Endoscopic correction of vesico-ureteric reflux in duplex systems

A successful centre for translational paediatric surgical research

The National Children's Research Centre (NCRC), the single largest paediatric research centre in Ireland, has been in existence for over 50 years and is located on the grounds of the largest children's hospital in Ireland; Children's Health Ireland at Crumlin. Professor Puri was appointed as the Director of the Research in 1989 and became President of the NCRC in 2009, a position he held until 2016. Professor Puri is one of the most cited paediatric surgical researchers in the world. His research work has been cited over 23,500 times in peer-reviewed articles with an h-index of 76 and i10-index of 494. The aim of this review is to analyse the most relevant areas of academic research at the NCRC, Dublin, during the years when Prof. Puri was Director/President of the NCRC. In addition, the relevant factors essential to create a successful paediatric surgical research centre will be discussed. A literature search using PubMed/Medline was carried out using the search terms "Prem Puri" over a 40-year period (1980-2020). Articles were analysed to identify the most significant research areas in the field of paediatric surgical research and the relevant laboratory and clinical findings. In addition, a separate analysis of successful funding and human factors, such as research fellows working at the NCRC, was also carried out. During the period under review, Professor Puri's team published 750 articles in peer-reviewed journals. Three main areas of research were reviewed with a total number of 391 articles: congenital diaphragmatic hernia (CDH) was the topic with the largest number of publications (153), followed by Hirschsprung's disease (HSCR) (144) and Vesicoureteral reflux (VUR) (94). Eighty research fellows, all paediatric surgeons, from 18 different countries were trained in basic science under the supervision of Professor Puri at the NCRC. Over the last three decades, the NCRC has been one of the most successful centres for paediatric surgical research in the world. The three areas of research with the largest number of publications were identified as CDH, HSCR and VUR. Various factors can explain the success of the NCRC: (a) the constant presence, for over 30 years, of a very successful paediatric surgeon leading the centre, (b) a multicultural laboratory with research fellows from all over the world and (c) grants of more than 15 million raised over the years, which guaranteed a constant flow of resources for laboratory research.

Antireflux endoscopic injection therapy in post-pubertal patients via techniques adopted for the dilated ureteral orifice: a retrospective single-center study

BACKGROUND

To investigate the efficacy and safety of endoscopic injection therapy for vesicoureteral reflux in post-pubertal patients with dilated ureteral orifice via modified hydrodistension implantation techniques.

METHODS

We retrospectively reviewed medical records including operational procedure and clinical course of all consecutive patients over 12 years old with a history of injection therapy. Endoscopic injection of dextranomer/hyaluronic acid copolymer was performed under hydrodistension implantation technique with some modifications in order to inject through dilated ureteral orifice align with the intramural ureter. Technical selections were done according to hydrodistension grade of the ureteral orifice. Voiding cystourethrography was evaluated at 3 months postoperatively. Hydronephrosis was evaluated using ultrasonography preoperatively until 6 months postoperatively.

RESULTS

From 2016 to 2019, 12 patients (all female, 16 ureteral units; median age 32 [range 15-61] years) underwent endoscopic injection therapy at one of our institutions. We have identified grade II vesicoureteral reflux in 5 ureters, grade III in 8, and grade IV in 3 ureters. Grade 3 ureteral-orifice dilation were presented in 12 ureters (75%), grade 2 in 3 and grade 1 in 1 ureter in the present cases. Postoperatively, vesicoureteral reflux was diminished to grade 0 in 12 ureteral units (75%), decreased to grade I in 3 (9%), and remained grade III in 1 (6%). Three patients reported dull flank pain for several days postoperatively and there was 1 case of acute pyelonephritis. Temporary hydronephrosis was confirmed in 3 ureteral units (19%) at 1 month postoperatively. Median follow-up duration was 23 (range 13-63) months long. Although, 3 patients were experienced f-UTI 1-2 times, repeated VCUG showed no VUR recurrence.

CONCLUSIONS

According to hydrodistension grade of the ureteral orifice, endoscopic injection therapy via modified hydrodistension implantation technique is an effective and safe treatment for vesicoureteral reflux in post-pubertal female patients with dilated ureteral orifice. While ureteral deformities or a history of anti-reflux surgery may increase the risks, these can be managed with appropriate methods that ensure sufficient mound appearance and height.

Robot-assisted ureteroureterostomy in pediatric patients: current perspectives

Developments in pediatric robotic surgery have increased the feasibility of minimally invasive surgery for complex urinary tract reconstruction. Ureteroureterostomy is a commonly employed strategy for the management of a duplicated ureteral system with either upper pole obstruction or lower pole vesicoureteral reflux, and this approach minimizes the risk to a healthy ureter as might be seen in a common sheath ureteral reimplant and avoids complex dissection around the renal hilum as with a heminephrectomy. The robotic platform enables optimum instrument manipulation for an end-to-side ureteral anastomosis as well as excellent visualization deep into the pelvis for excision of the distal ureteral stump. In this study, the indications and preoperative evaluation for pediatric robotic ureteroureterostomy (RUU) were described and intraoperative considerations for a successful repair were highlighted. In order to assess the outcomes, a PubMed search was performed to find the articles focusing on RUU in the pediatric population. The institutional experience of the authors was also reviewed. As with an open procedure, both minimizing dissection on the recipient ureter and ensuring a tension-free, watertight anastomosis are key principles to minimize complications. Although port placement is similar to that in robotic pyeloplasty, small adjustments may need to be made to ensure access to the pelvis. An assistant port and/or traction sutures is often used to aid in the dissection and anastomosis. RUU was first described in 2008, and several reports have demonstrated positive short-term results. However, median follow-up times are limited with most series reporting outcomes <1 year postoperatively. A future study is required to establish the long-term efficacy of this procedure and define the optimum patient population for a robotic approach.

Dextranomer/hyaluronic acid endoscopic injection is effective in the treatment of intermediate and high grade vesicoureteral reflux in patients with complete duplex systems

PURPOSE

Endoscopic subureteral injection of dextranomer/hyaluronic acid has become an established alternative to long-term antibiotic prophylaxis or surgical treatment for vesicoureteral reflux. We evaluated the effectiveness of endoscopic injection of dextranomer/hyaluronic acid in intermediate and high grade vesicoureteral reflux in patients with complete duplex collecting systems.

MATERIALS AND METHODS

A total of 123 children underwent endoscopic correction of intermediate or high grade vesicoureteral reflux using injection of dextranomer/hyaluronic acid into complete duplex systems between 2001 and 2010. Vesicoureteral reflux was diagnosed by voiding cystourethrogram, and dimercapto-succinic acid scan was performed to evaluate the presence of renal scarring. Followup ultrasound and voiding cystourethrogram were performed 3 months after the outpatient procedure and renal ultrasound thereafter every 2 years. Mean followup was 6.7 years.

RESULTS

Complete duplex systems were unilateral in 110 patients and bilateral in 13. Reflux severity in the 136 refluxing units was grade II in 1 (0.7%), III in 52 (38.2%), IV in 61 (44.9%) and V in 22 (16.2%). Dimercapto-succinic acid scan revealed renal functional abnormalities in 63 children (51.2%). Vesicoureteral reflux resolved after the first endoscopic injection of dextranomer/hyaluronic acid in 93 ureters (68.4%), after a second injection in 35 (25.7%) and after a third injection in 8 (5.9%). Febrile urinary tract infection developed in 5 patients (4.1%) during followup. No patient required ureteral reimplantation or experienced significant complications.

CONCLUSIONS

Our results confirm the safety and efficacy of endoscopic injection of dextranomer/hyaluronic acid in eradicating intermediate and high grade vesicoureteral reflux in patients with complete duplex systems. We recommend this minimally invasive, 15-minute outpatient procedure as a viable option for treating intermediate and high grade vesicoureteral reflux in patients with complete duplex collecting systems.

Polydimethylsiloxane (macroplastique®) injection for vesicoureteral reflux in duplex ureters: a comparison with single renal systems

OBJECTIVE

VUR in patients with a duplex system (DS) is often treated by open surgery. The aim of this study was to evaluate the efficacy of subureteric polydimethylsiloxane (Macroplastique(®)) injection (SMING) in the management of VUR in duplex and single (SS) renal systems.

PATIENTS AND METHODS

Fifteen children (24 refluxing renal units) with VUR in DS underwent SMING. VUR was more frequent in the lower moiety. VUR was graded moderate/severe in 88% of renal units. There was a history of urinary tract infections in 40% of cases. The outcome for DS patients was compared with 44 children (60 refluxing renal units) with moderate/severe VUR in SS.

RESULTS

The VUR resolution/improvement rate was 88% in DS and 95% in SS patients. Ureteric reimplantation was required because of recurrent VUR in 13% and 7% of DS and SS groups, respectively. Transient ureteral obstruction was observed in 1/15 and 5/44 patients. Two required double-J ureteric stenting for 3 months.

CONCLUSION

SMING seems an effective treatment for VUR in both DS and SS patients, even in severe cases. The complication rate does not significantly differ between the two groups.

The clinical utility and safety of the endoscopic treatment of vesicoureteral reflux in patients with duplex ureters

OBJECTIVE

A systemic review of published literature on the use of bulking agents in the treatment of vesicoureteral reflux (VUR) in patients with duplex systems was performed in order to evaluate the diagnostic challenges; determine success rates, and compare with use in single systems; and evaluate safety, in particular of Deflux.

METHODS

A PubMed/Medline search was conducted for index articles discussing duplex ureters published in 1963-2007. All types of publications were included. A multiple linear regression analysis was performed.

RESULTS

Overall, 28 different treatment arms originating in 17 separate studies (19 publications) satisfied the inclusion criteria for linear regression efficacy analysis. Data were available on 2879 patients: 2400 with single and 479 with duplex systems. Ten publications provided information on the frequency of failure to diagnose duplex systems using specific techniques. An overall 18% failure rate to detect duplex systems was reported for combined techniques. For patients in whom favorable anatomic location of ureters allowed successful endoscopic injection of a bulking agent, correction of VUR was achieved in 53-100% of cases. A univariant analysis showed no difference in success rate between single and duplex systems with the use of Deflux, or other bulking agent. The predicted probability of success in a single system was 68% and in a duplex system 64%.

CONCLUSIONS

There is significant potential for failing to detect duplex systems prior to preparing an individual for either open or endoscopic treatment. From the studies available, endoscopic injection of bulking agents is highly successful in correcting mild-to-moderate VUR in duplex systems, with no reports of serious or clinically significant adverse effects. At a minimum, duplex systems would not seem to be a contraindication to the use of Deflux or any other bulking agent.

Use of collagen for endoscopic correction in complicated vesicoureteral reflux

OBJECTIVE

Endoscopic treatment of children with primary vesicoureteral reflux (VUR) has become an alternative to long-term antibiotic prophylaxis and open surgery. The purpose of this study was to assess the efficiency and safety of endoscopic subureteral injections of collagen (STING) as a treatment for complicated VUR in children.

MATERIAL AND METHODS

Twenty-five patients (41 ureteral units) underwent a modified STING procedure for the correction of complicated VUR. Of these patients, five (nine refluxing units) had Hutch's diverticulum, 10 (17 refluxing units) had a duplex system, eight (10 refluxing units) had ureterocele, one (three refluxing units) had a unilateral triple ureter and one (two refluxing units) had a bilateral single ectopic ureter. Of these 41 ureteral units, 14 had grade III VUR, 17 grade IV and 10 grade V. Fourteen refluxing units (30%) received one session of STING, which was successful, and 27 (70%) needed a second session. A follow-up voiding cystourethrogram was performed 3 months after each session of STING.

RESULTS

The mean follow-up period was 24 months (range 3-36 months). Of these 41 refluxing units, 34 were treated successfully and regression or downgrading occurred in seven. Follow-up i.v. pyelography or sonography did not reveal any urinary tract obstruction.

CONCLUSIONS

The results of this study showed that endoscopic correction of these complicated refluxing ureters may be the first choice of treatment, but the technique must be modified to suit each individual case.

Endoscopic injection of dextranomer hyaluronic acid copolymer for the treatment of vesicoureteral reflux in duplex ureters

PURPOSE

Endoscopic injection of dextranomer hyaluronic acid copolymer (DxHA) has been increasingly utilized for the treatment of complex cases of vesicoureteral reflux (VUR). We present our 6-year experience with the use of DxHA for the treatment of VUR in duplex ureters.

MATERIALS AND METHODS

Between July 2001 and April 2007, 52 children were identified retrospectively who had been treated by endoscopic injection of DxHA for VUR into duplex ureters. Mean age was 3 years (range 9 months-10 years) with a mean maximum grade of reflux of III (range 2-5). The refluxing lower pole ureter was injected using a subureteric injection technique (STING) or intraureteric injection technique (utilizing the hydrodistention implantation technique). The endpoint in all cases was the loss of hydrodistention of the ureteral orifice. Voiding cystourethrograms was obtained at 6 weeks-3 months to evaluate for the presence of VUR. Cure was defined as complete resolution of reflux in the treated moiety.

RESULTS

After initial treatment, 38/52 (73%) patients were cured. Of the 14 failures, nine children underwent repeat endoscopic treatment with a 67% (6/9) resolution rate for repeat injection. Seven of the initial failures failed to grade I VUR. Overall, 85% (44/52) were cured after one or two treatments, 98% (51/52) were improved and only one (1.9%) with grade V VUR required open surgery. The treatment was well tolerated and there were no associated complications.

CONCLUSION

Endoscopic injection of DxHA copolymer corrected VUR in 85% of children with VUR into duplex ureters. This minimally invasive approach should be considered as a viable alternative to open surgery or antibiotic prophylaxis for the treatment of VUR associated with duplex ureters.

Endoscopic Treatment of Vesicoureteral Reflux Associated With Ureterocele

PURPOSE

We determined the value of endoscopic treatment for vesicoureteral reflux associated with ureterocele.

MATERIALS AND METHODS

From 1984 to 2005, 109 children with a median age of 6 months underwent endoscopic ureterocele puncture. Ureterocele presented as a part of a duplex system in 97 of patients (89%) and as part of a single system in 12 (11%). Vesicoureteral reflux was seen to the lower ipsilateral moiety in 53 patients and in 32 contralateral kidneys (85 refluxing renal units). Puncture was performed with a 3Fr Bugbee electrode. High grade vesicoureteral reflux or breakthrough infection while on antibiotic prophylaxis served as the indication for the surgical correction of vesicoureteral reflux. Median followup after endoscopic correction was 10 years (range 1 to 21).

RESULTS

Spontaneous vesicoureteral reflux resolution following successful ureterocele puncture was seen in 36 of the 85 refluxing renal units (42%) and in 5 (6%) reflux was downgraded. The latter patients were withdrawn from antibiotic prophylaxis and they did well. A total of 33 refluxing renal units with vesicoureteral reflux into the lower moiety of the ureterocele kidney and 11 contralateral refluxing renal units underwent endoscopic correction. Reflux was corrected in 31 of the 44 refluxing renal units (70%) after a single injection and it resolved after a second injection in another 9 (21%). In 4 refluxing renal units (9%) endoscopic correction failed and open reimplantation was done. Of the 109 patients (13%) 14 had vesicoureteral reflux to the ureterocele moiety following endoscopic puncture. Of those patients endoscopic correction resolved reflux in 3, reflux resolved spontaneously in 5 and upper pole partial nephrectomy was performed in 4 due to a nonfunctioning moiety. The remaining 2 patients did well without antibiotic prophylaxis.

CONCLUSIONS

Our data show that endoscopic treatment of vesicoureteral reflux associated with ureterocele is a simple, long-term effective and safe procedure, avoiding the need for open surgery in the majority of patients following endoscopic puncture of ureterocele.

Are there predictive factors for the outcome of endoscopic treatment of grade III-V vesicoureteral reflux with dextranomer/hyaluronic acid in children?

Dextranomer/hyaluronic acid (Dx/HA) copolymer has been used widely for the treatment of vesicoureteral reflux (VUR) in children since 2001. However, the factors that influence the outcome of injection therapy with Dx/HA have remained unclear. In this study, we retrospectively evaluated the outcomes in 101 consecutive children to determine the cure and to identify the factors that can impact treatment outcomes of Dx/HA injection. Endoscopic treatment with Dx/HA was performed in 133 ureters, in 101 patients with grade III-V VUR. Of the patients, 68 (67.3%) were girls and the mean age was 6.5 years. Before and after the treatment, the presence and grades of VUR were determined by voiding cystourethrograms. The patients' age, gender, laterality, preoperative reflux grade, ureteral duplication, morphology of ureteral orifice, renal hypoplasia and experience with surgery were assessed as predictive factors related to the success rates of Dx/HA injection therapy. The cure rates were 54.8% after the first injection, 66.9% after the second and 73.6% after the third injection. Patients with a high grade (grade IV or V), duplicated system, golf hole-shaped orifice and renal hypoplasia had significantly lower cure rates (P<0.05). Experience with the technique also correlated with the positive outcome of the procedure. New contralateral vesicoureteral reflux developed in five (7.2%) patients with unilateral VUR, and all of them resolved spontaneously during the first year of followup. No treatment-related significant complication was encountered. Although, endoscopic treatment of VUR with Dx/HA provides a high rate of success in children with medium or high grade VUR, treatment failure may be seen in some patients. However, we showed that endoscopic treatment with Dx/HA was effective in selected patients with grade V VUR, and we emphasize the need for further large-scale studies to confirm our findings.

Role of periureteral injections in children with vesicoureteral reflux

PURPOSE OF REVIEW

Periureteral injection has become an increasingly popular method for managing vesicoureteral reflux in children. This minimally invasive and seemingly effective technique, completed in a simple manner, is attracting more attention from urologists and parents alike. This review describes the contemporary experience with injection therapy and attempts to define its place in the algorithm for the management of vesicoureteral reflux.

RECENT FINDINGS

A variety of different substances have been tried as bulking agents to eliminate vesicoureteral reflux since the technique was introduced more than 20 years ago. Long-term follow-up has found drawbacks with each substance tried. Dextranomer polysaccharide microspheres crosslinked in sodium hyaluronan (Deflux; Ixion Biotechnology, Inc, Alachua, Florida, USA) have recently appeared as another alternative in treatment. Recent reports have focused on the efficacy of the material used in patients with different grades of reflux and in patients whose reflux is associated with other conditions. The substance has performed reasonably well in most initial studies but its cure rates do not approximate those of open surgery. Technical improvements and risk factors for failure are gradually being identified that are aimed at improving performance. The long-term efficacy of Deflux is not well defined and cost-analysis data of patients managed in a prospective randomized fashion are lacking.

SUMMARY

The role of periureteral injection therapy, for patients whose vesicoureteral reflux requires correction, remains unclear. Further studies are needed to elucidate its place in the algorithm for the management of this common problem in children.

[Complex vesicoureteral reflux. Our experience]

OBJECTIVE

To analize the proportion of complex reflux in the whole amount of patients treated endoscopically of vesicoureteral reflux in our hospital. To determine the endoscopic treatment success in complex reflux, and the influence of reflux grade in it.

MATERIAL AND METHODS

We present our experience between 1992 and 2003 with three kinds of substances (polytetrafluoroethylene, polydimethylsiloxane and dextranomer-hyaluronic acid copolymer). We treated complex reflux in 74 patients with endoscopic injection. All patients were scheduled to have voiding cystourethrogram 3 and 9 moths after injection. A positive response was defined as grade 0 or I reflux.

RESULTS

Reflux was solved using the endoscopic procedure in 86.25% after first injection, 93.75% after second and 96.25% after third. The corresponding results for reflux grade II, III and IV were 88.9%, 83.3% and 100%.

CONCLUSIONS

We conclude that subureteral injection of different sustances (Teflon, Macroplastique or Deflux) is a useful treatment for most cases of vesicoureteral reflux. We propose it as first step of treatment.

ENDOSCOPIC TREATMENT WITH DEXTRANOMER/HYALURONIC ACID FOR COMPLEX CASES OF VESICOURETERAL REFLUX

PURPOSE

The surgical correction of primary vesicoureteral reflux (VUR) is highly successful. This success decreases in more complex cases and often involves reoperation and increased morbidity. We present our experience with the use of subureteral injection of dextranomer/hyaluronic acid (Dx/HA) in complex cases of vesicoureteral reflux in which open surgery would have been indicated.

MATERIALS AND METHODS

Between October 2001 and July 2003, 72 patients 9 months to 31 years old (mean age 5.6 years) underwent subureteral injection of Dx/HA for complex VUR at our institutions. Dx/HA was injected submucosally within the intramural ureter (modified STING) in most cases. A guidewire was used to manipulate the ureteral orifice and a retrograde ureterogram was used to delineate the anatomy in selected cases. The average volume of injected material was measured for each ureter. Renal sonography was performed to determine if hydronephrosis was present. At 3 months fluoroscopic voiding cystourethrograms were used to evaluate for the presence of VUR.

RESULTS

A total of 93 ureters were treated in 55 girls and 17 boys. All cases were considered to be complex as 17 had persistent reflux after open surgery (7 megaureters repairs, 2 extravesical repairs, 7 intravesical reimplants and 1 blind ureter), 11 had persistent reflux and neurogenic bladder, 7 had ectopic ureters to bladder neck, 6 had bilateral Hutch diverticulum, 6 had persistent stump reflux, 5 had ureterocele after puncture or incision, 15 had duplications, 1 had the prune belly syndrome, 2 had posterior urethral valve following resection, 1 had epispadias and 1 had urogenital sinus. The average maximum reflux grade was IV. An average of 1.1 cc (range 0.4 to 2) was injected per ureter. Of the patients 69 had 3-month followup results. The overall success rate was 68% after 1 implantation (47 of 69).

CONCLUSIONS

Submucosal intraureteral implantation with Dx/HA corrected complex vesicoureteral reflux in 68% of patients. In all of these patients open surgery would have potentially been difficult. The use of fluoroscopy and/or guidewires is a useful adjunct in these cases. We believe that this minimally invasive approach is warranted as an initial step in the management of complex cases of VUR before resorting to more difficult open surgical procedures.

Polydimethylsiloxane Injection Versus Open Surgery for the Treatment of Vesicoureteral Reflux in Complete Duplex Systems

PURPOSE

We compared the efficacy of subureteral polydimethylsiloxane injection (Macroplastique, Uroplasty, Inc., Minneapolis, Minnesota) versus open surgery for correction of varying degrees of reflux in complete duplex systems.

MATERIALS AND METHODS

Between 1997 and 2000 polydimethylsiloxane injection was performed in 15 females (22 refluxing moieties). Mean patient age at presentation and at surgery was 54 and 94 months, respectively. Extravesical common sheath reimplantation (ECSR) was performed in 34 children (bilateral 10) with a mean age at presentation and at surgery of 31 and 57 months, respectively. Voiding cystourethrography and ultrasound were performed at 3 months. In cases of persistent reflux repeat voiding cystourethrography was performed at followup. We then analyzed the surgical outcome for both groups.

RESULTS

Mean followup for the injection and ECSR groups was 12 and 15 months, respectively. The success rate per moiety after injection was 68% at 3 months, which increased to 81.8% at 12 months. One patient had contralateral vesicoureteral reflux and none had de novo hydronephrosis, urinary tract infection or complications postoperatively. The success rate of ECSR was 95.5% at 3 months, which improved to 97.7% at an average of 15 months (p <0.04). After ECSR transient contralateral vesicoureteral reflux was seen in 4 renal units, de novo hydronephrosis was seen in 2 units and 4 patients had urinary tract infections.

CONCLUSIONS

Although endoscopic subureteral polydimethylsiloxane injection was simple and successful in more than 80% of patients with low grade vesicoureteral reflux in duplex systems, it is less effective than surgery with regard to elimination of reflux.

Vesico-ureteric reflux in adults with neuropathic bladders treated with Polydimethylsiloxane (Macroplastique)

OBJECTIVE

To establish the efficacy of Macroplastique in treating vesico-ureteric reflux (VUR) in adults with neuropathic bladder dysfunction.

PATIENTS AND METHODS

Fifteen patients (12 male and three female), age range 19 to 80 years (mean age 38) were included in this study. Diagnosis was confirmed by videourodynamics. In seven patients reflux was present bilaterally. Twenty-two refluxing ureters were treated. Twelve patients had detrusor hyper-reflexia, two had areflexic bladders and one had loss of bladder wall compliance. According to the International Grading System, 10 ureters had grade IV reflux, five had grade III reflux, five had grade II reflux, and two had grade I reflux. Macroplastique (0.5-1.5 ml) was injected submucosally under each ureteric orifice to convert the opening to a slit like shape. The patients were followed up from 9 to 68 months.

RESULTS

VUR was completely resolved in 72.7% (16) ureters following a single injection and in a further 4.5% (1) ureter following a second injection. 9.1% (2) ureters were improved and treatment failed in 13.7% (3) ureters. Two patients showed a recurrence of reflux 1 and 4 years after primary injection and subsequently had a curative second injection. Most of the patients in whom VUR was cured or improved showed a reduction in laboratory proven urinary infection rates.

CONCLUSION

Macroplastique produced an excellent result (86% with complete resolution or improvement of reflux) in treating VUR in adult neuropathic bladders. This is comparable to larger studies carried out on the paediatric population. This is an easy procedure, which avoids major surgery and can be performed as a day case. In cases of failure or recurrence, repeat injection or open surgery can be undertaken without any added complications.

Endoscopic treatment of reflux by subureteric collagen injection: critical review of 5 years' experience

In the past decade, subureteric endoscopic injection of Teflon or collagen has been propagated as a safe and successful treatment for vesicoureteral reflux. In our center, from 1990 through 1995, 118 children and 5 adults with reflux and recurrent urinary tract infections were injected with cross-linked bovine collagen in an open, prospective study. Efficacy and safety were assessed 6 and 12 months after injection, and long-term (> or =3 years) results were available in 78 cases. The overall success rate was 58% (64% of ureteral units) free from reflux at 12 months and 54% (58%) after 3 years. Analysis of anatomic, urodynamic, and technical features showed the grade of reflux to be the best predictor of success or failure. When only primary low- and middle-grade reflux, without concomitant anatomic disorders, is considered, the long-term success rate rose to 69% (74% of ureteral units). In conclusion, subureteric collagen injection cannot ultimately replace the highly effective surgical reimplantation. However, the procedure offers a minimally invasive alternative in selected cases of mild reflux when conservative management is inadequate.

The STING in the refluxing duplex system

OBJECTIVE

To assess the efficacy of the subureteric Teflon injection (STING) procedure in the refluxing duplex ureter.

PATIENTS AND METHODS

The STING procedure was performed in 23 patients (five boys and 18 girls, mean age 6.5 years, [range 1.5-14]) with six refluxing upper and 31 refluxing lower moieties. Teflon was injected separately into each moiety of the duplex. All patients were assessed by a micturating cystourethrogram and ultrasonography at least 3 months after treatment and the results were analysed retrospectively for the success rate of each refluxing unit and the overall cure rate of patients.

RESULTS

No patient suffered ureteric obstruction. After the first STING the unit cure rate was 57% but only nine of 23 patients were completely cured. This improved to a unit cure rate of 68% and 11 patients cured after a second STING.

CONCLUSION

Because the patient cure rate was poor we do not advocate using the STING to treat vesicoureteric reflux in the duplex kidney.