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Xie M, Xu X, Cao Z, Xiao H. Do Various Treatment Modalities of Vesicoureteral Reflux Have Any Adverse Effects in Pediatric Patients? A Meta-Analysis. Urol Int 2021; 105:1002-1010. [PMID: 34555831 DOI: 10.1159/000518603] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 06/02/2021] [Indexed: 11/19/2022]
Abstract
PURPOSE Vesicoureteral reflux (VUR) is a risk factor for various renal problems like recurrent urinary tract infections (UTIs), pyelonephritis, renal scarring, hypertension, and other renal parenchymal defects. The interventions followed by pediatricians include low-dose antibiotic treatment, surgical correction, and endoscopy. This meta-analysis aimed to assess the advantages and drawbacks of various primary VUR treatment options. SEARCH STRATEGY The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, reference lists of journals, and abstracts from conference proceedings were all used to find randomized controlled trials. The articles were retrieved from 1985 till 2020. Twenty articles were used for the data analysis. Criteria for Selection: Surgery, long-term antibiotic prophylaxis, noninvasive techniques, and any mix of therapies are also options for treating VUR. Collection and Interpretation of Data: Two authors searched the literature separately, determining research qualifications, assessing accuracy, and extracting and entering results. The odds ratio (OR) of these studies was used to construct the forest plot. The random-effects model was used to pool the data. Also, the random-effects model was used with statistical significance at a p value < 0.05 to assess the difference in side effects after treatment of VUR using different modalities. RESULTS We found no statistically significant differences between surgery plus antibiotics and antibiotic alone-treated patients in terms of recurrent UTIs (OR = 0.581; 95% confidence interval [CI] 0.259-1.30), renal parenchymal defects (OR = 1.149; 95% CI 0.75-1.754), and renal scarring (OR = 1.042; 95% CI 0.72-1.50). However, the risk of developing pyelonephritis after surgical treatment of VUR was lesser than that in the conservative approach, that is, antibiotics (OR = 0.345; 95% CI 0.126-0.946.), positive urine culture (OR = 0.617; 95% CI 0.428-0.890), and recurrent UTIs were more common in the placebo group than in the antibiotic group (p < 0.05; OR = 0.639; 95% CI 0.436-0.936) which is statistically significant. CONCLUSION Based on current research, we recommend that a child with a UTI and significant VUR be treated conservatively at first, with surgical care reserved for children who have issues with antimicrobials or have clinically significant VUR that persists after several years of follow-up.
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Affiliation(s)
- Min Xie
- Department of Pediatric Nephrology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Xiaogai Xu
- Department of Neurology, Children's Hospital of Shanxi (Women Health Center of Shanxi), Taiyuan, China
| | - Zhenjie Cao
- Pediatric Surgery, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Huijie Xiao
- Department of Pediatrics, Peking University First Hospital, Beijing, China
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Abstract
BACKGROUND Vesicoureteric reflux (VUR) results in urine passing retrograde up the ureter. Urinary tract infections (UTI) associated with VUR have been considered a cause of permanent renal parenchymal damage in children with VUR. Management has been directed at preventing UTI by antibiotic prophylaxis and/or surgical correction of VUR. This is an update of a review first published in 2004 and updated in 2007 and 2011. OBJECTIVES The aim of this review was to evaluate the available evidence for both benefits and harms of the currently available treatment options for primary VUR: operative, non-operative or no intervention. SEARCH METHODS We searched the Cochrane Kidney and Transplant Specialised Register to 3 May 2018 through contact with the Information Specialist using search terms relevant to this review. Studies contained in the Specialised Register are identified through search strategies specifically designed for CENTRAL, MEDLINE, and EMBASE; handsearching conference proceedings, and searching the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA RCTs in any language comparing any treatment of VUR and any combination of therapies. DATA COLLECTION AND ANALYSIS Two authors independently determined study eligibility, assessed quality and extracted data. Dichotomous outcomes were expressed as risk ratios (RR) with 95% confidence intervals (CI) and continuous data as mean differences (MD) with 95% CI. Data were pooled using the random effects model. MAIN RESULTS Thirty four studies involving 4001 children were included. Interventions included; long-term low-dose antibiotics, surgical reimplantation of ureters, endoscopic injection treatment, probiotics, cranberry products, circumcision, and oxybutynin. Interventions were used alone and in combinations. The quality of conduct and reporting of these studies was variable, with many studies omitting crucial methodological information used to assess the risk of bias. Only four of the 34 studies were considered at low risk of bias across all fields of study quality. The majority of studies had many areas of uncertainty in the risk of bias fields, reflecting missing detail rather than stated poor design.Low-dose antibiotic prophylaxis compared to no treatment/placebo may make little or no difference to the risk of repeat symptomatic UTI (9 studies, 1667 children: RR 0.77, 95% CI 0.54 to 1.09; low certainty evidence) and febrile UTI (RR 0.83, 95% CI 0.56 to 1.21; low certainty evidence) at one to two years. At one to three years, antibiotic prophylaxis made little or no difference to the risk of new or progressive renal damage on DMSA scan (8 studies, 1503 children: RR 0.73, 95% CI 0.33 to 1.61; low certainty evidence). Adverse events were reported in four studies with little or no difference between treatment groups (1056 children: RR 0.94, 95% CI 0.81 to 1.08; ), but antibiotics increased the likelihood of bacterial drug resistance threefold (187 UTIs: RR 2.97, 95% CI 1.54 to 5.74; moderate certainty evidence).Seven studies compared long-term antibiotic prophylaxis alone with surgical reimplantation of ureters plus antibiotics, but only two reported the outcome febrile UTI (429 children). Surgery plus antibiotic treatment may reduce the risk of repeat febrile UTI by 57% (RR 0.43, 95% CI 0.27 to 0.70; moderate certainty evidence). There was little or no difference in the risk of new kidney defects detected using intravenous pyelogram at 4 to 5 years (4 studies, 572 children, RR 1.09, 95% CI 0.79 to 1.49; moderate certainty evidence)Four studies compared endoscopic injection with antibiotics alone and three reported the outcome febrile UTI. This analysis showed little or no difference in the risk of febrile UTI with endoscopic injection compared to antibiotics (RR 0.74, 95% CI 0.31 to 1.78; low certainty evidence). Four studies involving 425 children compared two different materials for endoscopic injection under the ureters (polydimethylsiloxane (Macroplastique) versus dextranomer/hyaluronic acid polymer (Deflux), glutaraldehyde cross-linked (GAX) collagen (GAX) 35 versus GAX 65 and Deflux versus polyacrylate polyalcohol copolymer (VANTRIS)) but only one study (255 children, low certainty evidence) had the outcome of febrile UTI and it reported no difference between the materials. All four studies reported rates of resolution of VUR, and the two studies comparing Macroplastique with Deflux showed that Macroplastique was probably superior to dextranomer/hyaluronic acid polymer (3 months: RR 0.50, 95% CI 0.33 to 0.78; 12 months: RR 0.54 95% CI 0.35 to 0.83; low certainty evidence)Two studies compared probiotic treatment with antibiotics and showed little or no difference in risk of repeat symptomatic UTI (RR 0.82 95% CI 0.56 to 1.21; low certainty evidence)Single studies compared circumcision with antibiotics, cranberry products with no treatment, oxybutynin with placebo, two different surgical techniques and endoscopic injection with no treatment. AUTHORS' CONCLUSIONS Compared with no treatment, the use of long-term, low-dose antibiotics may make little or no difference to the number of repeat symptomatic and febrile UTIs in children with VUR (low certainty evidence). Considerable variation in the study designs and subsequent findings prevented drawing firm conclusions on efficacy of antibiotic treatment.The added benefit of surgical or endoscopic correction of VUR over antibiotic treatment alone remains unclear since few studies comparing the same treatment and with relevant clinical outcomes were available for analysis.
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Affiliation(s)
- Gabrielle Williams
- NSW Ministry of HealthAnalytics Assist73 Miller StNorth SydneyNSWAustralia2060
| | - Elisabeth M Hodson
- The University of SydneySydney School of Public HealthSydneyNSWAustralia2006
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchLocked Bag 4001WestmeadNSWAustralia2145
| | - Jonathan C Craig
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchLocked Bag 4001WestmeadNSWAustralia2145
- Flinders UniversityCollege of Medicine and Public HealthAdelaideSAAustralia5001
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3
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Abstract
BACKGROUND Vesicoureteric reflux (VUR) results in urine passing retrograde up the ureter. Urinary tract infections (UTI) associated with VUR have been considered a cause of permanent renal parenchymal damage in children with VUR. Management of these children has been directed at preventing UTI by antibiotic prophylaxis and/or surgical correction of VUR. The optimum strategy is not clear. OBJECTIVES To evaluate the benefits and harms of different treatment options for primary VUR. SEARCH STRATEGY In August 2010 we searched CENTRAL, MEDLINE and EMBASE and screened reference lists of papers and abstracts from conference proceedings. SELECTION CRITERIA RCTs in any language comparing any treatment of VUR including surgical or endoscopic correction, antibiotic prophylaxis, non-invasive non-pharmacological techniques and any combination of therapies. DATA COLLECTION AND ANALYSIS Two authors independently searched the literature, determined study eligibility, assessed quality, extracted and entered data. We expressed dichotomous outcomes as risk ratios (RR) and their 95% confidence intervals (CI) and continuous data as mean differences (MD) and their 95% CI's Data were pooled using the random effects model. MAIN RESULTS Twenty RCTs (2324 children) were included. Long-term low-dose antibiotic prophylaxis compared to no treatment/placebo did not significantly reduce repeat symptomatic UTI (846 children: RR 0.68, 95% CI 0.39 to 1.17) or febrile UTI (946 children: RR 0.77, 95% CI 0.47 to 1.24) at two years. There was considerable heterogeneity in the analyses and only one study was adequately blinded. At one to three years, antibiotic prophylaxis reduced the risk of new or progressive renal damage on DMSA scan (446 children: RR 0.35, 95% CI 0.15 to 0.80). Side effects were infrequent when reported, but antibiotics increased the likelihood of bacterial drug resistance threefold (132 UTIs: RR 2.94, 95% CI 1.39 to 6.25).When long-term antibiotic prophylaxis was compared with surgical or endoscopic correction of VUR plus antibiotics for one to 24 months (10 studies, 1141 children), the risk of symptomatic UTI was not significantly different at any time point. Combined surgical and antibiotic treatment caused a 57% reduction in febrile UTI by five years (2 studies, 449 children: RR 0.43, 95% CI 0.27 to 0.70) but did not decrease the risk of new or progressive renal damage at any time point. Postoperative obstruction was seen in 0% and 7% of children in two surgical studies and 0% in one endoscopic study. AUTHORS' CONCLUSIONS Compared with no treatment, use of long-term, low-dose antibiotics did not significantly reduce the number of repeat symptomatic and febrile UTIs in children with VUR. Considerable heterogeneity in the analyses and inclusion of only one adequately blinded study, made drawing firm conclusions challenging. Antibiotic prophylaxis significantly reduced the risk of developing new or progressive renal damage, but assuming an 8% baseline risk, 33 children would need long-term antibiotic prophylaxis to prevent one more child developing kidney damage over the course of two to three years.The added benefit of surgical or endoscopic correction of VUR over antibiotic treatment alone remains unclear. Eight children would require combined surgical and antibiotic treatment to prevent one additional child developing febrile UTI by five years, but it would not cause fewer children developing renal damage.
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Affiliation(s)
- Evi Vt Nagler
- Renal Division, Department of Internal Medicine, University Hospital Ghent, Ghent, Belgium
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Zilberman DE, Mor Y. Has the data efflux regarding the promising outcome following injection of deflux changed the management of adult vesicoureteral reflux? Adv Urol 2009; 2008:361324. [PMID: 19283076 PMCID: PMC2654058 DOI: 10.1155/2008/361324] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2008] [Revised: 10/08/2008] [Accepted: 12/30/2008] [Indexed: 11/17/2022] Open
Abstract
Primary vesicoureteral reflux (VUR), traditionally considered a problem of childhood, can also be detected during adulthood. However, while the concept regarding the therapeutic management of VUR in children has undergone revolutionary changes, moving from surgical to conservative approach, the optimal therapeutic approach in adult reflux is poorly addressed and is still unknown. Herein, we review clinical and therapeutic approaches of VUR in pediatric population as published throughout the years. With the introduction of Deflux injection as a minimally invasive procedure, we identify a beginning of a new trend that further extends the indications for endoscopic injections, including its introduction to adult patients as well.
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Affiliation(s)
- D. E. Zilberman
- Department of Urology, The Chaim Sheba Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel-Hashomer, Ramat-Gan 52621, Israel
| | - Y. Mor
- Department of Urology, The Chaim Sheba Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel-Hashomer, Ramat-Gan 52621, Israel
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5
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Hodson EM, Wheeler DM, Vimalchandra D, Smith GH, Craig JC. Interventions for primary vesicoureteric reflux. Cochrane Database Syst Rev 2007:CD001532. [PMID: 17636679 DOI: 10.1002/14651858.cd001532.pub3] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Vesicoureteric reflux (VUR) results in urine passing, in a retrograde manner, up the ureter. Urinary tract infections (UTIs) have been considered the main cause of permanent renal parenchymal damage in children with reflux. Management of these children has been directed at preventing infection by antibiotic prophylaxis and/or surgical correction of reflux. Controversy remains as to the optimum strategies. OBJECTIVES To evaluate the benefits and harms of different treatment options for primary VUR. SEARCH STRATEGY Randomised controlled trials (RCTs) were identified from the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, reference lists of articles and abstracts from conference proceedings. Date of last search: June 2006 SELECTION CRITERIA Any treatment of VUR including surgery, antibiotic prophylaxis of any duration, non-invasive techniques and any combination of therapies. DATA COLLECTION AND ANALYSIS Two authors independently searched the literature, determined study eligibility, assessed quality, extracted and entered data. For dichotomous outcomes, results were expressed as relative risk (RR) and 95% confidence intervals (CI). Data were pooled using the random effects model. MAIN RESULTS Eleven studies (1148 children) were identified. Seven compared correction of VUR (by surgery or endoscope) plus antibiotics for 1-24 months with antibiotics alone, two compared antibiotics with no treatment and two compared different materials for endoscopic correction of VUR. Risk of UTI by 2, 5 and 10 years was not significantly different between surgical and medical groups (2 years RR 1.07, 95% CI 0.32 to 2.09; 5 years RR 0.99, 95% CI 0.79 to 1.26; 10 years RR 1.06, 95% CI 0.78 to 1.44). Combined treatment resulted in a 50% reduction in febrile UTI by 10 years (RR 0.54, 95% CI 0.55 to 0.92) but no concomitant reduction in risk of new or progressive renal damage by 10 years (RR 1.03, 95% CI 0.53 to 2.00). In two small studies no significant differences in risk for UTI (RR 0.75, 95% CI 0.15 to 3.84) or renal damage (RR 1.70, 95% CI 0.36 to 8.07) were found between antibiotic prophylaxis and no treatment. AUTHORS' CONCLUSIONS It is uncertain whether the treatment of children with VUR confers clinically important benefit. The additional benefit of surgery over antibiotics alone is small at best. Assuming a UTI rate of 20% for children with VUR on antibiotics for five years, nine reimplantations would be required to prevent one febrile UTI, with no reduction in the number of children developing any UTI or renal damage.
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Affiliation(s)
- E M Hodson
- Children's Hospital at Westmead, Centre for Kidney Research, Locked Bag 4001, Westmead, NSW, Australia, 2145.
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6
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Abstract
Vesicoureteral reflux (VUR) is a common condition in children. It may cause and maintain urinary tract infections, eventually leading to progressive renal damage and end-stage renal disease. Ideally, VUR should be detected and treated before renal scarring occurs. Although fetal hydronephrosis on antenatal ultrasound may be the first indicator, the role of further diagnostic investigations in these newborns is still controversial. Because VUR is an inherited condition, offspring of women with a family history of VUR and urinary tract infection should be screened closely for early detection of VUR. Once diagnosed, however, the optimal management of VUR (i.e. medical or surgical treatment) remains controversial. Evidence-based treatment recommendations, like the American Urological Association guidelines, may aid physicians in their therapeutic decision making, but cannot replace personal experience or surgical skill.
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Affiliation(s)
- K Weingärtner
- Department of Urology, Julius Maximilians-University Medical School at Würzburg, Würzburg, Germany
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7
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Bensman A, Ulinski T. International Vesicoureteral Reflux Study: unsolved questions remaining. Pediatr Nephrol 2006; 21:757-8. [PMID: 16703370 DOI: 10.1007/s00467-006-0105-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2006] [Accepted: 01/20/2006] [Indexed: 11/30/2022]
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Kim HC, Shim KS, Moon DG. The Early Experience and Technical Aspects of Endoscopic Subureteral Polydimethylsiloxane Injection for Vesicoureteral Reflux. Korean J Urol 2006. [DOI: 10.4111/kju.2006.47.2.154] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Hyun-Chul Kim
- Department of Urology, Korea University College of Medicine, Seoul, Korea
| | - Kang-Soo Shim
- Department of Urology, Korea University College of Medicine, Seoul, Korea
| | - Du-Geon Moon
- Department of Urology, Korea University College of Medicine, Seoul, Korea
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9
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de la Peña Zarzuelo E. [Primary vesicoureteral reflux treatment in childhood: comparsion of two systematic review]. Actas Urol Esp 2005; 29:138-62. [PMID: 15881913 DOI: 10.1016/s0210-4806(05)73217-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
UNLABELLED Many medical practices are being carried out unawares of their efficiency, or of their actual impact on the health of the patients, therefore it is necessary to consider the support of professional recommendations with scientific evidence. THE PRIMARY OBJECTIVE To perform a systematic review (SR) of the therapeutic management of primary VUR in pediatric urology. MATERIAL AND METHODS A systematic review has been performed, including scientific evidence-based medicine criteria, of the articles published in all of the available databases. Inclusion criteria concerning basic quality of the articles were considered essential, as well as exclusion criteria to be able to reject the articles. RESULTS AND DISCUSSION Subsequently, and following the critic reading of greater than 320 articles, statistical study of the grouped data was performed according to the type of treatment and to the benefits contributed by each treatment, and also to their undesirable effects. Finally we have made a comparison between our results and recent Cochrane Systematic Review. The following Conclusions were drawn from the results obtained and from the analysis of the texts. Both medical and surgical treatment present with similar effectiveness concerning resolution of grades I, II and III of VUR, and the former one is the recommended initial treatment following diagnosis. Endoscopic treatment is exactly as effective as open surgery for grades I, II and III with fewer undesirable effects secondary. There are no differences concerning the efficacy of the different injected substances. Not enough evidences exist for degrees IV and V that may recommend or advise against any of the treatments. In any degree of VUR, open surgical treatment is superior as far as medical treatment is concerned only regarding the number of acute pyelonephritis episodes during followup. This conclusion cannot be applied on endoscopic treatment.
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Schlussel R. Cystoscopic correction of reflux. Curr Urol Rep 2004; 5:127-31. [PMID: 15028205 DOI: 10.1007/s11934-004-0025-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Vesicoureteral reflux is a well-recognized cause of childhood illness and renal damage. In the past, surgical reimplantation had been the only procedure available to gain the immediate cessation of reflux. The development of an endoscopic injection technique as a less morbid alternative to traditional surgery began in the 1980s. Teflon was the first injectable agent to be investigated. The record of Teflon is one of efficacy and apparent patient tolerance. However, concerns regarding possible migration and other side effects led to a search for other injectable agents. The most recently investigated agents are polydimethylsiloxane and dextranomer polymer. These agents do not have the long-term follow-up of Teflon, but appear to be effective and safe. Time will tell which agent will become the implant of choice, but it seems clear that endoscopic management will play an increasingly larger role in the care of vesicoureteral reflux.
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Affiliation(s)
- Richard Schlussel
- Children's Hospital of New York-Presbyterian, Department of Urology, 3959 Broadway, CHN-1118, New York, NY 10032, USA.
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Simsek F, Yucel S, Aktas M, Turkeri L. Ordinary Glass Spheres as an Alternative Injectable Material for Endoscopic Correction of Vesicoureteral Reflux. J Urol 2004; 171:1282-6. [PMID: 14767333 DOI: 10.1097/01.ju.0000112791.63272.6c] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Although they are therapeutically effective, injectable materials for urinary tract are associated with various disadvantages, precluding their universal acceptance. In this study we investigated glass spheres (GSs) as an alternative injectable substance to correct vesicoureteral reflux (VUR) in an animal model. MATERIALS AND METHODS We used 150 to 300 micro GSs suspended in agarose gel to form the injection paste. GS paste was injected into the rectus muscle and submucosa of the bladder in 8 adult New Zealand male rabbits. As a control group, vehicle only was injected into 4 rabbits. The rabbits were sacrificed to harvest the bladder, pelvic lymph nodes, kidney, liver, brain, spleen and lung at month 1 and year 1 of injection. A VUR model was then created by unroofing the 2 ureteral orifices of 12 adult sheep. GS paste was injected into the right subureter and vehicle only was injected into the left subureter. Cystourethrographies were performed at month 3 and year 1 of injection. The sheep were sacrificed at cystourethrography to harvest the bladder, lymph nodes, kidney, liver, brain, spleen and lung. RESULTS At month 3 and year 1 of injection into rabbit tissues nodule formation was stable in position and volume. Histopathological studies of local and distant organs of the rabbit did not show any granuloma formation or migration of GS. GS paste injection corrected VUR in sheep. Re-injection of GS into still refluxing left units corrected VUR. Local and distant organs harvested from sheep did not demonstrate distant migration. CONCLUSIONS When injected into bladder submucosa and rectus muscle, GS appears to be inert, biocompatible and efficient. Similarly it is effective for correcting VUR in an animal model. We present our data on GS, encouraging further investigation to develop an alternative injectable material for endoscopic VUR correction.
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Affiliation(s)
- Ferruh Simsek
- Department of Urology, Marmara University School of Medicine, Marmara, Italy
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12
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Wheeler DM, Vimalachandra D, Hodson EM, Roy LP, Smith GH, Craig JC. Interventions for primary vesicoureteric reflux. Cochrane Database Syst Rev 2004:CD001532. [PMID: 15266449 DOI: 10.1002/14651858.cd001532.pub2] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Vesicoureteric reflux (VUR) results in urine passing, in a retrograde manner, up the ureter. Urinary tract infections (UTIs) have been considered to be the main cause of permanent renal parenchymal damage in children with reflux. Therefore management of these children has been directed at preventing infection by antibiotic prophylaxis and/or surgical correction of reflux. However controversy remains as to the optimum strategies for management of children with primary VUR. OBJECTIVES To evaluate the benefits and harms of the different treatment options for primary VUR. SEARCH STRATEGY Published and unpublished randomised controlled trials (RCTs) were identified from the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, reference lists of articles and abstracts from conference proceedings. SELECTION CRITERIA RCTs were included if they compared any treatments of VUR including surgery (open and closed techniques), antibiotic prophylaxis of any duration, non-invasive techniques such as bladder training and any combination of therapies. DATA COLLECTION AND ANALYSIS Two reviewers independently searched the literature, determined trial eligibility, assessed quality, extracted and entered data. For dichotomous outcomes, results were expressed as relative risk (RR) and 95% confidence intervals (CI). Data were pooled using the random effects model. MAIN RESULTS Ten trials involving 964 evaluable children comparing long-term antibiotics and surgical correction of VUR with antibiotics (seven trials), antibiotics with no treatment (one trial) and different materials for endoscopic correction of VUR (two trials) were identified. Risk of UTI by 1-2 and 5 years was not significantly different between surgical and medical groups (by 2 years RR 1.07, 95% CI 0.55 to 2.09; by 5 years RR 0.99; 95% CI 0.79 to 1.26). Combined treatment resulted in a 60% reduction in febrile UTI by 5 years (RR 0.43, 95% CI 0.27 to 0.70) but no concomitant significant reduction in risk of new or progressive renal damage at 5 years (RR 1.05, 95% CI 0.85 to 1.29). In one small study no significant differences in risk for UTI or renal damage were found between antibiotic prophylaxis and no treatment. REVIEWERS' CONCLUSIONS It is uncertain whether the identification and treatment of children with VUR confers clinically important benefit. The additional benefit of surgery over antibiotics alone is small at best. Assuming a UTI rate of 20% for children with VUR on antibiotics for five years, nine reimplantations would be required to prevent one febrile UTI, with no reduction in the number of children developing any UTI or renal damage.
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Affiliation(s)
- D M Wheeler
- Department of Clinical Epidemiology, Children's Hospital at Westmead, Locked Bag 4001, Westmead, NSW, Australia, 2145
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Wheeler D, Vimalachandra D, Hodson EM, Roy LP, Smith G, Craig JC. Antibiotics and surgery for vesicoureteric reflux: a meta-analysis of randomised controlled trials. Arch Dis Child 2003; 88:688-94. [PMID: 12876164 PMCID: PMC1719586 DOI: 10.1136/adc.88.8.688] [Citation(s) in RCA: 143] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIMS To evaluate the benefits and harms of treatments for vesicoureteric reflux in children. METHODS Meta-analyses of randomised controlled trials using a random effects model. Main outcome measures were incidence of urinary tract infection (UTI), new or progressive renal damage, renal growth, hypertension, and glomerular filtration rate. RESULTS Eight trials involving 859 evaluable children comparing long term antibiotics with surgical correction of reflux (VUR) and antibiotics (seven trials) and antibiotics compared with no treatment (one trial) were identified. Risk of UTI by 1-2 and 5 years was not significantly different between surgical and medical groups (relative risk (RR) by 2 years 1.07; 95% confidence interval (CI) 0.55 to 2.09, RR by 5 years 0.99; 95% CI 0.79 to 1.26). Combined treatment resulted in a 60% reduction in febrile UTI by 5 years (RR 0.43; 95% CI 0.27 to 0.70) but no concomitant significant reduction in risk of new or progressive renal damage at 5 years (RR 1.05; 95% CI 0.85 to 1.29). In one small study no significant differences in risk for UTI or renal damage were found between antibiotic prophylaxis and no treatment. CONCLUSION It is uncertain whether the identification and treatment of children with VUR confers clinically important benefit. The additional benefit of surgery over antibiotics alone is small at best. Assuming a UTI rate of 20% for children with VUR on antibiotics for five years, nine reimplantations would be required to prevent one febrile UTI, with no reduction in the number of children developing any UTI or renal damage.
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Affiliation(s)
- D Wheeler
- Centre for Kidney Research and Cochrane Renal Group, NHMRC Centre of Clinical Research Excellence in Renal Medicine, The Children's Hospital at Westmead, Sydney, NSW, Australia
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Al-Hunayan AA, Kehinde EO, Elsalam MA, Al-Mukhtar RS. Outcome of endoscopic treatment for vesicoureteral reflux in children using polydimethylsiloxane. J Urol 2002; 168:2181-3. [PMID: 12394755 DOI: 10.1016/s0022-5347(05)64349-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE We reviewed the outcome of subureteral injection of polydimethylsiloxane as a bulking agent for endoscopic treatment for vesicoureteral reflux in patients younger than 12 years. MATERIALS AND METHODS A total of 40 children (59 ureters) with primary grades II to IV vesicoureteral reflux were treated with a single subureteral injection from 1997 to 2001 and followed an average of 26 months (range 4 to 45). Results in 38 patients (55 ureteral units) were available for review. Each child underwent preoperative voiding cystourethrography, renal ultrasound, dimercapto-succinic acid scan and urine culture. Treatment was done on an outpatient basis. With the patient general anesthesia polydimethylsiloxane implant was injected transurethrally below the ureteral opening of the affected renal unit. Renal ultrasound at 1 week and voiding cystourethrography at 2 months were done to rule out obstruction at the injection site and/or persistent reflux, respectively. Cure was defined as absent vesicoureteral reflux on voiding cystourethrography 2 months after injection. RESULTS After a single injection polydimethylsiloxane cured vesicoureteral reflux in 45 ureteral units (81.8%), while in 5 (9.1%) the condition was improved. The remaining 5 ureteral units (9.1%) showed no change in reflux grade. In 1 patient (1.9%) with unilateral grade IV vesicoureteral reflux contralateral reflux developed. None of the cured patients had recurrent reflux during followup. In 1 patient ureteral obstruction was successfully treated with ureteral reimplantation. CONCLUSIONS Endoscopic subureteral injection of polydimethylsiloxane implant in children with primary grades II to IV vesicoureteral reflux appears to be an effective, safe and minimally invasive technique.
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Affiliation(s)
- Adel A Al-Hunayan
- Department of Pediatric Surgery, Bin Sina Hospital, and Faculty of Medicine, Kuwait University, Safat, Kuwait
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15
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Outcome of Endoscopic Treatment for Vesicoureteral Reflux in Children Using Polydimethylsiloxane. J Urol 2002. [DOI: 10.1097/00005392-200211000-00092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Leonard MP. Endoscopic injection therapy for treatment of vesicoureteric reflux: A 20-year perspective. Paediatr Child Health 2002; 7:545-50. [PMID: 20046467 PMCID: PMC2798613 DOI: 10.1093/pch/7.8.545] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To review the application and outcome of endoscopic injection therapy for vesicoureteric reflux in regard to its evolution over the past two decades. DATA SOURCES Review articles, original reports and abstracts pertaining to endoscopic injection therapy were obtained through a PubMed search of English, German and French publications from 1981 to 2001. DATA SELECTION A total of 46 studies were selected. Four were selected to support basic concepts in the management of vesicoureteric reflux, and the remainder pertained specifically to endoscopic injection therapy for vesicoureteric reflux. DATA EXTRACTION The reports were analyzed with focus on the physical properties of the biomaterial injected, results of treatment in regard to the cure of vesicoureteric reflux, duration of cure, and possible adverse effects and clinical benefits engendered by the use of injectable materials. DATA SYNTHESIS Endoscopic injection therapy successfully cures vesicoureteric reflux in 60% to 80% of cases. Success rates are higher with particulate materials (Teflon and Macroplastique) than with bovine collagen or autologous chondrocytes. Long term data regarding cure are scant. Although concerns about particulate migration and autoimmune disease exist, these have not been borne out of clinical experience. Endoscopic injection may be accomplished on an outpatient basis, with less morbidity than with open ureteroneocystostomy. CONCLUSIONS Endoscopic injection therapy should be offered as an alternative treatment in patients with indications to consider ureteroneocystotomy, but should not change the indications for surgical intervention. The ideal biomaterial for injection has yet to be developed, but the field of autologous tissue engineering holds promise for future development.
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Affiliation(s)
- Michael P Leonard
- Departments of Surgery and Pediatrics, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario
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PITFALLS OF REPEAT SUBURETERAL BOVINE COLLAGEN INJECTIONS FOR THE ENDOSCOPIC TREATMENT OF VESICOURETERAL REFLUX. J Urol 2000. [DOI: 10.1097/00005392-200006000-00090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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18
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HAFERKAMP A, MÖHRING K, STAEHLER G, DÖRSAM J. PITFALLS OF REPEAT SUBURETERAL BOVINE COLLAGEN INJECTIONS FOR THE ENDOSCOPIC TREATMENT OF VESICOURETERAL REFLUX. J Urol 2000. [DOI: 10.1016/s0022-5347(05)67598-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- A. HAFERKAMP
- From the Department of Urology, University of Heidelberg, Heidelberg, Germany
| | - K. MÖHRING
- From the Department of Urology, University of Heidelberg, Heidelberg, Germany
| | - G. STAEHLER
- From the Department of Urology, University of Heidelberg, Heidelberg, Germany
| | - J. DÖRSAM
- From the Department of Urology, University of Heidelberg, Heidelberg, Germany
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Haferkamp A, Contractor H, Möhring K, Staehler G, Dörsam J. Failure of subureteral bovine collagen injection for the endoscopic treatment of primary vesicoureteral reflux in long-term follow-up. Urology 2000; 55:759-63. [PMID: 10792096 DOI: 10.1016/s0090-4295(00)00494-5] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To evaluate the long-term efficacy of subureteral glutaraldehyde cross-linked collagen injection (GAX 35) for endoscopic treatment of primary vesicoureteral reflux (VUR). METHODS We prospectively studied 36 patients (58 ureteral renal units), 30 girls and 6 boys with a median age of 6 years (range 2 months to 18 years). All patients had primary VUR and were treated with a single subureteral collagen injection (GAX 35). The patients were followed up by voiding cystography. RESULTS According to the International Reflux Study Classification, we found the following reflux grades preoperatively: grade I, 2 ureteral units; grade II, 21 units; grade III, 28 units; grade IV, 4 units, and grade V, 3 units. All patients were treated with subureteral bovine collagen injection (GAX 35, mean volume 1.7 mL, range 0.7 to 3.5). All but 3 cases of reflux resolved initially. The mean follow-up was 13 months (range 1 to 108). After 37 months of follow-up, only 5 (9%) of 57 treated units remained reflux free. One unit was followed up for 17 months and also remained reflux free. CONCLUSIONS These data suggest that a single endoscopic subureteral collagen injection is not effective in the long-term follow-up of patients with primary VUR. In the future, it will be important to determine whether the new, currently used, and soon be approved bulking agents show better long-term clinical results to prevent VUR recurrence than bovine collagen does.
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Affiliation(s)
- A Haferkamp
- Department of Urology, University of Heidelberg, Heidelberg, Germany
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Kershen RT, Atala A. New advances in injectable therapies for the treatment of incontinence and vesicoureteral reflux. Urol Clin North Am 1999; 26:81-94, viii. [PMID: 10086052 DOI: 10.1016/s0094-0143(99)80008-1] [Citation(s) in RCA: 109] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Clinical experience over the last two decades has demonstrated that the endoscopic correction of primary vesicoureteral reflux and urinary incontinence caused by intrinsic sphincteric dysfunction is both possible and effective. The ideal material for use in these regards has yet to be developed. As a result, there has been a continuing research effort directed towards the development of new injectable substances. Nonautologous substances, such as Teflon, collagen, and Deflux, and autologous substances such as fat, chondrocytes and muscle, have been used either clinically or are under investigation. Although the ideal substance has yet to be determined, many of the substances currently under development appear promising. The use of a particular substance may best be determined by the clinical circumstance involving each individual patient.
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Affiliation(s)
- R T Kershen
- Department of Urology, Children's Hospital, Boston, Massachusetts, USA
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