Endoscopic Treatment of Symptomatic Vesicoureteral Reflux after Renal Transplantation

Predictive factors for the success of subureteric injection in renal transplant patients with vesicoureteral reflux

BACKGROUND

Predicting the success of endoscopic treatment of VUR in transplant patients may not only protect both the physician and the patient from unnecessary investigations and treatment but may also prolong the life of the graft by preventing possible loss of time.

METHODS

This retrospective study included 116 patients with vesicoureteral reflux following kidney transplantation between 2014-2022. Demographic data, preoperative and intraoperative clinical aspects, and postoperative 6th-month success rates were evaluated.

RESULTS

The success rate of the injection treatment in the 6th month was 41.4%. As the patient age decreased, the success rate of the injection decreased (p = 0.025). While no significant relationship was observed between the preoperative reflux grade, injected volume of the bulking agent, and success (p = 0.109 and 0.222, respectively), a significant decrease in success was observed with an increase in UDR (p < 0.001) in group comparison. Regression analyses demonstrated that pre-injection visual assessment and post-injection orifice mound view influenced the success rate (p < 0.001 and p < 0.001, respectively).

CONCLUSIONS

Intraoperative visual assessment of the orifice is a reliable indicator for predicting the success of subureteric injection. It not only provides patients with trustworthy postoperative information but also saves clinicians time by anticipating the next surgical stage, ultimately contributing to the prolongation of graft life.

Patient-reported symptoms suggestive of vesicoureteral reflux after robotic ureteral reimplantation in adults

Little is known regarding the incidence of symptomatic, de novo vesicoureteral reflux (VUR) after ureteral reimplantation in adults. We sought to characterize this phenomenon in a contemporary cohort. We conducted a retrospective review of a multi-institutional database of robotic ureteral reconstruction (CORRUS, or Collaborative of Reconstructive Robotic Ureteral Surgery). Inclusion criteria were adult patients undergoing robotic ureteral reimplantation with at least 6 months of follow-up. Patients who had no evidence of recurrent ureteral stenosis were asked to complete a questionnaire characterizing their symptoms. The primary outcome was symptoms suggestive of VUR (SS-VUR), defined as flank pain of at least moderate severity that occurred at least weekly and worsened with voiding or a full bladder. We identified 257 patients who underwent robotic reimplantation, of which 97 (37.7%) were free from recurrent ureteral stenosis and responded to the questionnaire. At a median follow-up duration of 35.0 months (IQR 22.0-59.0), 26 patients (27.4%) reported flank pain of any severity on the same side as reimplantation. Nine patients (9.5%) met criteria for SS-VUR. Four patients underwent additional surgical intervention (two endoscopic, two robotic) after radiographic and functional workup confirmed VUR. On multivariable logistic regression, younger age was an independent predictor of SS-VUR (p = 0.041). In our contemporary series of robotic ureteral reimplantation in adults, over one-quarter of patients reported flank pain postoperatively in the absence of ureteral obstruction. A small proportion of patients had more bothersome symptoms particularly suggestive of VUR.

Does STING failure affect short-term graft functions in renal transplant patients: a single-center study

PURPOSE

The aim of the present study was to evaluate outcomes of symptomatic VUR treatment in transplant patients, compare open and endoscopic approaches in terms of graft functions, success rates, complications and recurrent UTIs.

METHODS

67 patients who undergone only STING and STING followed redo UNC due to symptomatic VUR after kidney transplantation were included into the investigation. Patients who had lower urinary tract dysfunctions were excluded from the trial. For 67 patients, baseline and before final surgery and 3rd month creatinine and GFR levels were recorded. Twenty-six of those 67 patients had redo UNC due to failed STING. The data of those patients were compared with the remaining 41 patients who had only STING.

RESULTS

In both groups no statistically significant variations in serum creatinine and GFR levels were detected during follow-up (p > 0.05). Serum levels after STING and in the 3rd month of redo UNC were compared. Although variation was observed in serum creatinine levels and in GFR levels, was not statistically significant (p: 0.59 and p: 0.23). The success rate of STING was %61.1 in 67 patients, and was not significantly different when three VUR grade groups (Grade 3 n:17, Grade 4 n:24, Grade 5 n:36) were compared (p > 0.05).

CONCLUSION

The present study revealed that subureteral endoscopic injection is cost effective and safe for the first-line treatment due to its minimally invasive nature, does not cause delay which leads to deterioration of graft functions. Redo-UNC has acceptable morbidity and complication rates, should be considered when STING is failed.

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.

Ureteral reimplantation after deflux failure for vesicoureteral reflux in renal transplant

PURPOSE

To evaluate the outcomes of ureteral reimplantation (UR) after failure of endoscopic treatment for symptomatic vesicoureteral reflux (VUR) in renal transplant recipients.

METHODS

We conducted a monocentric retrospective study that included all renal transplant recipients with failure of Deflux™ as first-line treatment of VUR from January 2007 to December 2020. Failure of Deflux™ was defined by: VUR on retrograde cystography and at least one acute pyelonephritis of the renal graft. The preferred surgical treatment was native ureteropyelostomy (NPUS) in the recent years. If the native ureter could not be used, ureteroneocystostomy (UNC) was performed. The primary outcome was the clinical efficacy of UR defined as the absence of acute graft pyelonephritis during follow-up.

RESULTS

Out of 1565 kidney transplantations, 119 (7.6%) had symptomatic VUR treated with bulking agent. 35 (29.4%) had Deflux™ failure and were addressed to UR: 21/35 (60%) NPUS and 14/35 (40%) UNC. The median estimated blood loss, operative time, and length of stay were 120 mL, 90 min, and 7 days, respectively. After a median follow-up of 7.1 (IQR 4.1-9.8) years, UR was clinically successful in a total of 32 patients (91.4%): 20 (95.2%) and 12 (85.7%) patients in the NPUS and UNC groups, respectively (p = 0.55). Three (8.5%) high-grade complications have been reported. No nephrectomy of native kidney was required in the NPUS group.

CONCLUSIONS

After failure of Deflux™ for VUR of renal graft, surgical treatment with native ureteropyelostomy or ureteroneocystostomy is associated to a high success rate and few high-grade complications.

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.

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.

Management of Vesicoureteral Reflux: What Have We Learned Over the Last 20 Years?

Vesicoureteral reflux (VUR) is associated with increased risks of urinary tract infection, renal scarring and reflux nephropathy. We review advancements over the last two decades in our understanding and management of VUR. Over time, the condition may resolve spontaneously but it can persist for many years and bladder/bowel dysfunction is often involved. Some factors that increase the likelihood of persistence (e.g., high grade) also increase the risk of renal scarring. Voiding cystourethrography (VCUG) is generally considered the definitive method for diagnosing VUR, and helpful in determining the need for treatment. However, this procedure causes distress and radiation exposure. Therefore, strategies to reduce clinicians' reliance upon VCUG (e.g., after a VUR treatment procedure) have been developed. There are several options for managing patients with VUR. Observation is suitable only for patients at low risk of renal injury. Antibiotic prophylaxis can reduce the incidence of UTIs, but drawbacks such as antibiotic resistance and incomplete adherence mean that this option is not viable for long-term use. Long-term studies of endoscopic injection have helped us understand factors influencing use and the effectiveness of this procedure. Ureteral reimplantation is still performed commonly, and robot-assisted laparoscopic methods are gaining popularity. Over the last 20 years, there has been a shift toward more conservative management of VUR with an individualized, risk-based approach. For continued treatment improvement, better identification of children at risk of renal scarring, robust evidence regarding the available interventions, and an improved VUR grading system are needed.

Pelvic Surgery in the Transplant Recipient: Important Considerations for the Non-transplant Surgeon

PURPOSE OF REVIEW

Classically, kidney transplantation (KT) consists of heterotopic implantation of the renal graft in the iliac fossa with vascular anastomosis on the iliac vessel and reimplantation of the graft ureter in the bladder of the recipient. However, a wide range of variations exist in both vascular anastomosis and urinary diversion that the non-transplant surgeon should know.

RECENT FINDINGS

For any pelvic surgery in a KT patient, the non-transplant surgeon should preoperatively evaluate the anatomy of the graft, its vascularization and its urinary tract. The transplant ureter should be identified and secured by preoperative JJ stenting whenever needed. For any surgery, maintenance and control of both immunosuppressive treatment and renal function is crucial. The advice or even the assistance of a transplant surgeon should be required because any damage to vascularization or urinary drainage of the renal graft could have dramatic and definitive consequences on graft function.

Endoscopic treatment of symptomatic VUR disease after the renal transplantation: analysis of 49 cases

BACKGROUND

To evaluate the outcome of endoscopic treatment for symptomatic vesicoureteral reflux (VUR) disease in renal transplantation patients and to determine the factors that were associated with the success rate of the treatment.

METHODS

A total of 121 symptomatic VUR diseases diagnosed between 2014 and 2018 in 3560 renal transplant patients. The results of 49 VUR cases that presented with febrile urinary tract infection (UTI) and were hospitalized for antibiotic treatment were included in the study. Reflux was detected by voiding cystourethrogram and treatment was performed by endoscopic Deflux® injection. The result of endoscopic treatment was evaluated clinically by 3 months periods.

RESULTS

The mean time between transplantation and endoscopic treatment was 59.6 (5-132) months, and the mean follow-up period after the endoscopic treatment was 14 (6-48) months, respectively. The success rate after the first injection was 59.1% (n = 29) and 67.3% (n = 33) after the second injection. One patient developed anuria, one patient febrile UTI and four patients developed minimal macroscopic hematuria after the procedure.

CONCLUSIONS

Endoscopic treatment of symptomatic VUR in transplanted kidney is a safe and feasible procedure. The amount of bulking agent or duration between the transplantation and diagnosis of VUR does not have any impact on the success of the treatment. However, the younger age of the patients and the female gender seem to have a positive effect on the outcome of the procedure.

Endourological application of polydimetilsiloxane in patients with symptomatic vesicoureteral reflux in the kidney graft

OBJECTIVE

To identify the results of polydimethylsiloxane application in the endourological management of symptomatic vesicoureteral reflux to the kidney graft and to determine the factors associated with persistent symptoms and with vesicoureteral reflux.

MATERIAL AND METHODS

We included 23 patients diagnosed with symptomatic VUR in kidney graft, evaluated from January 2010 to August 2018 in the High Specialty Medical Unit # 14 in Veracruz. These patients received endourological application of polydimethylsiloxane. The descriptive analysis was carried out, and, if possible, the relative risk measures for clinical failure (CF) were determined with odds ratio (OR).

RESULTS

18 (78.3%) patients presented clinical success (CS). There was a significant difference in the mean age (CS 30.61±9.7, CF 46.0±11.46; U Mann Whitney, P=.037), and in the number of episodes of AGPN prior to the application of PDMS (CS 2.27±1.27, CF 3.6±0.89, U Mann Whitney, P=.019). The most frequently identified pathogen was E. Coli, with 45.4%. VUR resolution was observed in 47.8% of the cases. There was a decreased degree of VUR in 73.9% of cases. A lower degree of VUR was determined as a protective factor for CF (OR: 0.031, 95% CI: 0.002-0.437, with P=.008).

CONCLUSIONS

The endourological application of PDMS proved to be useful in the management of patients with symptomatic VUR in kidney graft, as it decreased the VUR degree and allowed CS in most cases.

Urologic complications in renal transplants

Urologic complications of renal transplant occur commonly and can have significant impact on graft function, survival, and patient morbidity. This review examines the prevalence of urologic complications, risk factors, diagnosis and options for management of the most common urologic complications.

Urinary tract infections in solid organ transplant recipients: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice

These updated guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation review the diagnosis, prevention, and management of urinary tract infections (UTI) in solid organ transplantation, focusing on kidney transplant (KT) recipients. KT recipients have unique risk factors for UTI, including indwelling stents and surgical manipulation of the genitourinary tract. KT recipients experience multi-drug antibiotic-resistant infections-UTI prevention and management strategies must consider risks of antimicrobial resistance. Non-antimicrobial prevention strategies for UTI in KT recipients are reviewed. It is important to recognize that some renal transplant recipients with UTI may primarily present with fever, malaise, leukocytosis, or a non-specific sepsis syndrome without symptoms localized to the urinary tract. However, asymptomatic bacteriuria (AB) must be distinguished from UTI because AB is not necessarily a disease state. Accumulating data indicate that there are no benefits of antibiotics for treatment of AB in KT recipients more than 2 months after post-transplant. Further research is needed on management of AB in the early (<2 months) post-transplant period, prophylaxis for UTI in this era of antibiotic resistance, recurrent UTI, non-antimicrobial prevention of UTI, and uropathogens identified in donor urine and/or preservative fluid cultures.

Renal function outcomes in pediatric patients with symptomatic reflux into the transplanted kidney treated with redo ureteroneocystostomy

INTRODUCTION

Asymptomatic post-renal transplant reflux is common but only 5-10% patients are diagnosed with vesico-ureteral reflux in the setting of post-transplant febrile urinary tract infections, requiring redo ureteroneocystostomy (redo-UNC). Here we report the renal function outcomes of 37 such patients, stratified by lower urinary tract (LUT) status.

OBJECTIVE

We hypothesized that those with pre-transplant LUT dysfunction would have lower glomerular filtration rate (GFR) on follow-up.

STUDY DESIGN

Using procedure codes, 37 patients who underwent renal transplant followed by redo-UNC for transplant reflux at our institution between 1991 and 2014 were identified. Patient characteristics and GFR levels from four different time points were recorded. Comparisons were made between those with and without LUT dysfunction, using Fisher's exact, Wilcoxon rank sum, or signed-rank tests. Generalized estimating equations were constructed to account for the clustered nature of GFR within each LUT group and to assess their change over time.

RESULTS

Twelve patients (32%) had pre-transplant LUT dysfunction. The proportion of males in this group was significantly higher (75% vs. 32%, p = 0.032), and there was no statistical difference towards presenting earlier with post-transplant reflux (1.4 vs. 2.3 years, p = 0.087). After an average of 4.9 years, the median GFRs were similar between the two groups (53 mg/dL vs. 58 mg/dL, p = 0.936). There was no significant difference in GFR at this last follow-up time point in patients with and without LUT dysfunction.

DISCUSSION

Vesicoureteral reflux in the setting of renal transplantation is common and doesn't often require repair. In our series, we found that those with LUT dysfunction did not present statistically sooner with symptomatic transplant reflux. Longer-term follow-up did show a decline in GFR but did not reveal a difference in GFR in patients' with and without LUT dysfunction.

CONCLUSIONS

Pediatric post-transplant GFR after open redo ureteral reimplant decreases over time in similar fashion in patients with symptomatic reflux regardless of whether they have LUT dysfunction or normal anatomy. Vigilance should apply to the recognition, treatment, and follow-up of all symptomatic transplant reflux regardless of LUT status.

Endoscopic antireflux surgery leading to obstruction in pediatric renal transplant patients

To describe a multicenter experience with management of ureteral obstruction after injection of Dx/HA for VUR in pediatric renal transplant patients. The records of all pediatric renal transplant patients who underwent Dx/HA injection for VUR and had subsequent obstruction were identified, and the management and outcomes were reviewed. Follow-up ranged from 1 to 10 years. There were four patients identified, all of whom had a history of rising creatinine, recurrent UTI, and increasing hydronephrosis which led to the diagnosis of high-grade VUR. Obstruction was diagnosed within 24-72 hours after injection in three patients. One patient was asymptomatic, and rising creatinine and hydronephrosis were noted 1 month after injection. One patient was managed expectantly, while three patients underwent ureteral stent placement. After the stent was removed, one patient went on to open reimplant due to delayed obstruction, the second patient with voiding dysfunction is currently managed with an indwelling ureteral stent and may require further definitive surgery, the third patient recovered, and the fourth is being observed. Our cases illustrate that despite initial successful management of the obstruction in some, delayed obstruction is possible and may necessitate open reimplant. It is imperative that these patients have close follow-up after Dx/HA.