Treatment of vesico-ureteral reflux in infants and children using endoscopic approaches

Predictability of success of endoscopic vesicoureteral reflux treatment utilizing clinical risk factors and intraoperative injection characteristics

INTRODUCTION

The guidelines lack clarity on how to follow the patients after endoscopic treatment for vesicoureteral reflux (VUR). The most discussed question is the need for voiding cystourethrogram (VCUG). Risk-based approaches that consider patient characteristics, disease severity, or factors related to the surgery itself could reduce its use, but a satisfactory predictive model has not yet been established. We hypothesized surgeons can predict the treatment success evaluating the procedure and risk factors and analyzed the assessments of five experts on the subject.

MATERIALS AND METHODS

Clinical data of 50 patients (75 renal units) from 2015 to 2021 were analyzed. Detailed medical history (including DMSA, USG, VCUG reports, voiding symptoms, presence of febrile UTI, etc.) and video records of the procedure were evaluated blindly by five expert surgeons. Experts evaluated the injection volume, needle placement site, and mound appearance using a 5-point Likert scale. Based on these assessments, they predicted the likelihood of surgical success and if there was a high risk for obstruction (yes/no).

RESULTS

Consistent responses among evaluators were observed for needle placement site (p < 0.001), but not for injection volume and mound appearance (p = 0.055, p = 0.077, respectively). The scores provided by all evaluators for needle placement site, injection volume, and mound appearance were consistent with their predictions for success (p < 0.001 for all). However, none of the scores given by the evaluators for the three parameters were consistent with actual success (p > 0.05 for all) and predictability for success or obstruction was low for all evaluators (p > 0.05 for all).

CONCLUSION

The assessment of the operation videos even accompanied with a comprehensive medical history including all known risk factors does not aid in predicting outcomes for endoscopic VUR treatment. Our study highlights the need for better criteria to recommend individualized management strategies and the insecurity of categorizing surgeries as "high-risk" or "safe" based solely on the intraoperative satisfaction.

Recurrence of vesico-ureteral reflux in children: is still the endoscopic injection the best option?

Background

Endoscopic injection (EI) is a safe treatment for vesico-ureteral reflux (VUR) in children, but recurrences are not insignificant. This study aims to show if multiple EI is still the best first line management even if in case of recurrences.

Methods

All patients affected by primary VUR, treated with at least one EI and with at least 5 years follow up were included. All general data were analyzed. Recurrence rate after one, two and three EIs were calculated.

Results

One hundred and sixty-one patients (total number =210) were healed after 1 injection, 28 after 2 and 4 after 3 with a global success rate of 91.90%. Recurrence rate is higher in patients older than 3 years old and with IV and V reflux grade. Even if 67.7% of recurrent VUR after one injection was symptomatic, diagnosis of recurrences after multiple EI was mainly radiological. Only 8% of the patients underwent EI need an anti-reflux surgery.

Conclusions

Thanks to its low costs and the acceptable recurrence rate, Deflux EI should be proposed as the first therapeutic approach for children affected by VUR, especially in those with low and moderate grades of VUR. Multiple injections could be contraindicated only in older children thank 1 year with high-grade VUR (IV symptomatic and V grade).

Endoscopic injection of bulking agents in pediatric vesicoureteral reflux: a narrative review of the literature

In the last 20 years, endoscopic injection (EI) has affirmed as a valid alternative to open surgery for management of pediatric vesicoureteral reflux (VUR). This study aimed to investigate and discuss some debated aspects such as indications, bulking agents and comparison, techniques of injection and comparison, predictive factors of success, use in specific situations. EI is minimally invasive, well accepted by patients and families, with short learning curve and low-morbidity profile. It provides reflux resolution rates approaching those of open reimplantation, ranging from 69 to 100%. Obviously, the success rate may be influenced by several factors. Recently, it is adopted as first-line therapy also in high grade reflux or complex anatomy such as duplex, bladder diverticula, ectopic ureters. The two most used materials for injection are Deflux and Vantris. The first is absorbable, easier to inject, has lower risk of obstruction, but can lose efficacy over time. The second is non-absorbable, more difficult to inject, has higher risk of obstruction, but it is potentially more durable. The two main techniques are STING and HIT. To date, the ideal material and technique of injection has not yet clearly established, but the choice remains dependent on surgeon's preference and experience.

The color Doppler twinkling artifact of implants after endoscopic treatment of vesicoureteral reflux in children: A common finding with high potential for misdiagnosis

BACKGROUND

Endoscopic treatment of vesicoureteral reflux (VUR) is a common therapeutic procedure in children. Over the last years several studies reported on calcified deflux implants that were misinterpreted as ureteral stones leading to unnecessary diagnostic and therapeutic procedures.

OBJECTIVE

Based on an own case, where a calcified implant with a strong twinkling artifact was misdiagnosed as a ureteral stone, the purpose of our study was to evaluate the sonographic imaging appearance of implants after endoscopic VUR repair with special emphasis on the color twinkling artifact.

MATERIAL AND METHODS

In 40 children (mean age 9.5 years) with 62 treated ureteral units follow-up sonography was performed after a mean time interval of 48.8 months after surgery. The injected deposit was evaluated with B-mode sonography and color Doppler sonography and deposit volume, posterior acoustic shadowing and the appearance and extension of the twinkling artifact were evaluated.

RESULTS

47 of 62 injected units (75.8%) could be identified on follow-up sonography. In 13 of 47 units (27.7%) posterior acoustic shadowing was noted. On color Doppler sonography a twinkling artifact appeared in 26 of the 47 visible cases (55.3%). There was a statistically significant correlation between a positive twinkling sign and the deposit age.

CONCLUSION

In conclusion our study shows that the twinkling artifact is a common finding in follow-up sonography of children after endoscopic treatment of VUR. As the twinkling artifact is a sensitive imaging sign for the detection of ureteral calculi the risk of misinterpretation and mistreatment is given.

Fluoroscopy-guided percutaneous antegrade approach for ureteral stent placement in children: a single-center experience

BACKGROUND

Although there are many studies on percutaneous nephrostomy in urinary obstruction management in pediatric patients, there is a limited number of studies on percutaneous antegrade ureteral stenting (PAUS) on this issue.

PURPOSE

To evaluate the results of fluoroscopy-guided percutaneous antegrade approach for ureteral stent placement through the nephrostomy route in children.

MATERIAL AND METHODS

Between October 2005 and June 2019, the medical records of children who underwent PAUS through the nephrostomy route were reviewed retrospectively. Demographic data of the patients, technical and clinical success rates, technical details, and complications of the procedure were recorded. Patients were divided and evaluated into groups according to etiology. Categorical data were analyzed by using the Pearson chi-square test.

RESULTS

In total, 31 patients (19 boys, 12 girls; age range = 2 months-18 years; mean age = 7.4 ± 6.01 years) and 42 procedures were included in the study. The most common underlying diseases were ureteropelvic junction obstruction (16 stents, 38.1%) and vesicoureteral reflux (13 stents, 31%). The technical and clinical success rates were 97.6% and 90%, respectively. Clinical failure (10%) was not related to gender, underlying diseases, and stent size (P > 0.05). Mean stent dwelling time was 96.43 ± 58.1 days. Complications were urinary tract infection (two procedures), stent migration (two procedures), early occlusion (one procedure), and contrast material leak after balloon dilation (one procedure). The complication rate was 14.6%. No procedure-related death was observed.

CONCLUSION

PAUS through the nephrostomy route in children is an effective and reliable method when surgical treatment is not feasible.

Endoscopic Injection Treatment of Vesicoureteral Reflux in Children: Meeting with the Factors Involved in the Success Rate

The challenges and controversies in vesicoureteral reflux intervention guidelines resulted in a more individualized treatment planning. Endoscopic injection therapy is now widely used and is considered preferable, but still remains less successful than ureteral reimplantation. Τhe endoscopic vesicoureteral reflux approach should be risk-adapted to current knowledge, so more experience and longer-term follow-up are needed. The precise of preoperative, intraoperative, and postoperative factors that affecting endoscopic injection therapy success rates and outcome have not yet been clearly determined. The aim of this study was to investigate these associated factors. Although the reflux grade is the most well-known factor that can affect the success of the procedure, there is no agreement on which factors are the most influential for the efficacy of endoscopic reflux treatment. So, we carried out a broad review of published papers on this topic, and we presented all the potential predictive variables of endoscopic reflux resolution in children.

A review of novel STING bulking agents

OBJECTIVE

The objective of this study was to review the literature to compare the efficacy and complications of polyacrylate-polyalcohol copolymer (PPC) and polyacrylamide hydrogel (PAHG) with the current standard of care, dextranomer/hyaluronic acid (Dx/HA), when used to treat VUR in the paediatric population.

METHODS

PubMed, Embase and Cochrane databases were searched. Keywords included Vesicoureteral reflux (VUR), endoscopic; endoscopic injection, endoscopic treatment, dulking material, dextranomer/hyaluronic acid copolymer, polyacrylate-polyalcohol copolymer, Deflux, Dexell, Vantris, Bulkamid, outcome, treatment and children. Prospective or retrospective studies comparing PAHG/PPC directly with Dx/HA were included for review.

RESULTS

Four studies were identified comparing PPC with Dx/HA. All studies showed superior efficacy (on micturating cystourethrogram (MCUG) at 3 months) of PPC over Dx/HA. However, 1 study identified a significantly higher rate of vesicoureteric junction obstruction (VUJO) in the PPC group. One study was identified comparing PAHG with Dx/HA which showed similar efficacy on 3-month MCUG.

CONCLUSIONS

Current data suggest PPC confers a higher resolution rate of VUR and PAHG confers comparable resolution rates for VUR compared with Dx/HA in the paediatric population. However, the incidence of late-onset VUJO in one study is concerning, and high-quality randomised controlled trials with long-term follow-up are needed before making further recommendations.