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 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.

A short biodegradable helical spiral ureteric stent provides better antireflux and drainage properties than a double-J stent.

OBJECTIVE: The use of ureteric stents is a standard treatment for the relief of ureter blockages for benign or malignant reasons. The most common stent design in clinical use is a double-J stent with coiled ends to avoid stent displacement. However, there are a number of complications associated with stent use. A double-J stent design bypasses the ureterovesical junction, enables bladder pressure reflection to the renal pelvis and causes vesicoureteral reflux (VUR). This may result in scarring and renal failure. MATERIAL AND METHODS: An animal model was used to investigate whether VUR can be avoided in stented ureters using a short biodegradable partial helical spiral stent design that leaves the ureterovesical junction intact. MATERIALS AND METHODS: Eight female pigs were used. Ureters on the left side were stented using a short helical spiral SR-PLGA stent (group A) and ureters on the right side using double-J stents (group B). Simulated voiding cystoureterography and standard intravenous urography examinations were performed on all eight animals at 4 weeks and on the remaining four animals at 8 weeks. RESULTS: An SR-PLGA single coiled partial stent demonstrated superior drainage properties to a double-J stent at 4 weeks (p = 0.020). A marked but not statistically significant difference in favour of a SR-PLGA stent was also observed at 8 weeks (p = 0.102). A statistically significant difference was observed in VCUG findings in favour of group A at immediate postoperative control as well as in the 4 and 8 week follow-up studies (p = 0.011, p = 0.010, p = 0.046, respectively). CONCLUSION: A self-expandable, SR-PLGA partial ureteric stent presented with superior drainage and antireflux properties compared to a double-J stent. The reflux commonly related to double-J stent use can be minimized by using a partial ureteric stent design.

Endoscopic treatment of vesicoureteral reflux using dextranomer/hyaluronic acid copolymer in children: results of postoperative follow-up with real-time 3D sonography.

OBJECTIVES: We evaluated whether real-time 3D ultrasound (4D-US) together with clinical evaluation is an alternative to voiding cystourethrography (VCUG) after endoscopic treatment of vesicoureteral reflux (VUR) in children at postoperative follow-up. MATERIAL AND METHODS: We reviewed 178 children who underwent endoscopic therapy with dextranomer/hyaluronic acid copolymer in grade II or III VUR between 2002 and 2005. 4D-US was performed in all patients 1 day and 3, 9 and 18 months after endoscopic therapy. Only children with postoperative urinary tract infections (UTIs) and/or nonorthotopic position of the bulking agent were referred for VCUG. RESULTS: In 93% of the ureteral units, the depot could be detected in the orthotopic position after 3, 9 and 18 months. None of these children developed UTIs in the postoperative follow-up. Twelve children demonstrated a shifting of the depot, indicating a possible therapy failure. Eight of these 12 patients (66.7%) presented a positive VCUG, and 50% of them sustained UTIs. CONCLUSIONS: 4D-US seems to be a sufficient protocol in the follow-up of children after endoscopic treatment of low-grade VUR. VCUG should be performed in cases of a shifted position of the depot; invasive investigations are unnecessary in asymptomatic children with orthotopic bulk.

Efficacy of endoscopic subureteral injection for vesicoureteral reflux in adults with decreased bladder compliance.

OBJECTIVE: To evaluate the outcome of endoscopic subureteral injection (ESI) in adults with vesicoureteral reflux (VUR) associated with decreased bladder compliance (D-BC). METHODS: We retrospectively reviewed the medical records of 46 consecutive patients who underwent ESI for VUR at a single tertiary academic center. Fourteen patients (17 ureter units) who had underlying neurological disease with decreased bladder compliance, as determined by filling cystometry, were grouped as D-BC. Thirty-two patients (47 units) who had no signs or symptoms that suggested neurogenic lower urinary tract dysfunctions were grouped as normal bladder compliance (N-BC). We compared the cure rates for ESI between groups, defining cure as complete resolution of reflux on voiding cystourethrogram. RESULTS: In 70.6% of the D-BC group and 70.2% of the N-BC group, VUR resolved completely after the first injection (P = 0.977). One failed unit of D-BC was cured after second ESI, and seven failed units of N-BC were cured after additional treatments (second ESI, two patients; ureteroneocystostomy, five patients). No additional treatments were applied to three units of D-BC or seven units of N-BC without symptoms. No complications related to the ESI were observed. CONCLUSIONS: The ESI was found to be effective in adults with VUR regardless of the bladder compliance. As a minimally invasive procedure with a favorable outcome, ESI may represent the first choice for treatment of VUR even in adults with D-BC.

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.

Endoscopic submucosal Teflon injection (STING): an alternative treatment of vesicoureteric reflux in children.

The authors present their results in treating vesicoureteric reflux with an endoscopic submucosal teflon injection (STING) of the refluxing ureter. One hundred refluxing units in 68 children were treated with a maximum follow-up of five years. Indications were high grade reflux (III-V), persistence or progression of reflux despite conservative therapy, breakthrough urinary infections despite antibiotic prophylaxis and finally bad antibiotic compliance. Treatment was performed on an outpatient basis and appeared to be free of complications. Reflux was cured with a success rate of 75% after a single injection and 96% after two injections. With respect to the grade of reflux, best results were obtained in low grade reflux (Grade I-II). A 60-70% success rate was obtained in high grade reflux (III-V). The main advantage over open reimplantations lies in its non invasiveness, simplicity and possibility of being repeated in case of failure.

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.

[Early results of endoscopic treatment of vesico-ureteral reflux in children]. / Frühergebnisse der endoskopischen Behandlung des vesikoureteralen Refluxes bei Kindern.

Endoscopic treatment of vesicoureteral reflux (VUR) is based on transurethral injection of Teflon paste or collagen gel into the submucosa of the bladder wall beneath the distal ureter, resulting in support of the intramural part. This endoscopic procedure was performed in 75 children with VUR of varying severity. Altogether 111 ureters were treated, 94 with injections of Teflon paste and 17 with collagen gel. Improvement of VUR in the early postoperative period was achieved in 91.5% of the ureters treated with Teflon and in 82.4% of the ureters treated with collagen. No complications were observed. Endoscopic treatment of VUR seems to be an worthwhile alternative to open surgery. However, since long-term follow-up has not been completed, the efficacy of the method cannot yet be finally assessed.

[Results of endoscopic treatment of primary vesico-ureteral reflux with a follow-up of 2-5 years]. / Résultats du traitement endoscopique du reflux vésico-urétéral primitif avec un recul de 2 à 5 ans.

34 patients treated by endoscopic injection of Teflon for vesico-ureteric reflux were reviewed with a follow-up of 2 to 5 years. 45 of the 48 treated ureters showed no signs of reflux, i.e. 93.7% medium-term success rate. 3 cases of reflux recurred after two years and 2 of them were successfully reinjected. There were no upper urinary tract complications. Endoscopic injection of Teflon appears to be a reliable alternative to open surgery.

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.

Is a third endoscopic treatment for vesicoureteral reflux indicated if previous attempts have failed?

OBJECTIVE: To evaluate the efficacy of a third endoscopic injection to correct vesicoureteral reflux (VUR). PATIENTS AND METHODS: This was a prospective study of 605 patients, of whom 42 (6.4%), involving 44 (4%) ureteral units, received a third injection. The results were analysed regarding VUR grade and aetiology, substance used, volume, location and morphology of the mound, presence of poor prognostic factors, the urologist's experience, and complications. RESULTS: The treatment resolved the VUR in 38 (86.4%) units, 22 of primary cause (91.6%) and 16 with anatomical/functional abnormalities (80%) (no significant difference; P = 0.26). There was also no significant difference in success rate with regard to the substance injected (P = 0.23), the degree of VUR (P = 0.76) or the volume injected (P = 0.17). The success rate was higher (96.9%) if a less experienced urologist had performed the previous procedure versus a more experienced urologist (54.5%), and this difference was significant (P < 0.005). There was one complication (haematuria) (2.3%). CONCLUSION: Third treatment presents a similar efficacy to first and second treatments, with a very low rate of complications, and could be indicated before open surgery.

Polydimethylsiloxane (macroplastique®) injection for vesicoureteral reflux in duplex ureters: a comparison with single renal systems.

OBJECTIVE: VUR in patients with a duplex system (DS) is often treated by open surgery. The aim of this study was to evaluate the efficacy of subureteric polydimethylsiloxane (Macroplastique(®)) injection (SMING) in the management of VUR in duplex and single (SS) renal systems. PATIENTS AND METHODS: Fifteen children (24 refluxing renal units) with VUR in DS underwent SMING. VUR was more frequent in the lower moiety. VUR was graded moderate/severe in 88% of renal units. There was a history of urinary tract infections in 40% of cases. The outcome for DS patients was compared with 44 children (60 refluxing renal units) with moderate/severe VUR in SS. RESULTS: The VUR resolution/improvement rate was 88% in DS and 95% in SS patients. Ureteric reimplantation was required because of recurrent VUR in 13% and 7% of DS and SS groups, respectively. Transient ureteral obstruction was observed in 1/15 and 5/44 patients. Two required double-J ureteric stenting for 3 months. CONCLUSION: SMING seems an effective treatment for VUR in both DS and SS patients, even in severe cases. The complication rate does not significantly differ between the two groups.

Long-term results of endoscopic treatment of vesicoureteric reflux with different tissue-augmenting substances.

OBJECTIVE: To review the current literature regarding the outcome of endoscopic treatment of vesicoureteric reflux (VUR) using different tissue-augmenting substances, with special emphasis on long-term efficacy. MATERIAL AND METHODS: The current literature, including our own experience, on long-term results after endoscopic treatment was reviewed by MEDLINE/PubMed search. RESULTS: The short-term results are similar in the majority of series to those of open surgery, but there is a high recurrence rate with use of dextranomer/hyaluronic acid (Deflux) as a tissue-augmenting material. CONCLUSIONS: There is a significant shortage of evidence-based literature on long-term follow-up after endoscopic correction of VUR utilizing dextranomer/hyaluronic acid. The high recurrence rate that has been reported after Deflux injection highlights a need for close observation beyond routine protocols and appropriate parental counseling upon endoscopic correction, and also the need to search further for alternative tissue-augmenting substances. The algorithm for treating VUR is yet to be finally determined.

[Long-term results after endoscopic subureteral injection for VUR using dextranomer/hyaluronic acid copolymer : a five years experience]. / Endoskopische Unterspritzung des vesikoureteralen Refluxes mit Dextranomer/Hyaluronsäure : 5-Jahres-Langzeitergebnisse.

BACKGROUND: A number of bulking agents have been used for the endoscopic correction of vesicoureteral reflux in children. We present the long-term results of endoscopic use of dextranomer/hyaluronic acid copolymer (Deflux) for VUR grade I-IV in children. PATIENTS AND METHODS: Between 2004 and 2008, 21 children underwent endoscopic subureteral injection of Deflux in 30 ureters as an outpatient procedure. Twelve children had a unilateral reflux (two duplicated systems) and nine had a bilateral reflux. The median age was 5 years (6 months to 14.9 years). Six weeks postoperatively a voiding cystourethrogram (VCUG) was performed. This study examined the disappearance of VUR and urinary tract infection (UTI) as well as the quality of life (parents' questionnaire) during long-term follow-up. RESULTS: No intra- and postoperative complications were noticed. In 25 ureters (83%) VCUG showed no VUR 6 weeks postoperatively. In three children a second injection was done (two were successful). After a median follow-up of 2.5 years 27 ureters in 17 children (90%) had no UTI and VUR. The results of the questionnaire regarding quality of life were very good in the successfully treated children and the parents would choose the same treatment option again. CONCLUSION: Subureteral injection of Deflux for children with VUR is an effective treatment option for VUR with a low complication rate.

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. .

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.

Endoscopic treatment of vesicoureteral reflux.

PURPOSE OF REVIEW: The treatment of vesicoureteral reflux in children has seen a shift from invasive surgery to endoscopic management in recent years. Early studies demonstrate favorable outcomes but do not reach the success of surgery. Subspecialization also may play a role in the successful outcomes of all reflux management. This review focuses on the recent literature regarding endoscopic treatment of reflux and the role of subspecialization in treatment of children. RECENT FINDINGS: Dextranomer/hyaluronic acid copolymer has emerged as the favored bulking agent since its Food and Drug Administration approval in the United States. Although success is defined somewhat differently than surgery, overall success rates range from 82-89% with initial injection of dextranomer/hyaluronic acid. The outpatient nature of the procedure and its high success rate have led to a shift in treatment strategies especially in Europe, where endoscopic management is often considered first-line therapy. Extravesical reimplants can be performed on an outpatient basis safely. Subspecialization leads to improved outcomes with no difference in cost. SUMMARY: Endoscopic treatment of reflux is promising, but long-term results are not available to ascertain the efficacy of treatment into adulthood. Open surgery remains the gold standard.