Evaluation of the Diagnostic Value of Contrast-Enhanced Voiding Urosonography with Regard to the Further Therapy Regime and Patient Outcome-A Single-Center Experience in an Interdisciplinary Uroradiological Setting.

Background and Objectives: Vesicoureteral reflux (VUR) describes a common pediatric anomaly in pediatric urology with a prevalence of 1-2%. In diagnostics, in addition to the gold standard of voiding cystourethrography (VCUG), contrast-enhanced urosonography (ceVUS) offers a radiation-free procedure, which, despite its advantages, is not yet widely used. In the present single-center study, subsequent therapeutic procedures and outcomes after ceVUS of 49 patients were investigated. The aim of the study is to investigate the efficacy of ceVUS with the intention of broader clinical implementation. Materials and Methods: Between 2016 and 2020, 49 patients were retrospectively included and received a ceVUS to evaluate VUR. With a distribution of 47:2 (95.9%), a clear female predominance was present. The age of the patients varied between 5 months and 60 years at the time of ceVUS. All examinations were all performed and subsequently interpreted by a single experienced radiologist (EFSUMB level 3). Results: Compared to intraoperative findings, ceVUS shows a sensitivity of 95.7% with a specificity of 100%. Allergic reactions to the contrast medium could not be observed. Conclusion: With its high sensitivity and intraoperative validation, ceVUS offers an excellent alternative to VCUG, the gold standard in the diagnosis of VUR. In addition, ceVUS is a radiation-free examination method with a low risk profile that offers an exceptional diagnostic tool in the diagnostic clarification of recurrent urinary tract infections with the suspected diagnosis of VUR and should also be included in the consideration of a diagnosis next to the established VCUG, especially in younger children.

Randomized clinical trial between polyacrylate-polyalcohol copolymer (PPC) and dextranomer-hyaluronic acid copolymer (Dx/HA) as bulking agents for endoscopic treatment of primary vesicoureteral reflux (VUR).

OBJECTIVE: To compare the radiological and clinical outcomes of endoscopic treatment of primary VUR using polyacrylate-polyalcohol copolymer (PPC-Vantris®) or dextranomer-hyaluronic acid copolymer (Dx/HA-Deflux®). MATERIALS AND METHODS: From October 2014 to April 2017, patients with primary VUR grade III to V that needed endoscopic treatment (ET) were eligible for this randomized clinical trial. We excluded toilet-trained patients with lower urinary tract symptoms. Patients were randomized and allocated into two groups: PPC group and Dx/HA group. After endoscopic treatment a voiding cystourethrography (VCUG) was performed at 6 months; if VUR was still present a second ET was performed. Radiological success was considered if postoperative VUR grade was 0 and clinical success rate was considered if no more fUTI appeared during follow-up. RESULTS: Forty-six patients were eligible but 2 did not accept the trial. Forty-four patients with 73 refluxing ureters were included. PPC: 34 refluxing ureters; and Dx/HA: 39 refluxing ureters. Both groups were statistically homogeneous and comparable. Mean follow-up was 27.6 months. Radiological success rate (82.2%) and clinical success rate (92.3%) were similar in both groups (p > 0.05). The volume of bulking agent used in those successfully treated was greater in Dx/HA group (p < 0.05). Distal ureter was excise in all cases of ureteral reimplantation after PPC treatment; however, distal ureter was preserved in all ureters reimplanted after Dx/HA injection. CONCLUSION: PPC and Dx/HA had similar outcomes, but we must warn that ureteral reimplantation after endoscopic treatment with PPC is difficult because of the periureteral fibrosis.

[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.

Radiologic features of implants after endoscopic treatment of vesicoureteral reflux in children.

OBJECTIVE: Implants after endoscopic treatment of vesicoureteral reflux (VUR) in children will be more frequently detected on imaging studies and may lead to misinterpretation and unnecessary intervention. This article reviews the radiologic appearance of implants. CONCLUSION: Radiologic findings of implants depend on the imaging technique, bulking agent, and time after injection. A history of VUR or an antireflux procedure and the absence of hydronephrosis in cases of suspected urolithiasis are important clues to suggest implants.

Macroplastique and Botox are superior to Macroplastique alone in the management of neurogenic vesicoureteric reflux in spinal cord injury population with presumed healthy bladders.

CONTEXT/OBJECTIVE: Vesico-ureteric reflux(VUR) is a known complication of neuropathic bladder in spinal cord injury(SCI) population. Bulking agents such as Macroplastique are new minimally-invasive treatment option for VUR with good results. The aim of this study is to assess the efficacy of Macroplastique alone or in combination with Botox(BTX-A), in managing VUR in SCI population with presumed healthy bladders and correlate the pre-and post-injection urodynamic findings with the outcome. DESIGN: Retrospective comparative study. PARTICIPANTS: SCI patients with VUR and presumed health bladders (normo-compliant, low filling pressures), treated with macroplastique alone or in combination with BTX-A, who had pre and post-intervention Video-urodynamics (VUDS) and followed up for at least 12 months. INTERVENTIONS: Macroplastique and BTX-A injections, VUDS. OUTCOME MEASURES: The primary end point was the overall treatment rate of VUR at 3 months and the secondary outcomes were the success rate (treated + improved) and the comparison of urodynamic parameters (pre-and post-injection). RESULTS: We studied 34 intervention-naïve SCI patients. 19 had only Macroplastique (Group 1) and 15 had Macroplastique and BTX-A (Group 2). The overall treatment rate was 65.4% for group 1 and 88.9% for group 2 (P = 0.029). The overall success rate (treated + improved) was 80.8% and 94.4% respectively (P = 0.123). The comparison of follow up VUDS parameters showed a statistically significant rise in the detrusor pressure of group 1 (34.04cmH2O vs.19.2cmH2O, P = 0.008) and a drop in compliance (19.8mls/cmH2O vs.26.3mls/cmH2O, P = 0.018) as compared to baseline. CONCLUSION: The combination of BTX-A and Macroplastique is more effective that Macroplastique alone in the management of secondary VUR in SCI patients with presumed healthy bladders.

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.

New bulking agent for the treatment of vesicoureteral reflux: Polymethylmethacrylate/dextranomer.

Purpose: The aim of this study was to report preliminary results of endoscopic treatment of vesicoureteral reflux in children with a single injection of a new bulking agent, cross-linked dextran and polymethylmethacrylate mixture. Materials and Methods: We performed a single-center, single surgeon, prospective, off-label study using polymethylmethacrylate/dextranomer to treat vesicoureteral reflux. All patients underwent endoscopic injection, followed by renal ultrasound and voiding cystourethrogram at 3 months postoperatively to identify de novo or worsening hydronephrosis and vesicoureteral reflux correction (to Grade 0 or I). Results: Eighteen patients underwent injection of polymethylmethacrylate/dextranomer at our institution between April 2013 and December 2013. Ten were males and eight were females, with a median age of 58 months (range, 6 months to 5 years). Vesicoureteral reflux was unilateral in three patients and bilateral in 15, for a total of 33 renal refluxing units. Vesicoureteral reflux was Grade I in one renal refluxing unit, Grade II in 12, Grade III in 16, and Grade IV in four. Mean injected volume was 0.86 mL. Reflux was corrected in 23 renal refluxing units (69.7%) according to the 3-month voiding cystourethrogram. Complications included urinary retention in one patient. Mild pyelectasis was noted in one patient at 3 months, which spontaneously resolved 3 months later. Conclusions: Our short-term data show that polymethylmethacrylate/dextranomer injection can be used to treat vesicoureteral reflux with comparable efficacy to other substances currently used and a low rate of complications. Long-term follow-up is required to confirm the usefulness of this material in treating vesicoureteral reflux.

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.

Endoscopic treatment of vesicoureteral reflux in children with neurogenic bladders.

Endoscopic subureteral injection of Teflon was performed in 12 children (20 ureters) with neurogenic bladders and vesicoureteral reflux (grades III-IV). Follow-up evaluation by ultrasonography and voiding cystourethrogram at three-month intervals up to two years revealed successful correction of the reflux in 70 percent of the ureters.

[Echography in the follow-up of patients receiving an endoscopic injection of teflon for vesico-renal reflux]. / L'ecografia nel follow up di pazienti sottoposti ad iniezione endoscopica di teflon per reflusso vescico-renale.

The surgical treatment of vesicorenal reflux implies open surgery and consequently an hospitalization. The sub-ureteric injection of poly-tetra-fluoro ethylene (Teflon) for correction of vesicorenal reflux was first utilized in 1981 by Matouschek. We have reviewed our personal experience with endoscopic correction of vesicorenal reflux from 1985 to 1990 and evaluated the importance of ultrasonography especially in the follow up.

[Investigation of long-term follow up after endoscopic operation for vesicoureteral reflux].

BACKGROUND: Results with respect of the state of the infused agent and the cause of unsuccessful outcome were examined in patients who were followed for more than 5 years after endoscopic surgery for vesicoureteral reflux (VUR). METHODS: Of 259 ureters treated by TUI (Transurethral injection) after 1988, 41 ureters (29 patients) that were followed for more than 5 years postoperatively were investigated. In all patients, teflon paste had been infused. The intervals between surgery and study enrollment ranged from 5 to 10 years, with a mean of 5.1 years. RESULTS: After TUI was performed once, reflux disappeared in 30 (73%) of 41 ureters. The intervals between the detection of relapse and additional surgery ranged from 1 to 18 months, with a mean of 6.5 months. In 10 of 11 ureters with relapse, relapse was detected within one year after the initial surgery. When the presence or absence of reflux was examined at the final evaluation, there was no relapse in 34 of 39 ureters, with a mean postoperative follow-up of 5.9 years. Teflon paste could be sufficiently confirmed in 34 of 39 ureters excluding patients in whom TUI was changed to invasive surgery. However, this agent could not be confirmed in 5 ureters during follow-up. CONCLUSION: Teflon paste was not confirmed by bladder echo in any patient showing an unsuccessful outcome, suggesting that success or failure in this procedure depends on the persistence of paste.

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

In the five-year period 1990-95, 102 patients, 78 girls and 24 boys, aged ten weeks to 14 years were treated for grade III-V vesicoureteral reflux by the same surgeon using subureteric teflon injection--the STING procedure. Both primary, secondary and complex reflux were included. The reflux had disappeared in 90 of 133 refluxing ureters, the grade of reflux had diminished in 17 and were unchanged in 26 at the control three months after treatment. After re-STING in 22 reflux ureters, reflux disappeared in 13, was reduced in six and unchanged in three. Reappearance of low grade reflux was seen in eight of 88 ureters between the three months and one year control, but only one needed re-STING. Open surgery was performed in 13 patients (18 reflux ureters) because of unchanged reflux after STING, most of them due to complex reflux: duplex ureters, ectopic ureters, ureteroceles and paraureteral diverticula. It is concluded that most patients with vesicoureteral reflux can be successfully treated by using subureteric teflon injection.

[Prognostic value of the ultrasound visualization of the bulging agent after endoscopic treatment of vesicouretal reflux]. / Estudio del valor diagnóstico de la visualización ecográfica del material inyectado en el tratamiento endoscópico del reflujo vesicoureteral.

INTRODUCTION: The endoscopic treatment of vesicoureteral reflux constitutes an easy and simple option at the moment for its resolution in all degrees and ages. It is necessary to carry out an ECO and VCUG (vesical cystouretrography) during voiding to verify their resolution. The ultrasongraphy can detect the wheal of injected material (Teflon or Macroplastic), but it is ignored if its visualization implies its disappearance or not. OBJECTIVE: To see the correspondence or not between the sonographic presence of injected material wheal and disappearance of reflux in the VCUG. MATERIAL AND METHODS: It has been statistically selected a sample of convenience to calculate the sensibility and specificity of the sonographic visualization of the endoscopic injected material wheal. We have studied 115 ureters with all the reflux degrees and ages, chosen randomly among patients treated endoscopically of vesicoureteral reflux, independently of the injected material, polytetrafluoroethylene (Teflon) or polydimethylsiloxane (Macroplastic). Refluxes due to duplex systems and those in which there were doubts of their correct installation during endoscopy were rejected. Cases with two or more injections were rejected too. The ECO and corresponding cystographies were revised in the first control after treatment (three months later). With this data, a chart of 2X2 was built comparing the presence or not of wheal in the ECO with the presence or not of reflux in the VCUG. We calculate sensibility, specificity, PPV (positive predictive value) and NPV (negative predictive value) as well as the degree of agreement of both tests with the kappa index. RESULTS: In 115 ureteral units we visualized with ECO the wheal of injected material in 97 and not in 18 (16%). In those cases with visualized wheal, reflux disappeared in 59 (61%), and in 38 not (39%). In those cases where the wheal was not visualized, reflux disappeared in 13 and persisted in other 5 (28%). The degree of sensibility was 12%, the specificity 82%, the PPV 22% and the NPV 61%. CONCLUSIONS: Attending to the low specificity and predictive values, the sonographic presence of material wheal doesn't indicate that the reflux has been corrected, as well as its absence doesn't reflect the presence of the same one, being always necessary to carry out a cystography for its diagnosis.

[Endoscopic treatment of residual vesico-ureteral reflux after reimplantation in children: twelve cases]. / Traitement endoscopique du reflux vésico-urétéral résiduel après réimplantation chez l'enfant: a propos de 12 observations.

OBJECTIVE: To evaluate the safety and efficacy of endoscopic treatment of vesicoureteric reflux in children persisting after surgical reimplantation. MATERIAL AND METHODS: 12 children between the ages of 17 and 103 months were treated by endoscopic injection after failure of Cohen ureterovesical reimplantation. An associated uropathy was present in 4 children. Reflux was unilateral in every case. The operation was performed as a day-only procedure. All children were reviewed at 3 months. RESULTS: No early complications were observed. The follow-up cystography was normal in 10 children. The same degree of reflux persisted in 2 children, requiring a second ureterovesical reimplantation. A meatal stricture occurred 2 years after injection. The mean follow-up was 24.7 months. The success rate of the technique was 75% in this series. CONCLUSION: This technique is reliable, simple and can be performed in the day hospital. However, these good results must not mask the risk of long-term recurrence, requiring prolonged surveillance.

[Long term results of endoscopic treatment of reflux in hemodialysis patients waiting for transplantation]. / Résultats à long terme du traitement endoscopique du reflux chez les hémodialysés en attente de transplantation.

Between January 1986 and April 1988, 13 patients (mean age: 35 years) waiting for renal transplantation (mean duration of haemodialysis: 46 months) were treated by means of O'Donnell's technique. Vesico-ureteric reflux was unilateral in 6 patients and bilateral in 7 patients (20 refluxing ureteric units). Reflux was classified as Grade II for 7 ureters, Grade III for 8 ureters and Grade IV for 5 ureters. The volume of Teflon injected ranged from 1 to 4 cm3 and 6 patients received repeated injections. No complications were observed. Complete resolution of reflux was obtained in 9 patients (69%), i.e. 15 ureteric units (75%). Reflux persisted in 4 patients (31%), i.e. 5 ureteric units (25%). Three nephro-ureterectomies were performed in 2 patients with persistent high grade reflux, but 2 patients with Grade I reflux after endoscopic treatment were not operated. All patients were transplanted after endoscopic treatment (mean interval between correction of reflux and transplantation: 13 months) and a follow-up cystography was systematically performed after transplantation (mean follow-up after transplantation: 27 months): no recurrence of the reflux was detected (mean follow-up after endoscopic treatment: 40 months). Endoscopic treatment of reflux avoids the need for nephro-ureterectomy in 80% of haemodialysis patients waiting for renal transplantation and presenting with vesico-ureteric 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.

Endoscopic correction of VUR using vantris as a new non-biodegradable tissue augmenting substance: three years of prospective follow-up.

OBJECTIVE: To evaluate the efficacy of Vantris in children with vesicoureteral reflux (VUR) after 3 years of prospective follow-up. MATERIAL AND METHODS: Over the last 3 years, 109 children (72 girls and 37 boys) with a mean age of 6.2 ± 3.4 years (mean ± SD) underwent endoscopic correction of reflux using Vantris. VUR was unilateral in 53 and bilateral in 56 patients comprising 165 renal refluxing units (RRUs). Of these, primary VUR was present in 139 RRUs (84.2%) and 26 (15.8%) were complex cases. Ultrasound scan was performed 1 month, 1 year, and 3 years after injection, and voiding cystourethrogram (VCUG) was performed 3 months, 1 year, and 3 years after endoscopic correction. RESULTS: The reflux was corrected in 153 RRUs (92.7%) after a single injection and in 7 RRUs (4.2%) after a second injection. In 5 RRUs (3.1%), VUR downgraded to grade I (3 RRUs) and grade II (2 RRUs) and they were taken off antibiotic prophylaxis. Two patients (1.8%) had afebrile urinary tract infections (UTIs) and 2 patients (1.8%) developed febrile UTI. VCUG was performed in 32 of 71 children (39.1%) who completed 1 year and in 6 of 15 (40%) who completed 3 years of follow-up. None showed VUR recurrence. Ultrasound scan demonstrated normal appearance of kidneys in all but 2 patients (1.8%). One patient required stent insertion because of deterioration of hydronephrosis that resulted in complete resolution of obstruction and another patient required ureteral reimplantation. CONCLUSION: Our data show that Vantris injection provides a high level of reflux resolution with good clinical outcome during prospective follow-up.

Role of the Teflon deposit in the recurrence of vesicoureteral reflux.

A relationship between the Teflon deposit, visible with ultrasound, and long-term success of subureteric Teflon injection (STING) treatment was investigated. The study included only those patients with primary vesicoureteral reflux (VUR), in whom the reflux had disappeared and the Teflon deposits were visible 6 weeks following STING treatment. Cessation of VUR was proven by voiding cysto-urethrography (VCUG) in 99 patients (143 ureters). Average follow-up time was 9 (4-12) years. Patients were divided into two groups: group I, deposits visible with ultrasound [deposit (+)], and group II, no visible deposits at the end of the follow-up period [deposit (-)]. Reflux recurrence, the occurrence of urinary tract infection (UTI), and pyelonephritis were investigated, and technetium scintigraphy scans were examined. The deposit (+) group included 43 patients (65 ureters), and the deposit (-) group contained 56 patients (78 ureters). In the deposit (+) group there were no recurrences of VUR; however, 17 recurrences were found in the deposit (-) group (P < 0.05). Dimercaptosuccinic acid (DMSA) scintigraphy scans and occurrence of UTI showed significant difference between the groups (P < 0.05). A close relationship was found between the disappearance of the Teflon deposit and the recurrence of VUR. Disappearance of the Teflon deposit and repeated bacteriuria is a warning sign of the recurrence of VUR; therefore, VCUG might be warranted for these patients.

Endoscopic treatment for high grade vesicoureteral reflux in infants.

PURPOSE: Minimally invasive endoscopic treatment for vesicoureteral reflux has become an established alternative to long-term antibiotic prophylaxis and surgical intervention in children. We determined the long-term efficacy and safety of this treatment for high grade reflux in infants. MATERIALS AND METHODS: We retrospectively reviewed the medical records of 411 consecutive infants who underwent endoscopic treatment of grade III to V vesicoureteral reflux between June 1985 and October 2004. A total of 29 patients (7%) were excluded from study because they were lost to followup or the medical records were incomplete. Of the remaining 382 infants, including 203 males, 274 had bilateral and 108 had unilateral vesicoureteral reflux. This represented 642 high grade refluxing units with grade III to V disease in 232, 339 and 71, respectively. A dimercapto-succinic acid scan performed in 312 infants revealed renal scarring in 88 (28%). The tissue augmenting substance used for endoscopic injection was polytetrafluoroethylene and dextranomer/hyaluronic acid copolymer in 432 and 210 ureters, respectively. Endoscopic treatment was done at a median age of 7 months (range 2 months to 1 year). Median followup in these patients was 7 years (range 6 months to 20 years). RESULTS: Complete resolution of vesicoureteral reflux after a single injection occurred in 443 ureters (69%), including 73% with dextranomer/hyaluronic acid copolymer and 65% with polytetrafluoroethylene. Of the 642 ureters 127 (20%) required more than 1 injection to correct vesicoureteral reflux. In 60 ureters vesicoureteral reflux was downgraded to grade I or II and no further treatment was given, while 12 ureters that failed to respond to endoscopic treatment required open surgical intervention. Only 1 ureter required reimplantation to treat vesicoureteral obstruction. CONCLUSIONS: Endoscopic correction is a safe, effective, minimally invasive outpatient procedure for high grade vesicoureteral reflux in infants. Early correction of vesicoureteral reflux may provide protection from reflux associated renal damage and prolonged antibiotic use.

Role of positional instillation of contrast cystography in the algorithm for evaluating children with confirmed pyelonephritis.

OBJECTIVES: To assess the utility of positional instillation of contrast (PIC) cystography in detecting vesicoureteral reflux (VUR) in patients with renal scarring from recurrent febrile urinary tract infections that standard voiding cystourethrography and nuclear cystogram imaging failed to reveal. METHODS: Between June 2004 and November 2004, a total of 5 pediatric patients with recurrent febrile urinary tract infections and radiologic evidence of upper tract involvement were examined with PIC cystography. All patients had at least one previous negative standard reflux study (voiding cystourethrography or nuclear cystography). RESULTS: All 5 patients showed VUR on PIC cystography. Unilateral reflux was detected in 3 patients, and 2 patients had bilateral VUR. CONCLUSIONS: The PIC cystogram should be integrated into the algorithm for diagnosing patients with recurrent febrile urinary tract infection, who do not exhibit VUR on standard imaging modalities. The morbidity associated with undiagnosed VUR, as demonstrated by this group of patients, suggests that permanent renal damage may be prevented by early diagnosis and treatment.