Endoscopic Deflux^® injection for pediatric transplant reflux: A feasible alternative to open ureteral reimplant

Abstract 

Objective

Pediatric renal transplantation is frequently performed using a freely refluxing vesicoureteral anastomosis. The resulting vesicoureteral reflux (VUR) may increase the morbidity of urinary tract infections (UTIs) that commonly occur in this setting, yet open surgical correction of the refluxing anastomosis can prove difficult. We report our experience using endoscopic injection of dextranomer/hyaluronic acid (Deflux^®) to correct transplant VUR.

Materials and methods

We retrospectively reviewed the charts of patients treated with endoscopic injection of Deflux (Q-Med, Uppsala, Sweden) for VUR into their renal allograft. Indications for inclusion in the study were renal allograft transplantation for primary end-stage renal disease, radiographically proven VUR into the allograft, normal voiding history, and at least one documented febrile UTI. Preoperative and postoperative images, including voiding cystourethrogram and allograft ultrasound, were compared. Location of the transplant orifice and volume of Deflux were recorded. Clinical outcomes, including documented UTI and changes in serum creatinine following treatment, were also assessed.

Results

Eight patients were identified who were treated for transplant VUR, with a total of nine transplant ureters injected. Mean patient age at time of injection was 11.6 years (range: 7–19 years). Post-injection voiding cystourethrograms and allograft ultrasound were available for all patients. Following treatment, four ureters demonstrated resolution of VUR and one ureter demonstrated improvement to grade 1 VUR. The remaining four ureters demonstrated no change in VUR grade. No patients showed any change in their serum creatinine, and no episodes of transplant pyelonephritis have occurred during the follow-up period. Mean post-injection follow-up has been 17.3 months (range 9–26 months).

Conclusion

Initial results demonstrate that endoscopic treatment with Deflux is feasible and may provide a less invasive alternative for treatment of transplant VUR. Further investigation with a larger group of patients and longer follow-up is needed.

Keywords: Vesicoureteral reflux, Pyelonephritis, Kidney transplantation, Endoscopy