Summary
Introduction
Among the interventional treatment modalities for vesicoureteral reflux (VUR), endoscopic
subureteric injection seems to be the least invasive method with acceptable outcomes
when applied in appropriate patients.
Objective
The aim of the presented study is to investigate the parameters which may affect the
outcomes of endoscopic injection and to compare the efficacy of two different bulking
agents both composed of dextranomer-hyaluronic acid copolymer.
Study design
The data of patients who underwent endoscopic VUR treatment between 2003 and 2012
were retrospectively reviewed. Patients with history of previous open antireflux surgery,
more than one failed endoscopic treatment for reflux, VUR caused by posterior urethral
valve, duplex system and overt spinal dysraphism were excluded. Surgical technique
was the classical STING method. One of the two dextranomer-hyaluronic acid copolymer
agents was used (Deflux in 109 and Dexell in 131 patients). Both agents were composed
of similar amounts of hyaluronic acid gel (15 mg in Deflux versus 17 mg in Dexell)
but different sized dextranomer microspheres (80–250 μm in Deflux and 80–120 μm in
Dexell). During the follow-up, ultrasonography was performed with 3-month interval,
antibiotic prophylaxis was continued until the control voiding cystourethrography
(VCUG) was taken. Patient based success was defined as the disappearance of reflux
on control VCUG performed 3–6 months after the operation.
Results
Data were available for 240 patients. Mean age and mean postoperative follow-up were
78 ± 41 months and 19 ± 18 months. The overall success rate was 73.2%. Gender, laterality,
grade of VUR, presence of voiding dysfunction, renal scar and preoperative breakthrough
infection (BTI) were not found to affect the outcome, whereas age younger than 54
months and previous history of failed endoscopic injection were found to negatively
affect the outcome both in univariate and multivariate analysis. The postoperative
UTI (5 febrile and 43 nonfebrile) rate was 20%. Both univariate and multivariate analysis
showed that postoperative UTI was more common in patients with persisting reflux,
with preoperative breakthrough infections and in girls. Patient characteristics, treatment
outcome and postoperative UTI rate were similar regarding the used bulking agent.
No ureteral obstruction was experienced within the follow-up period.
Discussion
Our success rate for second injection is about 60%, which is significantly lower than
for the patients who underwent first injection. We could not find any affecting factor
for this difference. Contrary to the literature, our success rates were similar in
different reflux grades. We can explain this finding that we value the intraoperative
orifice configuration more than the grade which can be accepted as a patient selection
bias. The lower success rate in children younger than 54 months can be explained by
unstabilized bladder dynamics and higher voiding pressures in this age group, who
are still in the toilet-training phase. Despite successful endoscopic treatment, UTI
might occur. Postoperative UTI was more common in patients with persisting reflux,
preoperative BTI and girls. The similar success rates of both bulking agents proved
that dextranomer size does not affect the clinical outcome. Limitations of our study
can be counted as follows: 1. the data do not include the number of patients in whom
conversion to open surgery was decided intraoperatively because of the unfavorable
orifice configuration, 2. our data do not include the injected volume records.
Conclusion
TableComparison of treatment success regarding several factors (chi-square test).
| Male vs female | %66 vs 75.4 | p = 0.174 |
| Age < 54 m vs > 54 m. | %65.7 vs 78.5 | p = 0.043** |
| Unilateral vs bilateral | %77.5 vs 67.6 | p = 0.087 |
| Grade 1–2 vs 3 vs 4–5 | %77.9 vs 73 vs 67.4 | p = 0.455 |
| Grade 1–2–3 vs 4–5 | %74.7 vs 67.4 | p = 0.311 |
| VD, no vs yes | %80 vs 78.1 | p = 0.774 |
| Scar, no vs yes | %72 vs 72.4 | p = 0.941 |
| BTI, no vs yes | %73 vs 74.5 | p = 0.806 |
| Deflux vs Dexell | %75.2 vs 71.8 | p = 0.545 |
| Previous failed STING, no vs yes | %75.9 vs 59.5 | p = 0.038** |
BTI = breakthrough infection; VD = voiding dysfunction. *p is lower than 0.05 by chi-square
test.
Keywords
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Article info
Publication history
Published online: March 02, 2015
Accepted:
December 18,
2014
Received:
May 30,
2014
Identification
Copyright
© 2015 Journal of Pediatric Urology Company. Published by Elsevier Inc. All rights reserved.
