Ureteral Obstruction After Endoscopic Treatment of Vesicoureteral Reflux: Does the Type of Injected Bulking Agent Matter?

PURPOSE OF REVIEW: Endoscopic injection of bulking agents for the treatment of vesicoureteral reflux (VUR) has become a therapeutic alternative to antibiotic prophylaxis and ureteral reimplantation. Although considered as a safe and efficient procedure, several studies have reported cases of ureteral obstruction (UO) after endoscopic correction of VUR. This review article evaluates the present VUR literature to estimate the incidence of UO following endoscopic injection of different substances, while also discussing the impact of injection technique and implant volume. RECENT FINDINGS: Twenty-five publications were identified that provided detailed information on 64 females and 32 males (age range, 7 months-48 years) that developed UO after endoscopic treatment of VUR using dextranomer/hyaluronic acid (Dx/HA), polyacrylate polyalcohol (PP), polydimethylsiloxane (PDMS), calcium hydroxyapatite (CaHA), polytetrafluoroethylene (PTFE), or collagen. There was some variation in the reported incidence of UO among these materials: Dx/HA (0.5-6.1%), PP (1.1-1.6%), PDMS (2.5-10.0%), CaHA (1.0%), and PTFE (0.3%). Postoperative UO was described following subureteric transurethral injection (STING), intraureteric hydrodistension implantation technique (HIT), combined HIT/STING and double HIT. The injected volume ranged widely, also depending on the type of bulking agent: Dx/HA (0.3-3.0 mL), PP (0.3-1.2 mL), PDMS (1.0-2.2 mL), CaHA (0.4-0.6 mL), and PTFE (1.5-2.0 mL). The timing of UO varied from immediately after the procedure to 63 months. Over half of patients showed asymptomatic hydroureteronephrosis on follow-up imaging, whereas the remaining presented with symptoms of acute UO or fever. UO remains a rare complication after endoscopic correction of VUR, generally reported in less than 1% of treated cases, which appears to be independent of the injected substance, volume, and technique. However, long-term follow-up is recommended as asymptomatic or delayed UO can occur, potentially leading to deterioration of renal function.

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

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 control 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.

Early results of endoscopic treatment of vesicoureteral reflux with polyacrylate polyalcohol copolymer.

OBJECTIVE: To evaluate the early results of endoscopic treatment of vesicoureteral reflux (VUR) in children using polyacrylate polyalcohol copolymer (PPC). PATIENTS AND METHODS: We retrospectively reviewed 45 patients treated with subureteric injection of PPC in our clinic. The results of voiding cystouretrography performed on the 3rd postoperative month and the results of 1-year follow-up were evaluated. RESULTS: A total of 45 patients (57 ureters) underwent injection of PPC. The mean age of the patients was 6.5 years. There were 6 (10.5%) grade 1, 7 (12.2%) grade 2, 26 (45.6%) grade 3, 16 (28%) grade 4, and 2 (3.5%) grade 5 VUR. There were 11 overactive bladders, 2 duplex collecting systems, and 4 posterior urethral valves among the patients. Voiding cystouretrography postoperatively at the 3rd month showed that VUR had disappeared in 82.5% (47/57) of the ureters, downgraded to grade 2 and 3 in 7% (4/57), persisted in 5.2% (3/57) and upgraded in 5.2% (3/57). The success rate at the end of the first year was 98.1%. The procedure was free of complications such as fever, dysuria, lumbar pain or obstruction in all patients. No patient showed VUR recurrence at the end of the first year. CONCLUSIONS: The short-term results of our patients suggested that PPC can be safely and successfully used in the endoscopic treatment of VUR in children. However, further prospective, controlled trials showing the long-term results of the patients are needed.

Endoscopic treatment of vesicoureteral reflux with non-simultaneous involuntary detrusor contraction in chronic spinal cord injury patients with neurogenic detrusor overactivity.

OBJECTIVE: To analyze whether it is correct to use endoscopic treatment via bulking agents of vesicoureteral reflux (VUR) seen on video urodynamics with non-simultaneous involuntary detrusor contraction in chronic spinal cord injury (SCI) patients with neurogenic detrusor overactivity (NDO). METHODS: A retrospective study was performed with a cohort of 76 patients (age 48.9 ± 14.4 years) (mean ± standard deviation) of both sexes with chronic SCI who underwent endoscopic treatment of VUR during the years 2008 to 2011. Patients were subjected to clinical examinations and video urodynamic studies preoperatively and 22 ± 11.4 months after the intervention. RESULTS: Resolution of VUR was achieved in 46 cases (61%). Cured patients had a statistically significant younger age and showed stress urinary incontinence more frequently. On the contrary, a greater grade of VUR, presence of bilateral reflux and presence of NDO were positively associated with treatment failure. The variables that independently influenced the cure of the reflux were NDO and reflux grade. CONCLUSIONS: The failure rate was high in patients with NDO, even though the reflux was not synchronous with involuntary detrusor contraction, and therefore these patients should have NDO eradicated before doing any anti-reflux procedures.

Endoscopic correction of complex cases of vesicoureteral reflux utilizing Vantris as a new non-biodegradable tissue-augmenting substance.

PURPOSE: We aimed to evaluate prospectively the efficacy of Vantris as a new non-biodegradable tissue-augmenting substance in children with complex cases of VUR. MATERIALS AND METHODS: Over the last 4 years, 37 children (28 female and 9 male) with a mean age of 5.8 ± 3.1 years (mean ± SD) underwent endoscopic correction of complex VUR. A total of 38 renal refluxing units (RRU) was treated as 5 had persistent reflux after open surgery, 16 had duplication, 4 had Hutch diverticulum, 6 had small poorly functioning kidneys (less than 20% of relative renal function) with grade V VUR, 2 had ureterocele after puncture, 3 had persistent stump reflux, 1 had prune belly syndrome, and 1 had urogenital sinus. VUR was Grade I in 2, Grade II in 9, Grade III in 11, Grade IV in 10, and Grade V in 6 RRU, respectively. RESULTS: The reflux was corrected in 34 (89.4%) RRU after a single injection, after second injection in 2 (5.3%) RRU. In 2 (5.3%) RRU, VUR downgraded to Grade I (1RRU) and Grade II (1RRU) and they were taken off antibiotic prophylaxis. VCUG was performed in 11 (73.3%) of 15 children who completed 1 year and in 3 (33.3%) of 9 who completed 3 years of follow up as a part of the routine protocol. None showed VUR recurrence. US demonstrated normal appearance of kidneys in all patients. CONCLUSION: Our data show that Vantris injection provides a high level of reflux resolution in complex cases of VUR.

Endoscopic treatment of vesicoureteral reflux with polyacrylate polyalcohol copolymer and dextranomer/hyaluronic acid in adults.

PURPOSE: Aim of this study is to examine the effectiveness of dextranomer/hyaluronic acid copolymer and polyacrylate polyalcohol copolymer in endoscopic treatment of vesicoureteral reflux disease in adult patients with and without chronic renal failure. MATERIALS AND METHODS: Thirty two patients (12 female, 20 male) with a total of 50 renal units were treated for vesicoureteral reflux. There were 26 (81%) chronic renal failure patients. The success of treatment was evaluated by voiding cystouretrography at 3rd and 12th months after subureteric injection. The persistence of reflux was considered as failure. Patients were divided into two groups according to injected material. Age, sex, grade of reflux and treatment results were recorded and evaluated. RESULTS: Reflux was scored as grade 1 in seven (14%), grade 2 in 16 (32%), grade 3 in 21 (42%) and grade 4 in six (12%) renal units. There was not patient with grade 5 reflux. Fourteen renal units (28%) were treated with dextranomer/hyaluronic acid copolymer (group 1) and 36 renal units (72%) were treated with polyacrylate polyalcohol copolymer (group 2). The overall treatment success was achieved at 40 renal units (80%). The treatment was successful at 11 renal units (79%) in group 1 and 29 renal units (81%) in group 2 (p = 0.71). There was not statistically significant difference between two groups with patients with chronic renal failure in terms of treatment success (p = 1.00). CONCLUSIONS: The effectiveness of two bulking agents was similar in treatment of vesicoureteral reflux disease in adult patients and patients with chronic renal failure.

[Endoscopic treatment of vesicoureteral reflux in children].

The one of the most common defects of the ureter-vesical segment in children is the condition, leading to a disorder of obturative function of this segment. Complications of vesicoureteral reflux include continuously recurrent pyelonephritis, reflux nephropathy. In this regard, the choice of the optimal treatment strategy based on minimal invasion is considered as one of the priorities of pediatric urology. The article presents the data obtained during the treatment of VUR in children of different ages in the Clinic of Reproductive Health FSBSI SCCH. A comparative evaluation of the results of endoscopic correction of vesicoureteral reflux depending on the kind of the bulking agent was performed. It was found that the use of endocorrection of reflux is highly effective surgical procedure, with the high number of positive results against the background of use of bulking agent "vantris". The study discriminates a group of patients with vesicoureteral reflux, intractable for endoscopic correction with cystoscopically normal structure of the orifices that allows to refer this method to the initial stage of treatment of the disease.

Endoscopic Correction of Reflux Utilizing Polyacrylate Polyalcohol Bulking Copolymer (Vantris) as a Tissue Augmenting Substance: Lessons Learned Over the 10 Years of Experience.

Objectives: To prove the hypothesis that modifying the endoscopic correction of vesicoureteral reflux (VUR) technique (STING procedure) and sharpening its contraindications, lead to increased success rate and decline in the complication rate. Materials and Methods: All patients that underwent endoscopic correction of VUR utilizing Vantris were divided into two groups according to procedure date; before 2015 and 2015-2019. Indication for treatment included persistent high-grade VUR or breakthrough infections. Contraindications included voiding dysfunction, active infection and since 2015 suspicion for obstructive/refluxing ureterovesical junction (UVJ) presented by "beak" sign on voiding cystourethrography (VCUG). Follow-up regiment included ultrasound and VCUG at predetermined intervals. Results: The first group included 215 (158 girls and 57 boys) children with mean age of 4.8 ± 2.8 years who underwent endoscopic correction between 2009 and 2015 and the second group included 42 children (28 girls and 14 boys) with mean age of 3.9 ± 2.1 years who underwent surgery between 2015 and 2019. In the first group, VUR was unilateral in 74 patients and bilateral in 132 comprising 338 renal refluxing units. In the second group, VUR was unilateral in 14 patients and bilateral in 30 comprising 74 RRUs. In the first group reflux was corrected in 317 (94.9%) RRUs after a single injection, after the second in 7 (2.1%) RRUs. In seven (2.1%) RRUs, reflux downgraded to Grade I-II. Three RRUs (0.9%) failed endoscopic correction and required ureteral reimplantation. Nine (2.7%) RRUs developed UVJ obstruction. In the second group reflux was corrected in 61 (82.4%) RRUs after a single injection, after the second in 12 (16.2%) RRUs. In one (1.4%) RRU, endoscopic correction failed and required ureteral reimplantation. None of the patients developed UVJ obstruction. Reflux correction has led to the significant decrease of febrile urinary tract infection (UTI) in both groups. Conclusions: Our data indicate that endoscopic injection utilizing Vantris is safe and long durable procedure. Although utilizing the proper technique and contraindication criteria, the rates of post procedural VUJ obstruction is null.

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.

Minimally invasive treatment of vesicoureteral reflux.

Vesicoureteral reflux (VUR) is a common problem in childhood, affecting approximately 1% to 2% of the pediatric population. Mild cases of VUR are likely to resolve spontaneously, but high-grade VUR may require surgical correction. Pediatric urologists are familiar with open antireflux operations, which can be accomplished with minimal operative morbidity. Minimally invasive endoscopic and laparoscopic techniques that now exist may serve to reduce morbidity further. This article reviews the endoscopic materials, techniques, and outcomes in the treatment of VUR in addition to the techniques and outcomes of laparoscopic and robotic ureteroneocystotomy.

Endoscopic Treatment for Vesicoureteral Reflux in Recurrent Urinary Tract Infections in Kidney Transplant: Experience of One Center.

Vesicoureteral reflux (VUR) after renal transplantation in adult patients has been reported. In renal transplant recipients, symptomatic urinary tract infection can cause high morbidity despite improved immunosuppressive and antibiotic treatment. In our country there have been few reported cases about use of copolymer of dextranomer and hyaluronic acid (DX-HA) injection in a renal transplant. We present 3 cases of recurrent or complicated infections with evidence of high-grade VUR, which were treated with DX-HA. Only 1 case had a partial remission; however, there were no episodes of urinary tract infection in 12 months of follow-up. Suburethral injection is an endoscopic treatment modality with low morbidity in our country.

The deflux procedure reduces the incidence of urinary tract infections in patients with vesicoureteral reflux.

PURPOSE: The aim of this study was to review the experience of a single institution with the Deflux (Q-Med Scandinavia; Uppsala, Sweden) procedure and assess its effectiveness in reducing the incidence of urinary tract infections (UTIs) in children with vesicoureteric reflux (VUR). MATERIALS AND METHODS: After institutional review board approval, the charts of 100 patients with VUR, who presented between June 2003 and June 2005, were prospectively reviewed. Data collected included: demographics, the number of preoperative and postoperative UTIs, a radiologic grade of VUR on a voiding cystourethrogram (VCUG) and the presence of VUR on a radionuclide VCUG 3 months after the procedure. Patients were continued on oral antibiotics until urine culture at 3 months was negative and no reflux was demonstrated on VCUG. The student's t test was used for data analysis. RESULTS: The mean age was 3.8 +/- 0.3 years, and 76% were girls. From 155 ureters treated, 10 had Grade I reflux, 42 Grade II, 76 Grade III, 25 Grade IV, and 2 Grade V. A second injection was required in 22 ureters (14.2%). The overall success rate of the procedure (Grade 0 reflux at 3 months) was 77.4% after the first injection and 83.9% after a second injection. The success rate per grade was: 100% for Grade I, 88.1% for Grade II, 86.8% for Grade III, 64% for Grade IV, and 50% for Grade V. The mean follow-up was 446 +/- 20 days. The mean volume injected/ureter was 0.6 +/- 0.03 mL. Thirteen (13) patients had UTIs after the procedure, compared to 75 before. There was a 5-fold reduction in the incidence of UTIs/year, from a mean of 0.68 +/- 0.09 pre- to 0.12 +/- 0.04 postinjection (P = 0.001). The majority of UTIs were caused by Escherichia coli (74% pre- and 82% postinjection). CONCLUSIONS: We conclude that the Deflux procedure is effective not only in eliminating VUR on radiologic studies, but also in reducing the incidence of UTIs and antibiotic use in children with VUR.

[Endoscopic treatment of vesicoureteral reflux in children]. / Endoskopisk behandling av vesikoureteral refluks hos barn.

BACKGROUND: At Rikshospitalet, Norway, vesicoureteral reflux (VUR) in children has been treated with subureteric teflon (polytetrafluoroethylen) injection (STING) since 1994. After a biological injection substance became commercially available, we changed to Deflux (dextranomer/hyaluronic acid) in 2000. The aim of this study was to assess whether the VUR results following use of the new injection substance are comparable to those for the previously used substance. MATERIAL AND METHODS: 202 ureters with VUR grade II-V in 132 patients (91 girls) were treated for the first time with subureteric injections of teflon (n = 77) or Deflux (n = 125) during the 5-year period November 1998-2003. The charts were retrospectively reviewed. RESULTS: 201 ureters (131 patients) were followed up with urinary tract ultrasound and voiding cystogram 1-34 months after the last injection. After the first teflon injection 43% of the ureters had no reflux and an additional 9% were improved. After the first Deflux injection 48 % of the ureters had no reflux and 10% were improved. After 1-3 injections 78% (teflon 71%, Deflux 81%) were without or had reduced VUR. Three ureters showed terminal stenosis after the first Deflux injection. Statistically, the results were independent of VUR grade, injection substance and surgeon experience, and similar for duplex and single ureters. INTERPRETATION: Endoscopic treatment of VUR in children is safe and simple. The results after Deflux and teflon were similar. Urinary tract ultrasound and voiding cystogram should be used for follow-up of all patients some months after injection.

[Long-term experience with Cohen ureteral reimplantation in bilateral vesicoureteral reflux in childhood]. / Langzeiterfahrungen mit der Ureterozystoneostomie nach Cohen beim bilateralen vesikoureterorenalen Reflux im Kindesalter.

INTRODUCTION: In bilateral VUR, Cohen cross-trigonal ureteric reimplantation is a popular but also controversial surgical approach. We present our own experience in a retrospective analysis. PATIENTS AND METHODS: Between 1990 and 2005, 41 children (26 girls, 15 boys) with bilateral reflux [92 renal units (RU)] underwent ureteric reimplantation. The mean age was 4.5 (0.3-12) years. Eight patients had ureteral duplication (six unilateral, two bilateral); 12 of 41 patients had no intraoperative ureteral stenting. Seven patients had prior surgery for VUR. A successful result was defined as absence of VUR, significant UVJ obstruction, or voiding dysfunction throughout the follow-up. RESULTS: The mean follow-up was 7.8 (0.5-15) years. Eight patients (19.5%) had 13 complications. One patient had an intraoperative small bowel lesion (2%). Six patients (14.6%) had UTI. Four patients (9.8%) showed transient UVJ obstruction. Three required a temporary percutaneous nephrostomy. Two of these patients had no intraoperative ureteral stenting. Recurrence of VUR was found in 2 patients (4.8%) and 2/92 RU (2.2%), respectively. Complications were more frequent in high-grade VUR, ureter duplex, or unstented ureteral reimplantation. Prior surgery for VUR did not influence the postoperative outcome. Postoperative voiding disorders were not observed. CONCLUSIONS: Two unilateral recurrences of VUR were observed, requiring a reoperation in one patient. A reoperation for UVJ obstruction was not necessary. Related to 92 RU the surgical success rate was 97.8%. Intraoperative ureteral stenting has to be considered with respect to the current discussion of shortening inpatient procedures. In our experience, the perioperative risk was elevated in patients with high-grade VUR or ureteral duplication.

STING versus HIT technique of endoscopic treatment for vesicoureteral reflux: A systematic review and meta-analysis.

AIM: Our study aimed to compare the efficacy of two endoscopic techniques used for the correction of vesicoureteral reflux (VUR): subureteral transurethral injection (STING) and hydrodistension implantation technique (HIT). METHODS: A systematic review was conducted using MEDLINE, Google scholar, and Cochrane databases from 1984 to 2015. Meta-analysis of the selected studies was performed to compare the extent of reflux resolution following both techniques. RESULTS: Six observational studies met the inclusion criteria for content. These comprised 632 ureters treated by STING and 895 ureters treated by HIT procedure. All included studies utilized dextranomer/hyaluronic acid (Deflux) as the bulking agent. The overall resolution of VUR was significantly higher in HIT (82.5%) compared to STING (71.4%) [pooled odds ratio (OR)=0.54; 95% confidence interval (CI) 0.42-0.69; P<0.0001; I2=8%]. A subgroup analysis showed that HIT had better outcomes than STING for both lower grade (I-III) [OR=0.43; 95% CI 0.23-0.82; P=0.01; I2=0%] and high-grade VUR (IV-V) [OR=0.43; 95% CI 0.20-0.91; P=0.03; I2=0%]. However, there was no statistical difference in the requirement of additional injections between STING and HIT groups. CONCLUSION: HIT is superior to STING technique for resolution of VUR after Deflux injection. However, more randomized trials with longer follow-up are necessary to demonstrate the benefit of HIT compared to STING procedure. LEVEL OF EVIDENCE: Retrospective comparative studies - level III.

Anti-Reflux Ureteral Stent with Polymeric Flap Valve Using Three-Dimensional Printing: An In Vitro Study.

PURPOSE: This article aims to describe the design of an anti-reflux ureteral stent with a polymeric flap valve and the fabrication methods using three-dimensional (3D) printing. The stent effectively prevents backward flow with a negligible reduction in forward flow. Fabrication of miniaturized valves was easy with high precision and rapid prototyping. MATERIALS AND METHODS: The proposed stent comprised a 7F Double-J (DJ) stent and a polymeric flap valve. The valve was made of Tango Plus FLX980 and was fabricated using a 3D printer. Two types of stent were prepared for in vitro tests: DJ stents with (1) an uncoated valve (UCV) stent and (2) a parylene C coated valve (PCV) stent for enhanced biocompatibility. The flow characteristics of each stent were evaluated considering flow direction, parylene coating, and stent side holes, and were compared to the intact DJ stent. RESULTS: The forward flow rate for the distal portion of the UCV and PCV stents was 9.8 mL/min and 7.8 mL/min at applied pressure of 15 cm H2O (normal anterograde pressure in patients with stents), respectively. Backward flow rate for the distal portion of the UCV and PCV stents was decreased by 28 times and 8 times at applied pressure of 50 cm H2O (maximum bladder pressure), respectively, compared with the distal portion of the intact DJ stent. Forward flow rates of whole stents were 22.2 mL/min (UCV stent) and 20.0 mL/min (PCV stent) at applied pressure of 15 cm H2O, and backward flow rates of whole UCV and PCV stents were decreased by 8.3 times and 4.0 times at applied pressure of 50 cm H2O, respectively, compared with the intact DJ stent. CONCLUSIONS: The anti-reflux ureteral stent was successfully designed and fabricated using a 3D printer. In vitro studies showed that the stent effectively prevented backward flow while minimizing reduction in forward flow.

An alternative to the Penrose drain in children at risk for latex allergy.

We describe a simple and inexpensive technique to construct a nonlatex Penrose drain substitute using a latex-free surgeon's glove. We have found this to be a safe option for children who are at risk for a latex reaction.

Histological changes following submucosal Teflon injection in the bladder.

Histological examination following subureteric Teflon injection was carried out on 32 ureters and four granulomatous polyps. When the Teflon was correctly placed in the submucosa it remained circumscribed and reflux was more likely to be corrected. If the Teflon was placed more deeply it became diffuse, caused a giant cell reaction, and was less likely to correct the reflux. The granulomatous polyps may represent a reaction to leakage of Teflon from the injection site.

Treatment of vesico-ureteric reflux in children with neuropathic bladder: a comparison of surgical and endoscopic correction.

BACKGROUND/PURPOSE: Vesico-ureteric reflux (VUR) is a common problem in children with neuropathic bladder. Lesser-degree VUR may be manageable by intermittent catheterization or by anticholinergics, but higher grades usually require surgical treatment. If left untreated, two thirds of such patients may experience deterioration of the upper renal tracts. The aim of this study was to compare the results of the STING (Subureteric Teflon Injection) technique with surgical ureteric reimplantation as treatment for VUR in neuropathic bladder. METHODS: From January 1981 to December 1996, 58 children with NB (81 ureters) were treated for VUR. STING and Cohen ureteroneocystotomy were performed in 40 and 41 ureters, respectively. Mean age was 4.5 years (STING) and 5.1 years (Cohen). RESULTS: Twenty-nine of 40 refluxing ureters (72.5%) were cured by STING, whereas Cohen eradicated reflux in 39 of 41 ureters (95.5%). No complications were observed in either group. All the ureters in which STING failed were treated successfully by Cohen ureteroneocystostomy. The 2 ureters still refluxing after surgical reimplantation were cured successfully by a single STING. The mean follow-up was 6.8 years in the Cohen group and 4.8 years in the STING group. During follow-up, no recurrence was observed in patients cured by open reimplantation. In the STING group, 2 previously cured ureters showed recurrence of VUR: both were treated successfully by a further STING. CONCLUSIONS: Open ureteral reimplantation is more effective than STING in correcting VUR in children with neuropathic bladder dysfunction. Nevertheless, the good success rate, the relative technical simplicity, outpatient nature, and rapid recovery point to STING as a safe and effective procedure for the initial treatment of VUR. Failure of STING does not preclude a successful open operation.