[Failures of endoscopic treatment of vesico-ureteric reflux in children using Macroplastique]. / Echecs du traitement endoscopique des reflux vésico-urétéraux (RVU) de l'enfant par injection de Macroplastique.

INTRODUCTION: Macroplastique has been used since 1993 for the endoscopic treatment of vesico-ureteric reflux in children with a failure rate per injected ureteric unit of 21%. The objective of this study was to analyse these failures on the basis of endoscopic findings on injection, ultrasound data at 2 months post-endoscopy and operative findings during the secondary reimplantation. MATERIAL AND METHODS: The authors retrospectively reviewed cases of failure of Macroplastique treatment from September 1993 to December 2002. Only children undergoing subsequent surgical reimplantation were included in the study: 60 cases (57 girls, 3 boys). Another 68 patients also presented recurrence of reflux, but are currently asymptomatic and have not been reoperated. Twenty five patients (42%) initially presented unilateral vesico-ureteric reflux: bilateral injection was performed in 17 of these cases because of the anatomical findings on endoscopy. In 92% of cases, the refluxing ureteric orifice appeared to be abnormal (in terms of position, appearance and the submucosal course of the ureter). RESULTS: Eleven children (18%) presented symptomatic or asymptomatic urinary tract infection before the first clinical and radiological review at 2 months. On the first ultrasound examination, the implant was visualized in the bladder wall in 71% of cases. At reimplantation, the bladder mucosa was inflammatory in 56 patients (94%). The ureteric orifice remained gaping in 38% of cases and the implant appeared to be modified (migration, decreased volume) in 35% of cases. CONCLUSION: Failures of endoscopic treatment by Macroplastique can be due to persistence of pre-existing ureteric anatomical lesions (poor indication, technical error or difficulty) or modification of the injected product. Bladder inflammation and therefore previous or post-endoscopy urinary tract infections may also play a role.

[Endoscopic treatment of vesicoureteric reflux (VUR) in children: results of 9 years of use of Macroplastique (polydimethylsiloxane)]. / Traitement endoscopique des reflux vésico-urétéraux (RVU) de l'enfant: résultats de 9 ans d'utilisation du Macroplastique (polydiméthylsiloxane).

OBJECTIVE: Since 1993, the authors have used a Macroplastique (polydimethylsiloxane) implant for the endoscopic treatment of vesicoureteric reflux (VUR) in children instead of Teflon (polytetrafluoroethylene). They report their results after 9 years of use of Macroplastique and analyse their failures. MATERIAL AND METHODS: 477 children with 669 refluxing ureters, classified as grade I reflux in 96 cases (14%), grade II reflux in 435 cases (65%), grade III reflux in 125 cases (19%), and grade IV reflux in 13 cases (2%), were treated at Tours University Hospital by the same surgeon, by injection of 0.1 to 0.5 ml (mean: 0.3 ml) of Macroplastique. 189 cases of unilateral reflux (66%) required a bilateral procedure on the basis of the endoscopic findings. The efficacy of treatment was evaluated on the absence of clinical and bacteriological signs of urinary tract infection and the absence of reflux on cystography during the study period. RESULTS: 354 of the 477 children (74%) and 514 of the 669 refluxing ureters (77%), including 167 cases of bilateral VUR (65%) and 180 cases of unilateral VUR (35%) were cured. A significant difference was observed between the cure rate for bilateral reflux and unilateral reflux (p<0.05). The failure rate in cases of grade I and II reflux was significantly higher than in grade III and IV (p<0.05). The development of de novo contralateral reflux was not statistically related to unilateral or bilateral injection for the treatment of unilateral reflux. CONCLUSION: The authors believe that the failure rate for grade I and II reflux could be explained by the concomitant presence of detrusor-sphincter dyssynergia that was not systematically investigated preoperatively and by the fact that endoscopic correction of anatomical lesions gives better results in the case of probably more malformative grade III and IV reflux.

[Vesicoureteric reflux in children: long-term results of endoscopic treatment by Macroplastique injection]. / Reflux vésico-urétéral chez l'enfant: résultats à long terme du traitement endoscopique par injection de Macroplastique.

OBJECTIVE: To evaluate the long-term efficacy (from the fifth year after injection and up to seven years) of endoscopic treatment by Macroplastique implant for vesicoureteric reflux (VUR) in children, sometimes associated with urological malformations or renal complications. The secondary objective was to evaluate the local tolerance of the Macroplastique implant and the development of any local (haematuria, stones, ureteric stasis) or distant complications. MATERIAL AND METHODS: Retrospective analysis of the medical files of 389 patients, representing a total of 590 refluxing ureters treated by Macroplastique injection in eight different centres. RESULTS: With a follow-up of 5 to 7 years, reflux had not recurred in 309 of the 389 cases, i.e. 79.4% of cases and no case of ureteric stricture was observed. CONCLUSION: The good short-term results in terms of correction of reflux by Macroplastique injection and the very low morbidity are maintained with time. It therefore appears legitimate to propose endoscopic treatment of VUR by first-line Macroplastique injection instead of surgical ureteric reimplantation.