Incidence of UVJ obstruction during long-term follow-up after endoscopic correction of VUR utilizing polyacrylate polyalcohol copolymer (PPC)

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.

Endoscopic Correction of Reflux Utilizing Polyacrylate Polyalcohol Bulking Copolymer (Vantris) as a Tissue Augmenting Substance: Lessons Learned Over the 10 Years of Experience

Objectives: To prove the hypothesis that modifying the endoscopic correction of vesicoureteral reflux (VUR) technique (STING procedure) and sharpening its contraindications, lead to increased success rate and decline in the complication rate. Materials and Methods: All patients that underwent endoscopic correction of VUR utilizing Vantris were divided into two groups according to procedure date; before 2015 and 2015-2019. Indication for treatment included persistent high-grade VUR or breakthrough infections. Contraindications included voiding dysfunction, active infection and since 2015 suspicion for obstructive/refluxing ureterovesical junction (UVJ) presented by "beak" sign on voiding cystourethrography (VCUG). Follow-up regiment included ultrasound and VCUG at predetermined intervals. Results: The first group included 215 (158 girls and 57 boys) children with mean age of 4.8 ± 2.8 years who underwent endoscopic correction between 2009 and 2015 and the second group included 42 children (28 girls and 14 boys) with mean age of 3.9 ± 2.1 years who underwent surgery between 2015 and 2019. In the first group, VUR was unilateral in 74 patients and bilateral in 132 comprising 338 renal refluxing units. In the second group, VUR was unilateral in 14 patients and bilateral in 30 comprising 74 RRUs. In the first group reflux was corrected in 317 (94.9%) RRUs after a single injection, after the second in 7 (2.1%) RRUs. In seven (2.1%) RRUs, reflux downgraded to Grade I-II. Three RRUs (0.9%) failed endoscopic correction and required ureteral reimplantation. Nine (2.7%) RRUs developed UVJ obstruction. In the second group reflux was corrected in 61 (82.4%) RRUs after a single injection, after the second in 12 (16.2%) RRUs. In one (1.4%) RRU, endoscopic correction failed and required ureteral reimplantation. None of the patients developed UVJ obstruction. Reflux correction has led to the significant decrease of febrile urinary tract infection (UTI) in both groups. Conclusions: Our data indicate that endoscopic injection utilizing Vantris is safe and long durable procedure. Although utilizing the proper technique and contraindication criteria, the rates of post procedural VUJ obstruction is null.