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.

Prospective study using a new bulking agent for the treatment of vesicoureteral reflux: polyacrylamide hydrogel.

PURPOSE: Vesicoureteral reflux is frequently diagnosed in the pediatric population. Endoscopic treatment has become a popular form of first-line therapy. Available products offer good short-term success rates. However, the cost of these injected implants is an issue. We evaluated the success of endoscopic treatment for vesicoureteral reflux using polyacrylamide hydrogel. MATERIALS AND METHODS: We performed a single center, single surgeon, prospective, off-label study using polyacrylamide hydrogel to treat vesicoureteral reflux. All patients underwent endoscopic subureteral double hydrodistention implantation technique injection followed by renal ultrasound and voiding cystourethrogram at 3 months postoperatively to confirm the absence of de novo hydronephrosis and correction of vesicoureteral reflux (grade 0). RESULTS: A total of 40 patients (69 refluxing ureters) underwent polyacrylamide hydrogel injection. Median age at surgery was 50 months. Bilateral reflux was identified in 29 patients (73%). Nine patients had duplex systems, 2 with reflux into both moieties. Reflux was graded using the International Reflux Study in Children grading system, with grade I seen in 9 ureters, II in 17, III in 20, IV in 18 and V in 5. Mean volume injected was 1.1 ml. Success rate for grade I to III vesicoureteral reflux at 3 months after a single treatment was 87%, and the overall success for all grades was 81.2%. CONCLUSIONS: Off-label use of polyacrylamide hydrogel injection therapy for primarily low grade vesicoureteral reflux demonstrates that the technique and short-term success rates are comparable to the most popular bulking agent, dextranomer/hyaluronic acid. These results suggest that further trials comparing polyacrylamide hydrogel and dextranomer/hyaluronic acid would be worthwhile.

Is availability of endoscopy changing initial management of vesicoureteral reflux?

PURPOSE: The optimal management of vesicoureteral reflux continues to be controversial. Since dextranomer/hyaluronic acid copolymer implants were approved in 2001 for endoscopic antireflux surgery, the perception that endoscopy is less morbid than open surgery, combined with concerns over potential adverse effects of prophylactic antibiotics, has led some to advocate endoscopy as initial therapy for reflux. We examined whether the availability of endoscopy has changed the management of reflux. MATERIALS AND METHODS: The i3 Innovus database (Ingenix, Eden Prairie, Minnesota) contains longitudinal claims data on more than 39 million patients spanning a 5-year period. We analyzed children diagnosed with vesicoureteral reflux (ICD-9 code 593.7, plus claim for radiographic or nuclear cystogram within 90 days) and at least 1 year of followup. We assessed patient characteristics, and diagnostic and therapeutic interventions. We evaluated surgical trends, including the changing use of endoscopic vs open antireflux surgery. RESULTS: Among 9,496 children meeting inclusion criteria 1,998 (21%) underwent antireflux surgery during the study period (2002 to 2006). Median followup for surgical cases was 894 days. Of patients undergoing antireflux surgery 1,046 (52.4%) underwent an open procedure and 952 (47.6%) underwent endoscopy. Females were more likely to undergo endoscopy (52% vs 33% of males, p <0.0001), as were children older than 5 years (53% vs 45% of those younger, p = 0.0002). Of patients undergoing surgery 1,234 (62%) were treated early (within 12 months of diagnosis). During the study period the rate of newly diagnosed reflux cases managed by early surgery increased from 12.0% to 17.3% (Mantel-Haenszel chi-square test p <0.0001). This increase was primarily due to a more than doubling of patients undergoing early endoscopy (4.2% in 2002 vs 9.7% in 2006, p <0.0001). The rate of newly diagnosed cases managed by early open surgery did not change significantly (p = 0.3446). CONCLUSIONS: During a 5-year period after dextranomer/hyaluronic acid was introduced for endoscopic therapy the number of children newly diagnosed with vesicoureteral reflux treated with early antireflux surgery increased primarily due to increased use of endoscopy. This finding suggests that despite the lack of evidence of benefit, endoscopy is increasingly viewed as first line therapy for reflux.

Can distal ureteral diameter measurement predict primary vesicoureteral reflux clinical outcome and success of endoscopic injection?

OBJECTIVE: The objective of the study was to evaluate the predictive value of distal ureteral diameter ratio (UDR) on outcome of primary vesicoureteral reflux (VUR) and reflux resolution after endoscopic injection. PATIENTS AND METHODS: Three hundred eighty-three patients treated for primary VUR between January 2010 and October 2015 were retrospectively reviewed. The parameters analyzed were age at diagnosis, sex, grade and lateralite of VUR, complaints at admission (febrile urinary tract infection, antenatal hydronephrosis, family history),bladder-bowel dysfunction (urgency, incontinence, constipation), dimercaptosuccinic acid (DMSA) scintigraphy findings, follow-up period, clinical course (spontaneous resolution or surgical correction), time of spontaneous resolution, surgical treatment time and age, materials used for injection and success of endoscopic injection. Ureteral diameter ratio was calculated on the initial VCUG at the time of the diagnosis as the largest ureteral diameter within the false pelvis divided by the distance between L1-L3.The correlation between UDR, clinical outcome (spontaneous resolution/surgical correction) and success of endoscopic injection was evaluated by logistic regression analysis. To compare the effect of UDR and grade of reflux on spontaneous resolution, multivariate logistic regression analysis was performed in three models together with sex, age, resolution time, presence of febrile UTI and DMSA scan findings. RESULTS: Three hundred eighty-three patients were enrolled. There was a strong correlation between UDR and grade of reflux (p < 0,0001). Ureteral diameter ratio was higher in patients whose complaints at admission were family history and febrile UTI, but this correlation was not statistically significant (p > 0.05). When the correlation between UDR and the DMSA scan findings was evaluated, UDR was found to be significantly higher in patients with moderate and severe scarring. Bladder-bowel dysfunction was present in 111 patients (28.9%). There was no significant correlation between BBD and UDR (p > 0.05). 62 patients showed spontaneous resolution in a median duration of 1.55 years. The predictive value of UDR for spontaneous resolution was more significant than grade (p < 0.001).There was no spontaneous resolution in patients with UDR over 0.45.321 patients underwent operation (248 endoscopic injection, 17 ureteroneocystostomy, 56 endoscopic injection+ureteroneocystostomy). When the predictive value of the reflux grade and UDR in the success rate of endoscopic correction was compared, UDR was shown to be significantly more predictive than the grade of reflux (p < 0.05). Ureteral diameter ratio was significantly higher in patients whose injection treatment was unsuccessful. Each 0.05 unit increase in UDR affected the success of endoscopic injection negatively (95% CI:<0.001-0.071). CONCLUSION: Ureteral diameter ratio is an objective measurement of VUR and appears to be a new predictive tool for clinical outcome and success after endoscopic injection.

Postoperative cystography and endoscopic treatment of low-grade vesicoureteral reflux.

INTRODUCTION: The endoscopic subureteral injection of tissue-bulking agents has become an established alternative to long-term antibiotic prophylaxis and open surgery with a high success rate, especially for low-grade reflux (>90%). Though it is recognized that a routine postoperative voiding cystourethrography (VCUG) is unnecessary following a ureteroneocystostomy, most teams perform one after an endoscopic treatment. MATERIALS AND METHODS: In this paper, we report on our experience with the endoscopic correction of vesicoureteral reflux in 72 ureteral units, for whom no routine postoperative cystography was performed. DISCUSSION: Two children presented with postoperative recurrent febrile urinary tract infections (UTIs), which were not correlated with cystography findings. Postoperative VCUGs after a ureteroneocystostomy are invasive and expose the child to radiation, they are associated with a substantial cost, and most of all, they do not allow the identification of those patients at risk of recurrent febrile UTIs. Further, the endoscopic subureteral injection of tissue-bulking agents have been used for several years, and numerous studies, set in various clinical settings, have since been published, confirming excellent long-term results for low-grade reflux. CONCLUSIONS: We feel that postoperative cystograms should be reserved for children who present with recurrent UTIs, new sonographic abnormalities, or who were treated for high-grade reflux.

Endoscopic correction of vesico-ureteric reflux by subureteric Teflon injection: follow-up ultrasound and voiding cystography.

The technique of subureteric Teflon injection for the correction of vesico-ureteric reflux was first described by Puri and O'Donnell in 1984. The Teflon granuloma that occurs after the injection anchors the submucosal ureter, thereby preventing reflux. This paper reviews the ultrasound and cystographic findings in 88 patients with 115 refluxing ureters followed-up for periods ranging from 3 months to 3 years. Reflux disappeared in 91 ureters (79.1%) and the degree of reflux improved in 22 ureters (19.1%). In this follow-up study, the size of the granuloma on ultrasound was assessed in relation to the number of injections, the total volume of Polytef paste used and the outcome of the procedure. A well circumscribed granuloma was seen at the orifices of 92 ureters. There was no ureteric granuloma evident in 23 ureters and Teflon plaques were found at the trigone in six patients. Complications were rare. One large granuloma caused severe obstruction requiring re-implantation. The size of the granuloma appears to depend on individual tissue reaction rather than on the other factors. The presence or the size of the granuloma bears no direct relationship to the success of the procedure.

Correction of primary and secondary vesicoureteral reflux by subureteric Teflon injection.

Polytetrafluoroethylene (Teflon) has been used for various purposes since 1963 and in urologic practice for the treatment of vesicoureteral reflux (VUR) since the 1980s. In this study we report on our experience with Teflon injection for the treatment of 28 children with primary or secondary reflux. An overall success rate of 91.3% was achieved in the treatment of primary and 66.6% in secondary reflux. With these results we conclude that Teflon injection is a good alternative in the treatment of VUR.

Successful treatment of vesicoureteric reflux by subureteric injection of silicone.

Although the technique of subureteric injection has been widely accepted as an alternative to reimplantation in the treatment of vesicoureteric reflux (VUR), the choice of the material to be used is controversial. We report our experience with the endoscopic treatment of VUR by a submucosal injection of silicone. A 24-year-old man who had VUR (Grade II) and renal insufficiency was treated by endoscopic injection of silicone. Cystography after the treatment showed absence of reflux.

[Endoscopic treatment of vesicoureterorenal reflux in the child]. / Die endoskopische Behandlung des vesikoureterorenalen Refluxes beim Kind.

In the first part of this review reflux per se and its conventional surgical therapy are presented. Then the minimally invasive, endoscopic subureteral injection is discussed as an alternative treatment of reflux. Last, the advantages and disadvantages of the substances used are evaluated. In the second part our experience with endoscopic subureteral collagen injection is presented and the results are critically analysed.

[Treatment of idiopathic vesico-ureteral reflux in children]. / Traitement du reflux vésico-urétéral idiopathique de l'enfant.

Vesicoureteral reflux is the principal cause of pyelonephritis in children. Medical treatment is designed to prevent the development of renal parenchymal scars, as these lesions are irreversible and frequently interfere with growth of the kidney. Treatment must therefore be specific and sufficiently prolonged. In infants under the age of 2 years, reflux may resolve in 50% of cases as the ureterovesical junction develops. During this period, treatment consisting of alternating antiseptics should be proposed to prevent the development of pyelonephritis. In all other cases, reflux must be corrected. Two techniques can be proposed at the present time: surgery which gives 98% immediate and permanent good results, using Cohen's technique, and injection of Teflon, which is much less reliable, with risks of distant dissemination, particularly to the brain, and the possibility of developing ureteric stenosis and bladder stones. These problems have led many paediatric urologists to abandon endoscopic treatment.

[Surgical treatment of vesico-ureteral reflux: comparison between sub-ureteric injection of Polytef and the Cohen technique]. / Traitement chirurgical du reflux vésico-urétéral: comparison entre l'injection sous-urétérale de Polytef et la technique de Cohen.

40 patients who need surgical treatment for their vesico-ureteral reflux have been operated between 1989 and 1992; 26 of them have got the subureteric injection of Polytef (S.U.I.P.) and 14 the neo-uretero-cystostomy (N.U.C.) of Cohen. Even the N.U.C. of Cohen keeps the best results in our experience with only one stenosis on 28 operated ureters (3%), the S.U.I.P. is still an excellent technic because of its simplicity, low morbidity with 90% rate of success. This rate seems stable after a recoil of 19 +/- 13 months. Research must focus on finding a new substance to replace the Polytef and stop the fear of its particles migration found experimentally in animals.

[Endoscopic treatment of vesicoureteral reflux].

OBJECTIVES: Endoscopic subureteral injection of tissue-augmenting substances, a 15-minute outpatient procedure has become an alternative to long-term antibiotic prophylaxis and surgical intervention in the treatment of vesicoureteral reflux (VUR) in children. MATERIALS AND METHODS: We searched MEDLINE using the words: vesicoureteral reflux, treatment, the long-term results of endoscopic treatment of reflux. We summarized the worldwide data regarding endoscopic treatment of VUR using various tissue-augmenting substances presently available. RESULTS: In terms of effectiveness and long-term successful results, polytetrafluoroethylene is still the most reliable injectable material for the endoscopic treatment of VUR. However, Dextranomer/hyaluronic acid copolymer (Deflux) is a new promising tissue augmenting substance which might be able to replace Teflon in the endoscopic treatment of reflux in terms of a similar to Teflon reflux cessation rate and exhibiting no evidence of migration. CONCLUSION: Endoscopic subureteral polytetrafluoroethylene injection is a simple and effective outpatient procedure for in the treatment of vesicoureteral reflux. No long-term morbidity was observed in our patients with small amounts of injectable polytetrafluoroethylene.

[Extravesical treatment of the ureter and endoscopic correction of reflux in children]. / Ekstravezikalizatsiia mochetochnika i éndoskopicheskaia korrektsiia refliuksa u detei.

The authors have suggested the presence of reflux regulating the relationship between the urinary bladder and vesicoureteral segment which was called the vesico-osteal reflex (VOR). An original method of diagnostics of VOR with the help of profilometry was developed. A method of endoscopic correction of reflux was proposed with the help of glue MK-2 and KL-3 in combination with metoclopramide++ which made the treatment considerably more effective.

Endoscopic correction of vesicoureteric reflux: 10-year experience of a tertiary care center.

Endoscopic treatment (ET) of vesicoureteric reflux (VUR) is becoming the new gold standard for surgical correction. ET for VUR using newly available bulking agents is a reliable and safe alternative procedure to open ureteral reimplantation for the treatment of VUR in children. We retrospectively reviewed our experience over 10 years of patients with primary VUR who underwent ET and had at least one year of follow-up at our center from 1998 to 2008. We looked at laterality, success rate, need for a second procedure and complication rate. We observed 321 patients with ET for VUR during this period; 115 (35.8%) of them were males and the total intervened ureters were 480. Correction of VUR was defined as either the resolution of reflux or a downgrading to grade 1 revealed with a follow-up voiding cystourethrogram and no ipsilateral renal or ureteric dilatation detected on renal ultrasound. At two to three months of follow-up, VUR was corrected in 393/480 (81.8%) refluxing ureters after a single endoscopic injection. With a second, repeated injection in the failed cases, VUR was corrected in a total of 418 (87.1%) refluxing ureters. Only three patients had post-operative complications (<1%). We conclude that our study suggests that the majority of patients will be cured after undergoing, as out-patients, this endoscopic procedure. We believe that the widely reported safety of bulking agents and the short learning curve will make ET the standard treatment for VUR once surgical correction is warranted.

The role of endoscopic treatment in the management of grade v primary vesicoureteral reflux.

OBJECTIVES: Although endoscopic treatment provides a high rate of success in children with grades II-IV vesicoureteral reflux (VUR), its role in the management of grade V reflux has been questioned. In this study we reviewed our 21-yr experience of endoscopic treatment in children with grade V primary VUR. METHODS: We retrospectively reviewed the medical records of 132 children who underwent endoscopic treatment for primary grade V reflux from 1984 to 2004. VUR was unilateral in 39 patients and bilateral in 34, and 59 patients had ipsilateral grade V reflux with a lower grade of VUR on the contralateral side. Endoscopic treatment was performed in a total of 166 grade V ureters; polytetrafluoroethylene was used from 1984 to 2000 and dextranomer/hyaluronic acid from 2001 to 2004. Median follow-up was 12.2 yr and mean follow-up was 13.4 yr. RESULTS: VUR was completely resolved after first injection in 88 (53%) ureters and downgraded to grade I or II in 26 (15.7%). VUR resolved after a second and third injection in 36 (21.7%) and 10 (6%) of ureters, respectively. Endoscopic treatment failed to correct VUR in 6 (3.6%) ureters, requiring ureteral reimplantation in 5 and nephrectomy in 1. Thirteen patients developed urinary tract infections during the follow-up period, and on investigation 9 ureters (5.4%) had recurrence of VUR. No injection or morbidity related to tissue-augmenting substances was noted in any patient. CONCLUSION: Endoscopic treatment should be the first-line of treatment in management of grade V vesicoureteral reflux.

Correlation of the endoscopic appearance with clinical outcome for submucous Polytef paste injection in vesico-ureteric reflux.

The endoscopic injection of Polytef paste is now a well established method of treating vesico-ureteric reflux. In this study the video tapes of 64 treatments were independently reviewed to assess any predictors of failure. The visual appearance of the mound of paste was found to correlate with the clinical outcome, except when less than 0.2 mL of paste was used for smaller ureteric orifices, or when the ureteric orifice was large enough to admit the 9.3 FG cystoscope. In cases with a large ureteric orifice effective treatment was achieved without the neat crescent-on-a-mound appearance, provided a larger than average volume of paste was used. Meticulous placement of the needle was also shown to be important if success was to be ensured.

Intramural Teflon injection of the ureter for treatment of vesicoureteral reflux: sonographic appearance.

Endoscopic injection of Teflon paste under the submucosal portion of the ureter in the bladder is a new treatment for vesicoureteral reflux. Twenty-one children at The Montreal Children's Hospital and at St. Justine Hospital were treated with this technique over a 2-year period. In 15 children, abdominal sonography was performed 1-5 days after Teflon paste injections. Follow-up sonograms performed 5 weeks to 1 year after the procedure are available in nine children. Sonographically, the Teflon paste at the injection site appears as a hyperechoic focus within the bladder wall with distal shadowing seen postoperatively and on follow-up examinations. This finding occurred in 22 (88%) of 25 treated ureters. The location of Teflon paste after injection as viewed via cystoscopy is correlated with the sonographic appearance. This preliminary report suggests that sonography is useful in determining the location and size of the Teflon mass, in evaluating surrounding soft tissues at various time intervals after injection, and in assessing possible complications such as obstruction.

Newly diagnosed contralateral reflux after successful unilateral endoscopic correction: is it due to the pop-off mechanism?

PURPOSE: Our aim was to analyze the incidence of newly diagnosed contralateral vesicoureteral reflux after successful endoscopic correction of unilateral reflux by subureteral Teflon (polytetrafluoroethylene) injection and to explain the possible mechanisms responsible for new contralateral reflux. MATERIALS AND METHODS: A total of 1,195 children underwent successful endoscopic correction of high grade primary and duplex grades III to V vesicoureteral reflux by subureteral polytetrafluoroethylene injection. Unilateral and bilateral reflux was noted in 495 and 700 children, respectively. The 495 cases of unilateral reflux were retrospectively analyzed for new contralateral reflux. Voiding cystourethrography was performed in all cases 3 months and 1 year after injection. RESULTS: New contralateral reflux was diagnosed in 37 children (7%), including reflux in a single system in 33 and into a lower pole of a completely duplicated system in 4. There was no correlation of grade of ipsilateral reflux with the subsequent development of new contralateral reflux. No abnormality of the contralateral ureteral orifice was identified at initial cystoscopy, except for laterally placed ureteral orifices in 2 patients. CONCLUSIONS: The low incidence of new contralateral vesicoureteral reflux diagnosed after subureteral polytetrafluoroethylene injection versus open ureteral reimplantation may be due to noninterference with the contralateral trigone in endoscopic correction. The risk of new contralateral reflux did not increase with reflux severity (grades IV and V), suggesting that the pop-off mechanism is unlikely to be the cause of contralateral reflux.