| Abstract|| |
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.
|How to cite this article:|
Neel KF. Endoscopic correction of vesicoureteric reflux: 10-year experience of a tertiary care center. Saudi J Kidney Dis Transpl 2012;23:48-52
|How to cite this URL:|
Neel KF. Endoscopic correction of vesicoureteric reflux: 10-year experience of a tertiary care center. Saudi J Kidney Dis Transpl [serial online] 2012 [cited 2019 Jul 22];23:48-52. Available from: http://www.sjkdt.org/text.asp?2012/23/1/48/91300
| Introduction|| |
Primary vesicoureteral reflux (VUR) is the most common urological anomaly in children, and has been reported in up to 50% of those who present with urinary tract infection (UTI). , Additionally, there is a high association between VUR, UTI and renal damage. Accordingly, reflux nephropathy is the cause of end-stage renal failure in about 25% of children and 15% of adults. In Saudi Arabia, VUR attributed to 26.3% of end-stage renal failure cases in children. 
Conservative medical management, in which patients are continued on prophylactic antibiotics to prevent the recurrence of infection, constitutes the standard initial management of VUR. However, the international reflux study and the American Urological Association , put forth absolute and relative indications for surgical interventions, and breakthrough UTI is the leading cause for anti-reflux procedures.
Endoscopic management (ET) of VUR in children has now become an acceptable alternative to open ureteral reimplantation for the treatment of pediatric VUR.  This treatment was pioneered by O'Donnell and P Puri when they presented their first report in 1984. 
Since 1998, this mode of management has become our standard of management for patients with VUR in need of surgical correction.
We aim in this study to review our last 10-year experience with ET for VUR in patients.
| Materials and Methods|| |
We retrospectively reviewed the charts of all patients with primary VUR who underwent ET to correct their VUR at our center from 1998 to 2008. We included in our review the indication for ET, status of the bladder function, grade and laterality of VUR, post-operative complications and success rate. Success was defined as either complete resolution or downgrading of VUR to grade 1.
Initially, we obtained history from all children diagnosed with VUR regarding frequency, urgency, incontinence and constipation. If the children were diagnosed with non-neuropathic bladder sphincter dysfunction (NNBSD), they would be started on a voiding day program involving dietary changes, stool softeners and anti-cholinergic medication at least one month before the procedure. This program was continued until the resolution of reflux and then tapered gradually, according to the active symptoms.
Our routine procedure included a screening urine test to rule out acute urinary tract infection. The patients were then prepared for surgery. A single pre-operative prophylactic antibiotic according to weight was administered with the induction of anesthesia.
The ET procedure was performed under general anesthesia with a tracheal mask, and caudal analgesia was performed for male patients. After routine cystoscopic preparation in the lithotomy position, a standard 10F angled offset cystoscope was introduced under visual control. The bladder was emptied of urine and partially filled with standard irrigation fluid.
Cannulation of the ureteric orifice was preserved only for bizarre-shaped ureteric orifices; otherwise, there was no need for routine ureteric cannulation. The ureteric orifice was checked for suitability for ET.
The injectable material was prepared according to the standard instructions. For Deflux® , the needle provided was flushed with sterile normal saline, connected to the syringe, flushed with material through the working channel and then introduced for injection. The same procedure was performed with Macroplastique® , but the lubrication of the needle was performed with a special gel provided in the package. The injection was made with a gun made especially for this procedure.
In the initial five years, we injected just below the ureteric orifice. Later, we adopted the "HIT" technique,  in which the needle was introduced inside the ureteric orifice with the bevel of the needle facing superiorly.
The injected volume varied from 0.5 to 1.3 mL per refluxing ureter until proper cooptation of the ureteric orifice was seen, with the ureteric orifice lying at the top of a mountain-shaped bolus [Figure 1]. If the desired configuration was not achieved after one injection, another was attempted with a different angle. The same procedure was performed on the other side in cases of bilateralness. The bladder was then drained as the last step of the procedure.
|Figure 1: Endoscopic treatment of vesicoureteric reflux. (a) Hydrodistension of the ureter, (b) intraureteric injection, (c) mountain-shaped ureteric orifice post injection.|
Click here to view
The children were observed for six h, and then another intravenous dosage of prophylactic antibiotics was administered. The children were then sent home with oral analgesia and a full dosage of antibiotics for seven days. The families then continued the prophylactic antibiotic treatment until the children returned for clinic visit for a follow-up examination, which included an ultrasound and voiding cystourethrogram (VCUG), after two to three months.
| Results|| |
We treated 321 patients with ET for VUR over ten years. This group included 115 male (35.8%) and 206 female (64.2%) patients, with a total of 480 treated ureters. A total of 159 patients had bilateral VUR (49.5%), 68 had right-side VUR only and 94 had left-side VUR only [Table 1].
Correction of VUR was defined as either the resolution of reflux or a downgrading to Grade I revealed with follow-up VCUG and no ipsilateral renal or ureteric dilatation-detected renal ultrasound. At the two to three months follow-up visit, VUR was found corrected in 393 of 480 refluxing ureters (81.8%) 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. In this group, correction of VUR after a single endoscopic injection occurred for 87% of the patients in Grade I, 83.8% of the patients in Grade II, 82.2% of the patients in Grade III, 80.2% of the patients in Grade IV and 74.5% of the patients in Grade V [Figure 2]. With repeated endoscopic injections, reflux correction occurred in 95% of the patients in Grade I, 90.5% of the patients in Grade II, 84% of the patients in Grade III, 89% of the patients in Grade IV and 79.7% of the patients in Grade V [Figure 2]. Unilateral reflux was corrected after a single endoscopic procedure in 143 of 162 patients (88.2%), and bilateral reflux was corrected after a single endoscopic procedure in 125 of 159 patients (78.6%).
Two patients, both with a single kidney, became anuric after the injection. We placed a ureteric stent in both patients for one month. After removal of the stents, the patients normalized their urine output with no upper tract changes. One child who had undergone prior surgical correction developed high fever during the 24 h after the procedure secondary to a UTI; this child required hospitalization for 48 h. There were no episodes of post-operative toxicity or illness that might indicate adverse reaction to or migration of the implant.
| Discussion|| |
Endoscopic injection of bulking agents for the treatment of VUR in children offers a viable alternative to open ureteral reimplantation, with good surgical results and minimal complications. , For many years, open surgery was the gold standard for the treatment of VUR that failed medical treatment due to its very high success and low complication rate. 
The basic principle behind the endoscopic correction of VUR is that providing additional submucosal bulking to the subureteric space results in adequate coaptation of the ureteral orifice during active bladder filling and contraction, and prevents the retrograde flow of urine to the upper urinary tract. 
For an injectable biomaterial to be ideal, it must have the following specific qualities: (1) be non-toxic and stable without migration to vital organs, (2) cause minimal local inflammation and (3) be well encapsulated by normal fibrous tissue and fibrocytes. The material should be easy to inject through a long needle that passes easily through most standard endoscopic instruments. It must be viscous enough to prevent leakage from the puncture site and maintain the injected volume after the normal process of exchange and excretion of any carrier molecules. ,
In the most recent years, since the first report by O'Donnell and Puri,  ET for VUR has gained great popularity. It is becoming the method of choice for managing patients with primary VUR in need of surgical correction. ,,, In general, ET is a shorter, minimally invasive procedure that is cost-effective. It has a short learning curve, better accepted by patients and their families and is associated with no reported post-operative complications.
Here, we report our experience using two widely used bulking agents. Polydimethylsilone (Macroplastique Uroplasty Inc® . Geleen, the Netherlands) is a silicone elastomer that is soft and flexible when suspended in a bioexcretable carrier gel. It is widely used in Europe and North America. , The other bulking agent employed was Dextranomer microspheres (Deflux, Q-Med Inc, Uppsal, Sweden), which are made of a network of cross-linked dextran polysaccharide molecules with a larger particle size (80-120 um). These gained wide popularity as a bulking agent both in Europe and in North America, where they became the first FDA-approved bulking agent for the treatment of VUR. ,
In our series, the 81.8% success rate after one injection and 87.1% success rate after the second injection renders ET an excellent alternative to open surgical technique treatment for VUR.
The only instance in which we did not perform ET was when the ureteric orifice was too wide, where the bulking agent would not produce the desired coaptation of the ureteric orifice.
From our experience and the experience of other units worldwide, the learning curve is quite short, and the procedure itself is not technically demanding, with a low complication rate (in our series <1%). We believe that most urologists dealing with children will be comfortable with this procedure and should achieve a success rate similar to that reported here after a short period.
From our experience, ET for VUR using newly available bulking agents is a reliable and safe alternative to open ureteral reimplantation for the treatment of VUR in children. This study suggests that the majority of patients will be cured after undergoing this outpatient endoscopic procedure. Furthermore, the widely reported safety of the agents used in this procedure and the short learning curve opt for ET as the standard treatment for VUR once surgical correction is warranted.
| References|| |
|1.||Medical versus surgical treatment of primary vesicoureteral reflux: report of the international reflux study committee. Pediatrics 1981; 64:392-400. |
|2.||Elder JS, Peters CA, Arant BS Jr, et al. Pediatric vesicoureteric reflux Guidelines Panel summary report on the management of primary vesicoureteral reflux in children, J Urol 1997; 157:1846-51. |
|3.||Al-Harthi AA. Chronic renal failure in children at Aseer Region, Curr Pediatr Res 2009;13:5-7. |
|4.||O'Donnell B, Puri P. Treatment of vesicoureteric reflux by endoscopic injection of Teflon. Br Med J 1984;299:7-9. |
|5.||Cerwinka WH, Scherz HC, Kirsch AJ. Endos-copic treatment of vesicoureteral reflux with dextranomer/hyaluronic acid in children. Adv Urol 2008:513854. |
|6.||Lackgren G, Wahlin N, Skoldenberg E, Stenberg A. Long term follow-up of children with dextranomer/hyalurouric acid copolymer for vesicoureteral reflux. J Urol 2001;166:1887-92. |
|7.||Herz D, Hafez A, Bagli D, Caplicchio G, Mclorie G, Khoury A. Efficacy of endoscopic subureteral polydimethylsioloxane injectin for treatment of vesicoureteral reflux in children: A North American Clinical Report. J Urol 2001;166:1880-6. |
|8.||Shulmann CC. Use of particulate silicone microimplants for the endoscopic correction of vesicoureteric reflux. Dialogues Pediatr Urol 1994;17:11-5. |
Khalid Fouda Neel
Associate Professor and Consultant Pediatric Urologist, Urology Division, Department of Surgery (37), King Khalid University Hospital, King Saud University, P. O. Box 7805, Riyadh 11472
[Figure 1], [Figure 2]