concerned with primary VUR.

To screen or not to screen for vesicoureteral reflux in children with ureteropelvic junction obstruction: a systematic review.

Ureteropelvic junction obstruction (UPJO) and vesicoureteral reflux (VUR) are the most common uropathies. The co-occurrence of both anomalies has led to the practice of screening for VUR in children with UPJO to prevent deterioration of kidney function due to renal scarring following urinary tract infections (UTIs). We determined the prevalence of VUR in children with UPJO for a critical assessment of VUR screening by voiding cystourethrography (VCUG). A systematic search strategy in MEDLINE, EMBASE, and CENTRAL was carried out for all articles that included VCUG, and renal scintigraphy or any other appropriate imaging technique for the diagnosis of UPJO. Twenty studies were eligible for inclusion. We found a pooled prevalence for VUR of 8.2 % (95 % CI = 3.6-12.7), about a threefold increase compared to the general pediatric population. VUR occurred bilateral or contralateral to the kidney with UPJO in 5.7 % (95 % CI = 3.0-8.5), equivalent to 75 % of all children with VUR. Considering the effect size of VUR treatment with antibiotics, about 207 and 278 children would need to undergo VCUG to prevent one febrile UTI and one case of renal scarring by 1-2 years, respectively. CONCLUSION: Against this background, screening for VUR needs to be scrutinized and restricted to selected risk groups. What is known: • Screening of patients with ureteropelvic junction obstruction (UPJO) for vesicoureteral reflux (VUR) is recommended based on a small number of repeatedly cited studies. • The lack of conclusive evidence results in different treatment strategies and leads to difficulties when communicating diagnoses and treatment options to parents. What is new: • A robust prevalence for VUR in children with UPJO based on all published evidence and the resulting number needed to screen are given for decision-making in daily clinical practice. • The results may be a precursor for implementation into guidelines.

[Vesicoureteric reflux in children: many questions still unanswered]. / Vezikoureterální reflux u detí: stále mnoho nezodpovezených otázek.

Vesicoureteric reflux (VUR) is the most common congenital anomaly of the uropoetic system. The gold standard for its diagnosis is the voiding cystourethrogram. Sonographic cystourethrography is an alternative method for reflux detection, but it is still not used routinely. Static scintigraphy enables us to diagnose renal scarring reflux nephropathy (RN). While congenital RN is a result of prenatal kidney injury, acquired RN results from pyelonephritis-induced renal damage.Risk factors for RN include VUR, recurrent APN, lower urinary tract dysfunction and delay in treatment of febrile urinary tract infection. Management of children after APN with VUR consists of antibiotic prophylaxy, surgery or surveillance only. The conclusions of performed studies are controversial, thus unified guidelines for the management of patients with VUR are not available.

Ultrasonographic mound height as predictor of vesicoureteral reflux resolution after endoscopic treatment in children.

PURPOSE: Endoscopic dextranomer/hyaluronic acid copolymer (Dx/HA) injection is a safe and efficacious treatment option for vesicoureteral reflux (VUR) in children. Endoscopic appearance, hydrodistention and amount of injected Dx/HA have been demonstrated not to be reliable predictors of outcome. Aim of this study was to evaluate Dx/HA mounds on ultrasound scans (US) and find out any eventual correlation with reflux resolution. METHODS: We selected patients treated with endoscopic injection for moderate to high VUR, renal scaring or repeated infections under antibiotic prophylaxis. Success was defined by absence of VUR at control 3months after surgery; at 3months we also measured mound height ultrasonographically. RESULTS: We considered a total of 32 children (15 male, 17 female; 53 ureters) with a median age of 3years (±24months). Overall success rate was 77% per ureter. Success rate correlates directly with age and inversely with VUR grade. Mound height is the major predictive parameter for reflux resolution (sensitivity 100%, specificity 65.9%); mean mound heights of success-group vs. persistence-of-reflux group were 9.97±1.61mm and 7.29±1.74mm respectively (p<0.0005). CONCLUSION: A mound measuring at least 9.8mm at post-operative US scan is a predictor of reflux resolution. Age and grade also seems to influence success rate.

Profile of urinary tract infections in paediatric patients.

BACKGROUND & OBJECTIVES: This cross-sectional study was conducted at a tertiary care centre in Puducherry, south India, with the aim of finding the profile of the paediatric urinary tract infection (UTI), bacterial pathogens involved, and also to observe vesicoureteric reflux (VUR) and renal scarring in these patients. METHODS: A total of 524 paediatric patients ≤13 yr, suspected to have UTI, were included in the study. Urine samples were collected, processed for uropathogen isolation and antibiotic susceptibility test was performed as per the Clinical and Laboratory Standards Institute (CLSI) guidelines. Thirty two culture proven children with UTI underwent micturating cysto-urethrography (MCU) and dimercaptosuccinic acid (DMSA) scanning was done for 69 children. RESULTS: o0 f the 524 children, 186 (35.4%) had culture proven UTI with 105 (56.4%) being infants, 50 (27.4%) between 1-5 yr, 30 (16.12%) between 5-13 yr and 129 (69.35%) males. Posterior urethral valve (PUV) was noted in three, hydronephrosis in one, VUR in 18 and renal scarring in 33. VUR as well as renal scarring were more in males >1 yr of age. A significant association (P=0.0054) was noted with a combined sensitivity and specificity of these investigations being 83 and 90 per cent, respectively of the MCU and DMSA scans for detecting VUR. Escherichia coli was the most common pathogen isolated, sensitive to nitrofurantoin, followed by cefoperazone-sulbactam, aminoglycosides and meropenem. INTERPRETATION & CONCLUSIONS: Our results indicate that UTI varies with age and gender and extensive evaluation is required in boys over one year of age with UTI. This study also highlights the better efficacy of aminoglycosides, cefoperazone-sulbactam and nitrofurantoin in vitro compared with meropenem in Gram-negative uropathogens.

Can distal ureteral diameter predict reflux resolution after endoscopic injection?

OBJECTIVE: To test the predictive value of distal ureteral diameter (UD) on reflux resolution after endoscopic injection in children with primary vesicoureteral reflux (VUR). MATERIALS AND METHODS: This was a retrospective review of patients diagnosed with primary VUR between 2009 and 2012 who were managed by endoscopic injection. Seventy preoperative and postoperative voiding cystourethrograms were reviewed. The largest UD within the false pelvis was measured. The UD was divided by the L1-L3 vertebral body distance to get the UD ratio (UDR). One radiologist interpreted the findings of voiding cystourethrography in all patients. Clinical outcome was defined as reflux resolution. RESULTS: Seventy patients were enrolled in this series (17 boys and 53 girls). Mean age was 5.9 years (1.2-13 years). Grade III presented in 37 patients (53%), and 33 patients (47%) were of grade IV. Mean distal UD was 5.5 mm (2.5-13 mm). Mean UDR was 37.8% (18%-70%). Macroplastique injection was performed in all. Subureteric injection was performed in 60 patients (86%), whereas intraureteric injection was performed in 10 patients. No postoperative complications were detected. The effect of grade, UD, and UDR on success after endoscopic injection was tested. UD and UDR were significant predictors of reflux resolution on logistic regression analysis (P <.007 and .001, respectively). CONCLUSION: UDR provides an objective measurement of VUR and appears as a predictive tool of success after endoscopic injection.

Evaluation and management of urinary tract infections in the school-aged child.

The evaluation and management of urinary tract infection in the school-aged child is an important part of primary care in the ambulatory setting. In this article, the salient features of how this condition presents to the clinician, how it is properly diagnosed and treated, and follow-up care are reviewed.

Does the modified STING method increase the success rate in the management of moderate or high-grade reflux?

PURPOSE: To evaluate the efficacy of subureteral injection types in patients with middle- to high-grade vesicoureteral reflux (VUR). MATERIALS AND METHODS: Between June 1999 and September 2010, subureteral dextranomer was applied at our clinic to 149 patients (214 refluxing ureters) with grades II, III, and IV VUR. Group 1 consisted of 54 patients (80 ureters), and group 2 consisted of 95 patients (134 ureters). The standard subureteric transurethral injection (STING) procedure was applied to group 1, and the modified STING procedure was applied to group 2. A second and if needed a third injection was applied to unsuccessfully treated patients. The mean follow-up period was 2 years. Patients were evaluated by cystography and ultrasonography in the third month of follow-up. RESULTS: VUR was resolved completely after a single injection in 54/80 ureters (67.5%) in group 1 and in 94/134 ureters (70.1%) in group 2. Overall successes after a second or a third injection were 61/80 (76.2%) and 111/134 (82.8%), respectively. There was a statistically significant difference between the groups only for grade IV reflux following multiple injections (p<0.05). CONCLUSIONS: Endoscopic treatment of VUR is a recommended treatment because it is minimally invasive, efficient, and repeatable. Our study confirmed that a modified STING procedure can be an alternative treatment to the standard technique.

Prospective study of polydimethylsiloxane vs dextranomer/hyaluronic acid injection for treatment of vesicoureteral reflux.

PURPOSE: Endoscopic injection of a bulking agent is becoming a first-line treatment for low grade vesicoureteral reflux. We prospectively compared the efficacy of 2 such products commercially available in Canada. MATERIALS AND METHODS: A total of 275 patients with documented grade I to V vesicoureteral reflux were prospectively enrolled in a comparative study between April 2005 and February 2011 to be randomly treated endoscopically with either polydimethylsiloxane (Macroplastique®) or dextranomer/hyaluronic acid copolymer (Deflux®). Of the ureters 202 were treated with polydimethylsiloxane and 197 with dextranomer/hyaluronic acid copolymer. Patients were followed with voiding cystourethrography at 3 months and renal ultrasonography at 3 months and at 1 year. Median followup was 4.3 years. The primary outcome was surgical success (resolution vs nonresolution), and secondary outcomes included occurrence of adverse events. RESULTS: Vesicoureteral reflux was fully corrected in 182 of 202 ureters (90%) treated with polydimethylsiloxane, compared to 159 of 197 (81%) treated with dextranomer/hyaluronic acid copolymer (p <0.05). Obstruction was found in 5 ureters. Univariate and multivariate analyses did not allow identification of any characteristics that could explain the significant difference in the success rates except for the type of product used. CONCLUSIONS: We present the largest known prospective evaluation comparing 2 bulking agents for the treatment of vesicoureteral reflux. Endoscopic injection of polydimethylsiloxane resulted in a better success rate than dextranomer/hyaluronic acid copolymer. The rate of resolution obtained with the latter is lower than those previously published due to the inclusion of high grade reflux.

Longterm outcome of Macroplatique injection for treatment of vesicoureteral reflux in children.

BACKGROUND: This study examined our experience with one year follow-up of 20 cases of vesicoureteric reflux in children after treatment with Macroplastique ® injection. PATIENT AND METHODS: A total of 20 children (31 ureters) with primary grades II to V vesicoureteral reflux were treated with subureteral Macroplastique ® injection from 2010 to 2011 and followed for an average of 12 months (range 3 to 24). Vesicoureteral reflux was grade II in 3, III in 7, IV in 9 and V in 12 ureters. Each child underwent pre-operative voiding cystourethrography, abdominopelvic ultrasound, urine analysis/culture, S. creatinine and CBC. Dimercapto-succinic acid scan (DMSA scan) and magnetic resonance urography (MRU) were done in some patients. Voiding cystourethrography at 3 months was done to rule out persistent reflux. RESULTS: Overall, reflux was corrected in 11 (35.5%) ureters and 9 (45%) children after a single injection. With repeat injection, reflux was corrected in 16 (51.6%) ureters and 11 (55%) children, reflux improved/downgrade in 4 (12.9%) ureters and 2 (10%) children. Correction by grade was 100%, 100%, 9.7%, 9.7% for grades II to V, respectively. There were no surgical complications. None of the cured patients had recurrent reflux during follow-up. There were 9 (45%) children who required open ureteral re-implantation for failed injection. CONCLUSION: Sub-ureteral Macroplastique ® injection therapy could be a primary treatment for low grade VUR (grade III or less) in children because it is simple, safe, effective, less invasive, decreased.