Laparoscopic and Robot-assisted Laparoscopic Reimplantation for Lower Ureter Pathology. A Multi-institutional Comparative Study in 1343 Patients.

OBJECTIVE: To evaluate the outcomes of children with vesicoureteral reflux (VUR) and obstructive megaureter (OM) utilizing various laparoscopic and robot-assisted approaches. MATERIALS AND METHODS: Retrospective review of all pediatric laparoscopic and robot-assisted cases for lower ureter pathology was performed between 2016-2022 in 13 academic centers worldwide. Five surgical approaches were assessed: LEUR, LVCUR, LDECUR, RALUR, and RADECUR. RESULTS: One thousand three hundred forty-three patients (490 boys and 853 girls) with a median age of 30 months (IQR 12-63) were treated at 13 centers. Nine hundred and eight patients (68%) underwent reimplantation due to VUR (unilateral in 818 and bilateral in 90 patients). Four hundred thirty-five (32%) had a surgery due to ureterovesical junction (UVJ) obstruction. Mean length of follow-up was 14 months (IQR 8-33). Median operative time was 202 minutes (IQR 142-220) in the robotic arm compared to 240 minutes (IQR 160-267) in the laparoscopic (P = .45). Intracorporeal excisional tapering was performed in 118 (8%) of the patients. Six patients in the OM group required additional surgery due to progressive obstruction. In the VUR group, 84% underwent voiding cystourethrography postoperatively. 5.6% showed residual reflux. Grade 1-2 Clavien-Dindo complications occurred in 10 patients (0.7%) and 6 (0.4%) in the laparoscopic and robotic arm, respectively. Grade 3 complications occurred in 17 (1.2%) and 8 (0.5%) in both arms, respectively. Surgical success was achieved in 96% of patients. CONCLUSION: Laparoscopic and robot-assisted laparoscopic approaches are simple, safe, and effective for treating all grades of VUR and OM. Robot-assisted approach is beneficial in terms of operative time, intracorporeal suturing, and lower complications rate.

The Effectiveness of Deflux® Treatment for Vesicoureteral Reflux Following Pediatric Renal Transplantation: A Single-Institution Challenging Experience.

PURPOSE: To validate the effectiveness of Deflux® treatment for vesicoureteral reflux (VUR) following pediatric renal transplantation (RT), based on our single-institution experience. METHOD: A retrospective study was conducted using the medical records of pediatric patients who underwent Deflux® treatment for VUR after RT from April 2008 to March 2022. RESULTS: Sixty-eight pediatric patients underwent RT. VUR was subsequently detected in 22 (32 %) of these patients. Seven of the 22 patients (32 %) underwent Deflux® treatment to avoid renal dysfunction due to urinary infection (UTI). The median age at the time of RT was 4 years (range:2-12). All 7 patients had urinary UTIs before Deflux® treatment. The median estimated glomerular filtration rate (eGFR) before Deflux® treatment was 67 ml/min/1.73 m2 (range:42-138 ml/min/1.73 m2). After Deflux® treatment, VUR was downgraded in three cases (43 %). Four patients (57 %) experienced postoperative UTI, two of who underwent a second Deflux® treatment, one underwent submuscular tunnel reconstruction, and the other one experienced UTI without VUR after 1st Deflux® treatment but did not reoccur. All seven patients continued prophylactic medication after Deflux® treatment, without any history of recurrent UTIs during the observation period after treatment (median 37 months [range 7-86 months]). Furthermore, the eGFRs did not significantly decrease after Deflux® treatment (median eGFR 58 ml/min/1.73 m2 [range:33-99 ml/min/1.73 m2], p > 0.1). CONCLUSION: Deflux® treatment for VUR after RT is technically challenging because the new ureteral orifice is ventrally anastomosed at the bladder. We believe our results indicate the possibility of reducing the frequency of UTIs and contributing to preservation of the renal function after RT. TYPE OF STUDY: Retrospective Study. LEVEL OF EVIDENCE: Level III.

Successful rescue pneumovesicoscopic surgery for post-Deflux® vesicoureteral junction obstruction.

BACKGROUND: Vesicoureteral junction (VUJ) obstruction after Deflux® subureteral injection for vesicoureteral reflux (VUR) is rare and minimally invasive management has not been reported. This work investigated the patients who underwent Deflux® injection for VUR and identified those with subsequent VUJ obstruction. METHODS: Medical records of matched patients from October 2003 to March 2022 were reviewed, and parameters were retrospectively studied. All patients underwent Deflux® injection. The injection was performed under general anesthesia using the same manner. For patients complicated with VUJ obstruction, the symptoms, signs, management, images, renal ultrasounds, Tc-99m dimercaptosuccinic acid renal scintigraphy, histology of VUJ region, and outcomes were documented and reported. VUJ stenosis was diagnosed by performing renal ultrasound and magnetic resonance imaging. RESULTS: Totally 407 patients (554 ureterorenal units) received Dx/HA injections for VUR. VUJ obstruction was found in three patients (four ureterorenal units). Originally, three were grade V VUR, and one was grade IV. The repeated injection was not a risk factor for VUJ obstruction. The overall incidence of VUJ obstruction post-Dx/HA injection was 0.7% by ureter. The incidences were 0%, 0.75%, and 2.25% for grade I-III, IV, and V VUR, respectively. After the initial conversion case of pneumovesicoscopic ureteral reimplantation, the procedure was performed smoothly and successfully in the two following cases. CONCLUSIONS: Pneumovesicoscopic ureteral reimplantation offers an alternative for VUJ obstruction following Dx/HA injection for VUR. Fibrosis and foreign-body reaction may influence the feasibility. High-grade VUR and young age of injection were related to VUJ obstruction.

Four-Point Injection Technique of Polyacrylate/Polyalcohol Copolymer in Vesicoureteral Reflux After KidneyTransplant.

OBJECTIVES: Vesicoureteral reflux after kidney transplant is mostly asymptomatic, but recurrent urinary tract infections can cause graft rejection. Although the gold standard treatment is open surgical repair, we believe that endoscopic treatment can be further improved. Here, we investigated the long-term outcomes of 4-point endoscopic injection of polyacrylate/polyalcohol copolymer in patients with vesicoureteral reflux after kidney transplant. MATERIALS AND METHODS: Patients who had undergone 4-point endoscopic injectionofpolyacrylate/polyalcohol copolymer for symptomatic vesicoureteral reflux after kidney transplant and were followed for atleast 3 years were included. Patients with dysfunctional and/or obstructive voiding patterns, unsuccessful primary endoscopic treatment, concomitant injection of native kidney reflux, and incomplete follow-up were excluded. We evaluated patient characteristics, perioperative data, and clinical and radiological outcomes. Urine culture, serum creatinine, and renal ultrasonography were assessed every 3 months. Voiding cystourethrography was performed at month 3 and when recurrence was suspected. Clinical success was defined as absence of febrile urinary tract infection during follow-up, and radiological success was defined as absence of vesicoureteral reflux in the voiding cystourethrography. RESULTS: Of 21 study patients, 14 (66.6%) were female and 7 (33.3%) were male patients. Average age was 37.1 years (range, 12-62 years). According to preoperative voiding cystourethrography, 3 patients (14.2%) had grade II, 13 patients (61.9%) had grade III, and 5 patients (23.8%) had grade IV vesicoureteral reflux. Eighteen patients (85.7%) had clinical success with the first injection, and 20 patients (95.2%) had success with the second injection. Eleven patients (52.3%) demonstrated radiological success. The reflux degree of all patients, except 2, had partially or completely regressed. Ureteral balloon dilatation and double J stent implantation was performed in 1 patient (4.7%) due to ureteral obstruction. CONCLUSIONS: The 4-point injection of polyacrylate/- polyalcohol copolymer provided long-term permanent success for symptomatic vesicoureteral reflux after kidney transplant.

Ureteral stricture after pediatric kidney transplantation: Is there a role for percutaneous antegrade ureteroplasty?

INTRODUCTION: Ureteral obstruction following pediatric kidney transplantation occurs in 5-8% of cases. We describe our experience with percutaneous antegrade ureteroplasty for the treatment of ureteral stricture in pediatric kidney transplant patients. METHODS: We retrospectively reviewed all pediatric kidney transplantation patients who presented with ureteral stricture and underwent percutaneous antegrade ureteroplasty at our institution from July 2009 to July 2021. Variables included patient demographics, timing of presentation, location and extent of stricture, ureteroplasty technique and clinical outcomes. Our primary outcome was persistent obstruction of the kidney transplant. RESULTS: Twelve patients met inclusion criteria (4.2% of all transplants). Median age at time of ureteroplasty was 11.5 years (range: 3-17.5 years). Median time from kidney transplantation to ureteroplasty was 3 months. Patency was maintained in 50% of patients. Seven patients (58.3%) required additional surgery. Four patients developed vesicoureteral reflux. Patients with persistent obstruction had a longer time from transplant to ureteroplasty compared to those who achieved patency (19.3 vs 1.3 months, p = 0.0163). Of those treated within 6 months after transplantation, two patients (25%) required surgery for persistent obstruction (p = 0.06). All patients treated >1 year after transplantation had persistent obstruction following ureteroplasty (p = 0.06). CONCLUSION: Percutaneous antegrade ureteroplasty can be considered a viable minimally invasive treatment option for pediatric patients who develop early ureteral obstruction (<6 months) following kidney transplantation. In patients who are successfully treated with ureteroplasty, 67% can develop vesicoureteral reflux into the transplant kidney. Patients who fail early percutaneous ureteroplasty or develop obstruction >1 year after transplantation are best managed with surgical intervention.

An innovative diagnostic procedure in children: videourodynamics with contrast-enhanced voiding urosonography.

Contemporary videourodynamic (VUD) investigation combines voiding cystourethrography (VCUG) and urodynamics into one study, which allows simultaneous visualization of the urinary tract by ionizing radiation alongside the measurement of sensation, capacity, compliance, and detrusor pressure during bladder filling and voiding using one double lumen catheter. Today VUD is a benchmark for evaluating the lower urinary tract disorders in children because it evaluates urinary bladder and sphincter function and visualizes bladder morphology and vesicoureteral reflux (VUR) presence at the same time. Several previous studies of fluoroscopic videourodynamics issued concerns regarding radiation exposure. This technical report aims to describe a new modality of VUD in children by replacing fluoroscopic VCUG with contrast-enhanced voiding urosonography (ceVUS). ceVUS using second-generation contrast media and harmonic imaging is a radiation-free and highly sensitive imaging modality used to detect VUR in children. We simultaneously performed an infusion of ultrasound contrast through the double lumen urodynamic catheter during urodynamic evaluation. This article describes the advantages of this method compared with a conventional technique. In addition to being radiation-free, this procedure of advanced videourodynamics method can better detect vesicoureteral reflux and intrarenal reflux combined with urodynamic disorders associated with VUR.

Is Anti-Reflux Anastomosis an Advantage in an Orthotopic Ileal Neobladder? A Systematic Review and Meta-Analysis.

INTRODUCTION: We conducted a systematic review and meta-analysis to assess the available literature regarding the postoperative effects of anti-reflux anastomosis and direct anastomosis in orthotopic ileal neobladder (ONB). METHODS: We searched PubMed, Embase, and the Cochrane Library in October 2021. We included 11 studies of patients with bladder cancer who underwent radical cystectomy and ONB as urinary diversion. Outcomes evaluated in this review were ureteroenteric anastomotic stricture (UEAS), vesicoureteral reflux, renal function (RFn) impairment, and pyelonephritis. All data were analyzed using Review Manager 5.4.4 and subgroup analyses were applied. RESULTS: A total of 11 studies were eligible for meta-analysis. The synthetic data suggested that anti-reflux anastomosis and direct anastomosis were comparable in terms of RFn impairment (odds ratio (OR) = 1.69; 95% confidence interval (CI): 0.18-15.6; p = 0.65, I2 = 69%) and pyelonephritis (OR = 1.13; 95% CI: 0.65-1.99; p = 0.66, I2 = 1%) without significant difference in each group statistically. The pooled study data showed a significantly higher incidence of UEAS (OR = 2.84; 95% CI: 1.75-4.61, p < 0.0001, I2 = 50%) and a lower incidence of vesicoureteral reflux (OR = 0.24; 95% CI: 0.10-0.59; p = 0.002, I2 = 75%) in anti-reflux anastomosis compared to direct anastomosis. In subgroup analysis, anti-reflux anastomosis was more likely to result in UEAS than direct anastomosis, especially when ureteral stent was removed within 14 days. CONCLUSION: Although meta-analysis showed that overall incidence of vesicoureteral reflux was higher with direct anastomosis than anti-reflux anastomosis, the rate of vesicoureteral reflux was not directly related to impairment of RFn. The anti-reflux mechanism of ONB was positively associated with a higher incidence of significant UEAS compared to the direct approach, which can lead to kidney damage and an increased risk of secondary surgical procedures.

Laparoscopic Extravesical Reimplantation in Children with Primary Obstructive Megaureter.

Introduction: Conservative management of primary obstructive megaureter (POM) appears as the best option in patients with adequate ureteral drainage. Nevertheless, surgical intervention is indicated in cases of recurrent urinary tract Infections (UTIs), deterioration of split renal function, and significant obstruction. The gold standard includes: Ureteral reimplantation with or without tapering by open approach. Our objective is to report our results in the treatment of POM by Laparoscopic-Assisted Extracorporeal Ureteral Tapering Repair (EUTR) and Laparoscopic Ureteral Extravesical Reimplantation (LUER) and to evaluate the efficacy and security of this procedure. Materials and Methods: From January 2011 to January 2018 a retrospective study was carried out by reviewing the clinical records of 26 patients diagnosed with POM. All patients underwent laparoscopic ureteral reimplantation following Lich Gregoir technique. In cases of ureteral tapering, an EUTR was performed with Hendren technique. Results: In all patients LUER and EUTR were performed without conversion. No ureteral tapering was necessary in six patients. There were no intraoperative complications. At 3 months in postoperative, 1 patient presented a febrile UTI, and subsequently, a vesicoureteral reflux (VUR) grade III was diagnosed by voiding cystourethrogram. In this case, a redo laparoscopic surgery was performed. After long-term follow-up, all patients were asymptomatic without recurrence of POM or VUR. Conclusion: Laparoscopic-assisted EUTR and LUER following Lich Gregoir technique for POM constitutes a safe and effective option, with a success rate similar to that of open procedure. Nevertheless, larger randomized prospective trials and long-term follow-up are required to validate this technique.

Renal Cyst after Heminephrectomy in a Pediatric Patient: Complication or Normality?

INTRODUCTION: In this work, we present two cases of heminephrectomies with postoperative findings of cystic lesions in the bed of the excised renal segment. MATERIAL AND METHODS: Description of the clinical cases, therapeutic management and description of the ultrasound findings. A review of the published cases was carried out. RESULTS: We present a case of open heminephrectomy due to atrophy of the upper hemirrenal in a case of ureterocele, and another case with bilateral lower heminephrectomy in a case of vesicoureteral reflux disease. In the first case, the cystic lesion disappeared during follow-up, while in the second, the cysts remained stable. In none of the cases published in the literature was it necessary to perform any intervention to resolve the cysts. CONCLUSIONS: The appearance of cystic lesions in the heminephrectomy bed in pediatric patients is a radiological finding that occurs frequently. Due to its favorable evolution, without the need for additional procedures for its resolution, we do not consider the presence of these lesions as a complication after heminephrectomy.

Laparoscopic triple-ureteral ureteroureterostomy in a patient with ureteral triplication: A case report.

RATIONALE: Ureteral triplication (UT) is a very rare disorder, with a challenging diagnosis and varied therapeutic methods. In the past, the treatment usually involved heminephrureterectomy of the stunted moiety. Here, we reported a case of complete UT that was treated by laparoscopic triple-ureteral ureteroureterostomy (UU). PATIENT CONCERNS: A 2-year-old girl presented with frequent urine incontinence. Intravenous pyelography and voiding cystourethrography revealed a 3-segment left kidney with pelvi-ureteric dilation of the upper and middle moieties and grade IV to V vesicoureteral reflux. Laparoscopic triple-UU was successfully performed in the child, after which vesicoureteral reflux and urinary incontinence disappeared completely, hydronephrosis was improved, and hemirenal resection was avoided. DIAGNOSIS: Based on the imageological examination results, the final diagnosis of the 2-year-old girl was as follows: left 3 renal pelvis with complete ureteral duplication, combined with upper and middle hydronephrosis, and upper and middle vesicoureteral reflux grade IV to V. INTERVENTION: Laparoscopic triple-ureteral ureteroureterostomy was performed under general anesthesia. OUTCOMES: The patient recovered smoothly without complications after surgery. At 6 months follow-up, ultrasonography of the urinary system showed that hydronephrosis of the dilated kidney segment was attenuated. LESSONS: Laparoscopic triple-ureteral UU was successful in our patient. For children with duplex kidney and multiple ureteral duplications, minimally invasive urinary tract reconstruction can be a suitable intervention.

Revision ureteroneocystostomy in pediatric renal transplant patients for symptomatic vesicoureteral reflux and its effect on recurrent hospitalizations.

BACKGROUND: Nearly 13,000 pediatric renal transplantations have been performed since 1987 with improving overall mortality and morbidity; however, graft infection remains a significant post-transplant concern. Recurrent urinary tract infections in pediatric patients with vesicoureteral reflux into their renal transplant can result in graft dysfunction, increased hospital cost, and impaired social and cognitive development due to time spent hospitalized. OBJECTIVE: To evaluate the effect of revision ureteroneocystostomy on pediatric renal transplant patients with symptomatic vesicoureteral reflux in reducing hospitalizations and recurrent urinary tract infections. METHODS: We retrospectively reviewed pediatric patients from 2002 through 2021 who underwent renal transplantation and required revision ureteroneocystostomy due to symptomatic vesicoureteral reflux. We analyzed the differences in days hospitalized, days hospitalized due to urinary tract infection, and treated urinary tract infections prior to and after revision ureteroneocystostomy. RESULTS: Ten patients requiring revision ureteroneocystostomy secondary to symptomatic vesicoureteral reflux were identified. There was no difference in the observation time between transplant to revision, and revision to last follow up (2.3 years (IQR 1.3-6.5) vs 1.7 years (IQR 1-6.7), p = 0.4446). Overall, there was a significant decrease in the total number of hospitalization days (21.5 days (IQR 3-43) vs 5.5 days (IQR 0-9), p = 0.006), total number of hospitalization days related to urinary tract infection (14.5 days (IQR 3-28) vs 0 days (IQR 0-3), p = 0.008) and treated urinary tract infections (3.5 (IQR 3-6) vs 1 (IQR 0-2), p = 0.019) following revision ureteroneocystostomy. The rate of hospitalization days for urinary tract infection was also significantly decreased following revision ureteroneocystostomy (7.15 per/year (IQR 0.4-11.75) vs 0 per/year (IQR 0-0.8), p = 0.008). DISCUSSION: Symptomatic vesicoureteral reflux in pediatric transplant patients is difficult to manage and some patients will ultimately require surgery. There have been previous studies on the success of revision ureteroneocystostomy in treating reflux but no data on the reduction in hospitalizations associated with recurrent infections following the procedure. Limitations of this study are the small cohort size, retrospective nature, multi-surgeon study, and inherent selection bias due to evaluation of only surgical patients. CONCLUSION: Revision ureteroneocystostomy can limit the negative consequences of recurrent graft infections with reduction in hospitalization days and improved hospitalization rates due to urinary tract infections. The reduction in hospitalizations can greatly improve the cost of care along with quality of life for transplant patients and should be strongly considered in children with symptomatic vesicoureteral reflux who have failed conservative therapy.

Vesicoureteral reflux treatment following kidney transplantation potentially prevents graft function deterioration and allows long-term graft survival.

OBJECTIVES: The impact of vesicoureteral reflux post-kidney transplantation on graft survival remains unclear, and guidelines on appropriate vesicoureteral reflux management post-kidney transplantation are lacking. For this reason, we conducted a retrospective study on the impact of vesicoureteral reflux and its treatment on graft survival. METHODS: We evaluated 347 consecutive kidney transplantation recipients, who also underwent a ureteroneocystostomy, between 1996 and 2012. RESULTS: Vesicoureteral reflux was diagnosed in 55 cases (15.9%), with a median post-kidney transplantation duration of 50 months (range 0-172 months). Among these, 22 were monitored, 17 underwent transurethral collagen injections, and 16 received a ureteroneocystostomy. The 10-year graft survival rate was significantly lower in recipients with vesicoureteral reflux (68.9%) than in those without vesicoureteral reflux (84.4%) (P = 0.0165). Moreover, among the vesicoureteral reflux recipients, the 10-year graft survival rate was significantly higher in those whose vesicoureteral reflux was cured (80.1%) than in those whose vesicoureteral reflux persisted (53.6%) (P = 0.0062). Multivariate analysis showed that vesicoureteral reflux was significantly associated with both overall and death-censored graft loss (odds ratio 3.737 and 3.685; P = 0.0015 and P = 0.0052, respectively). Lastly, the incidence of interstitial fibrosis and tubular atrophy was higher in recipients with vesicoureteral reflux than in those without vesicoureteral reflux (P = 0.0009). CONCLUSIONS: Post-kidney transplantation vesicoureteral reflux has a negative impact on long-term graft survival, and that treatment prevents graft deterioration. From the perspective of maintaining long-term graft function in kidney recipients, vesicoureteral reflux may be one of the most important complications to be addressed.

A systematic review & meta-analysis comparing outcomes of endoscopic treatment of primary vesico ureteric reflux in children with polyacrylate poly alcohol copolymer versus dextranomer hyaluranic acid.

BACKGROUND & AIMS: There are conflicting reports on the efficacy of bulking agents for vesico ureteric reflux (VUR). In this meta-analysis we have compared the outcomes of endoscopic treatment with polyacrylate polyalcohol copolymer (PPC) and dextranomer hyaluronic acid (DxHA). METHODS: A systematic review of publications between 2010 and 2020 was conducted covering databases like PUBMED, MEDLINE etc. for (endoscopic treatment) AND (VUR) AND (PPC OR DxHA) AND (recurrence OR complications). PRISMA guidelines were followed and only comparative studies were included. Outcomes were early success defined as absence of VUR in voiding cystourethrogram at 3-months followup, urinary tract infections (UTI) and occurrence of vesico-ureteric-junction obstruction (VUJO). Risk of bias was analysed with Robvis tool and odds-ratios were compared with Revman-3.0. RESULTS: Among nine studies (heterogeneity; I 2 69-79%) all cleared the risk of bias assessment. There was no significant difference in high grade VUR (p = 0.94) between PPC (40%) and DxHA (43%). Success rate after single injection was significantly higher (p = 0.0001) at 86% (477/555) for PPC vs 69% (474/685) for DxHA. UTI rate between PPC (12%) and DxHA (14.6%) was not statistically significant (p = 0.54). VUJO rate between PPC (3.9%) and DxHA (0.8%) was also not significantly different (p = 0.47). Significantly lesser volume (p = 0.02) was used for PPC (0.7 ml) compared to DxHA (0.9 ml). CONCLUSION: Reflux resolution was significantly higher with PPC than DxHA. Postinjection UTI/VUJO incidence was not significantly different between them. Limitation of this meta-analysis was heterogeneity & small number of articles. Further studies should focus on long-term outcomes and cost-effectiveness.

Prenatal hydronephrosis: Bridging pre- and postnatal management.

Urinary tract dilation (UTD), including hydronephrosis (HN) is the most common prenatally detected anomaly and affects up to 1%-2% of pregnancies. Postnatally, it resolves without surgical intervention in approximately 75%-80% of children, however this may take several years to occur, necessitating repeated clinic visits and additional invasive testing for many. For the remainder, a surgical intervention will be offered to relieve obstruction or to correct vesicoureteral reflux. During the monitoring period, many of these infants will be offered continuous antibiotic prophylaxis for the prevention of urinary tract infections, however this remains a controversial topic among pediatric urologists and nephrologists. Herein, we present an up-to-date review of the early management of prenatally detected UTD including timing of postnatal imaging, the use of antibiotics, when circumcision may be beneficial and long term outcomes of the most common HN etiologies. We also propose a decision making tool to help guide the care of infants with UTD.

Allograft Vesicoureteral Reflux after Kidney Transplantation.

Allograft vesicoureteral reflux (VUR) is a leading urological complication of kidney transplantation. Despite the relatively high incidence, there is a lack of consensus regarding VUR risk factors, impact on renal function, and management. Dialysis vintage and atrophic bladder have been recognized as the most relevant recipient-related determinants of post-transplant VUR, whilst possible relationships with sex, age, and ureteral implantation technique remain debated. Clinical manifestations vary from an asymptomatic condition to persistent or recurrent urinary tract infections (UTIs). Voiding cystourethrography is widely accepted as the gold standard diagnostic modality, and the reflux is generally graded following the International Reflux Study Committee Scale. Long-term transplant outcomes of recipients with asymptomatic grade I-III VUR are yet to be clarified. On the contrary, available data suggest that symptomatic grade IV-V VUR may lead to progressive allograft dysfunction and premature transplant loss. Therapeutic options include watchful waiting, prolonged antibiotic suppression, sub-mucosal endoscopic injection of dextranomer/hyaluronic acid copolymer at the site of the ureteral anastomosis, and surgery. Indication for specific treatments depends on recipient's characteristics (age, frailty, compliance with antibiotics), renal function (serum creatinine concentration < 2.5 vs. ≥ 2.5 mg/dL), severity of UTIs, and VUR grading (grade I-III vs. IV-V). Current evidence supporting surgical referral over more conservative strategies is weak. Therefore, a tailored approach should be preferred. Properly designed studies, with adequate sample size and follow-up, are warranted to clarify those unresolved issues.

Long-term results of endoscopic treatment in vesicoureteral reflux after kidney transplantation.

OBJECTIVES: To assess the long-term clinical outcomes and identify factors predicting success of endoscopic treatment for symptomatic vesicoureteral reflux (VUR) after kidney transplantation. PATIENTS AND METHODS: A retrospective chart review of all patients who had a symptomatic VUR after renal transplantation at our centre between January 2000 and December 2020 was performed. VUR was documented by retrograde cystography and was determined by at least one episode of acute graft pyelonephritis (AGPN). Endoscopic injections of polydimethylsiloxane (MacroPlastique™) or dextranomer/hyaluronic acid copolymer (Deflux™) were performed by expert urologists via rigid cystoscopy with a bevelled needle system. The results of endoscopic treatment were evaluated by cystography at three months. The primary endpoint was clinical efficacy as defined by the absence of AGPN during follow-up. Radiological success was defined by the absence of VUR at the three months follow-up cystography. RESULTS: Out of 2135 kidney transplantations, a total of 117 (5.5%) patients had symptomatic VUR: 100 (85.5%) underwent Deflux™ and 17 (14.5%) MacroPlastique™. Preoperative high-grade VUR was recorded in 71% of patients. One postoperative complication was observed, Clavien > II. After a median follow-up of 11.2 years (IQR 6.5-14.4), clinical success was achieved in 73 patients (62.4%). Radiological success was obtained in 42 patients (36%). Multivariable analysis failed to identify predictors of endoscopic treatment success, which was independent of the preoperative grade of VUR and the type of bulking agent used. CONCLUSION: Endoscopic treatment of VUR is a simple and well-tolerated procedure with long-term clinical efficacy.

A systematic review of outcomes of Deflux® treatment for vesicoureteral reflux following pediatric renal transplantation.

INTRODUCTION: Vesicoureteral reflux (VUR) after renal transplant in the pediatric population may be associated with an increased incidence of urinary tract infection (UTIs) leading to increased morbidity, including graft dysfunction and graft loss. The non-orthotopic location of the transplanted ureter, and lack of submucosal tunnel may pose challenges in correcting the VUR using endoscopic injection techniques. Herein we report the results of a systematic review evaluating the outcomes of endoscopic treatment of VUR using Deflux® in this population. METHODS: Pubmed and Embase databases were searched from October 2001 to April 2019. Full-text English articles involving patients less than 18 years old at the time of transplant, with a diagnosis of VUR post-transplantation, who underwent Deflux® treatment were included. Figure 1 outlines our PRISMA-compliant search strategy. RESULTS: We found 6 eligible studies describing Deflux® treatment outcomes in 67 pediatric patients with post-transplant VUR where voiding cystourethrogram (VCUG) confirmed the diagnosis and resolution of VUR. The mean success rate was 36.8%. Ureteral obstruction occurred in 7/67 cases (10.4%). In all these 7 cases of obstruction, ureteric stenting was the initial management, but was only successful in 1 patient. Open ureteroneocystostomy (UNC) was performed in 4/7 cases, while 2/7 were managed expectantly (unknown outcomes). Persistent VUR with UTI despite Deflux® were reported in 20 out of 67 cases. Of these, 7 were managed with prophylactic antibiotics, and 13 with UNC. Success rates were consistently low for UNC after failed Deflux® in comparison to redo UNC in transplant ureters without prior injection. CONCLUSION: Low success rates are seen following injection techniques for VUR after pediatric renal transplant. Although an appealing option, Deflux® may prove counterintuitive due to the high rate of obstruction and suboptimal results if open reimplantation is required. A multi-institutional prospective study with a larger population size may further elucidate these results.

Assessment of the Grades of Vesicoureteral Reflux in Stented Ureters: An Experimental Study.

INTRODUCTION: The aim of this experimental study is to assess, in a porcine model, the onset and grades of vesicoureteral reflux associated with ureteral stents. METHODS: Twenty-four female porcine models were used. A 4.7-Fr ureteral stent was placed in all right ureters and kept in place for 6 weeks. Follow-ups were performed on weeks 1, 3, 6, and 12. Ultrasonography, cystoscopy, and fluoroscopy were used to analyze grade of hydronephrosis, presence and grade of vesicoureteral reflux, bacteriuria, and macroscopic changes of the ureteral orifices. Vesicoureteral reflux was classified using a modification of the International Reflux Study Committee grades. RESULTS: 91.7% animals present vesicoureteral reflux, 89.5% grade IA, 3.5% grade IB, and 7% grade II. There is a significant increase in reflux during follow-ups at 3 and 6 weeks, whereas 6 weeks after removal, 26.3% of the ureters still present vesicoureteral reflux. Hydronephrosis and macroscopic changes of the ureteral orifice increase significantly with stenting, but there is no significant association between them and vesicoureteral reflux; the relationship between bacteriuria and the presence of vesicoureteral reflux is not significant either. CONCLUSION: Vesicoureteral reflux caused by ureteral stents in an animal model is mostly low grade and mainly affects the distal ureter.

Treatment of Vesicoureteral Reflux Detected After Renal Transplant in Pediatric Patients: A Single-Center Experience.

OBJECTIVE: In children who undergo renal transplant, vesicoureteral reflux on the transplanted kidney is a serious complication that may result in organ loss. In this study, we aimed to evaluate the results of endoscopic and open surgical techniques in the treatment of patients with recurrent urinary tract infections and vesicoureteral reflux after renal transplant. MATERIAL AND METHODS: The files of pediatric patients who underwent renal transplant in our hospital between January 2016 and January 2019 were evaluated retrospectively. In this single-center analysis, we investigated the incidence of vesicoureteral reflux in the kidney transplant recipients and the results of various approaches to treat it. RESULTS: Eighty pediatric patients underwent renal transplant between January 2016 and January 2019. Fourteen of those patients (17.5%, 7 female and 7 male) were diagnosed with vesicoureteral reflux in the postoperative period. Twelve of 14 patients received endoscopic injections as the first treatment. Clinical or radiological success was achieved in 5 patients (5 of 15 injection treatments, 33%); in 4 patients (4/12, 33.3%) success was after the first endoscopic injection treatment, and in 1 patient (1/3, 33.3%) success was after the second injection. Meanwhile, clinical or radiological success was achieved in 6 of 7 patients who underwent redo ureteroneocystostomy (6/7, 85.7%). CONCLUSION: Although symptomatic vesicoureteral reflux after renal transplant is rare in pediatric patients, it is an important cause of morbidity as it requires recurrent surgical procedures. Although endoscopic treatment is safe and minimally invasive, the success rate is lower than expected, and redo of ureteral reimplant may be required in most cases.

Laser-puncture of the ureterocele in neonatal patients significantly decreases an incidence of de novo vesico-ureteral reflux than electrosurgical incision.

INTRODUCTION: Endoscopic laser-puncture or electrosurgical incision are the most commonly used minimaly invasive approaches for the treatment of the ureterocele. Both techniques are mainly successful in decompressing of ureteroceles, but the consequence of such treatment may be formation of de novo vesicoureteral reflux and febrile urinary tract infection which could impact the final results. OBJECTIVE: To compare outcomes of treatment of two endoscopic techniques used in management of neonatal patients with intravesical ureterocele. STUDY DESIGN: A case records of 64 neonates who underwent endoscopic procedures for intravesical ureterocele, performed at our institution from January 2005 to January 2021, were retrospectively reviewed. The patients were divided in two groups depending on used endoscopic procedure. The first group (n = 41) consisted of patients who underwent electrosurgical incision of the ureterocele, while the second group (n = 23) consisted of patients in whom 6 to 8 laser-punctures of the ureterocele were performed. The groups were compared in regards to outcomes of treatment, with special emphasis on de novo vesicoureteral reflux and the need for further treatment and surgery. RESULTS: Median follow-up was 7.5 (IQR 3, 11.5) and 3.5 (IQR 1.5, 5) years in the electroincision and laser-puncture groups, respectively (P = 0.017). No significant differences between the groups in regards to medians of duration of surgery (12 min vs. 11 min, P = 0.670), length of hospital stay (2 days in both groups, P = 0.988) or postoperative obstruction (n = 1 vs. n = 0, P > 0.999) were recorded. Ureterocele decompression was achieved after endoscopic treatment in 87.9% and 100% of the patients in electrosurgery and laser-puncture groups, respectively (P = 0.150). Five patients (12.1%) from electrosurgery group required endoscopic retreatment. The laser-puncture group had a significantly decreased rate of de novo vesicoureteral reflux (8.7% vs. 58.5%; P = 0.0001) and lower incidence of subsequent surgery due to de novo vesicoureteral reflux (50% vs. 62.5%; P = 0.727). CONCLUSION: Both electrosurgical incision and laser-puncture endoscopic techniques are safe and effective in relieving the obstruction. Laser-puncture technique is associated with significantly lower incidence of de novo vesicoureteral reflux and accordingly fewer invasive procedures for neonatal patients.