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OBJECTIVES: The main reasons of this review are: To determine some of the embryological and genetic mechanisms of vesicoureteral reflux (VUR) and associated congenital reflux nephropathy (NR); recognize different patterns of familiar clustering and identify appropriate cases where genetic counselling and investigations might be indicated; and finally, to establish the association of these phenomena (VUR and NR).METHODS: Bibliographic search of related articles until June 2007.RESULTS: There are two kinds of primary VUR: isolated VUR and syndromic VUR; the last one has an inherited Mendelian transmission and we know the mechanisms. Epidemiological studies seem to demonstrate that isolated VUR also presents familiar clustering and its inheritance pattern is the main object of interest in some studies; most authors support the hypothesis that VUR is genetically heterogeneous and is caused by a number of different genes acting with random environmental effects. There are lots of candidate implicated genes. The characteristics of VUR (incomplete penetrance, variability of expression, spontaneous resolution…) make difficult to configure a selection of patients subsidiary of genetic study. Despite different treatment options, the incidence of renal chronic failure secondary to VUR has not decreased. Some of the candidate genes identified regulate the position of ureteral budding, a critical step in both kidney and urinary tract development. Analysis of data from humans and mice suggests that some of the renal damage associated with VUR is congenital and is due to a kidney malformation. Therefore, in these cases, the association of VUR and renal failure may be caused by a genetic defect affecting the formation of the kidney and the urinary tract and not by evolution of VUR. Investigation in animals is fundamental to know more about this issue (candidate genes and VUR-NR association).CONCLUSION: It is important to learn patterns of familiar clustering of isolated and syndromic VUR to offer genetic counselling if possible. For this reason, we should be screening carefully all patients suffering from VUR. It is known that limitations in actual indications of genetic study exist. Prenatal diagnosis may be realized if there is a syndromic VUR with known mutation, invariable expressivity or if clinical manifestations involve risk of death. Epidemiological data and laboratory studies may give us guidance to elicit new cases of nephropathy associated to severe VUR.
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OBJECTIVES: Vesicoureteral reflux is a pathologic entity with different forms of therapeutic management, one of which is endoscopic injection of various materials. We show some histological changes produced by these materials in the bladder wall.METHODS: We study three samples of intravesical ureter from three children suffering vesicoureteral reflux. The ureters were obtained during ureteral reimplantation surgery.RESULTS: We show the changes found with various materials under study (polytetrafluorethylene , polydimethylsiloxane, hyaluronic acid and dextranomer copolimer) observing less conjunctive tissue with the two latter and with the more encapsulated hyaluronic acid - dextranomer copolimer.CONCLUSIONS: Migrations and granulomas are described with various materials and we ascertained the presence of foreign body reaction and fibrosis within the bladder wall. More studies in human beings are required to determine the best product for endoscopic injection.
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OBJECTIVES: According to our ex-perience, we present a proposal for the treatment of vesicoureteral reflux, based on both clinical and radiolo-gical evidences. We also describe how the introduction of endoscopic procedures has influenced the evolution of treatment indications as well as the time intervals for treatment.METHODS: We have analysed all cases of vesicourete-ral reflux treated in our Department in two periods of similar length: The first one (106 patients) comprised from 1995 to March 2001 (when endoscopic procedures were introduced). The second one (138 patients), comprised from March, 2001 to March 2007. Clini-cal, diagnostic, therapeutic and outcome-related varia-bles were studied for all cases.RESULTS: The number of patients was higher in the se-cond period. In this period the number of cases requiring ureteral reimplantation decreased with respect to the first one (from 24 to 7). The success rate with en-doscopic treatment reached 94,9%, with no significant differences regarding age or grade of reflux, although higher rates of failures were observed in children aged less than 3 years old and in high-grade reflux. The asso-ciation of reflux with other malformations was not related with a worse evolution after treatment.CONCLUSIONS: Endoscopic treatment, due to its similar efficacy and low aggressiveness, should be con-sidered a valid alternative to open surgery (which offers good results but non-negligible comorbidity) for persistent reflux in which medical treatment has not been useful. We propose a tentative therapeutic scheme to establish the indications for each type of treatment depending on the grade of reflux and its clinical evolution.
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OBJECTIVES: Although minimally invasive pro-cedures have created a groundswell, supportive of early inter-vention as an expedient alternative to surveillance, we present a patient-driven model of care that weighs risk and benefit for each individual.METHODS: A practice review was performed for the period 2000-2006. The records of all patients diagnosed by, or re-ferred to, our group (three full-time Pediatric Urologists with a regional service population of 1.7 million) were included in an analysis of vesicoureteral incidence, initial management, and surgical approach.RESULTS: During the review period, the incidence of newly diagnosed VUR increased at a rate of 4% per year, with 66% of these accrued from evaluation of pre-natal hydronephrosis and asymptomatic siblings of known reflux patients. The num-ber of children with VUR and a significant component of DES also increased over time. During this period of higher case volume, surgical intervention failed to increase significantly, but did show a dramatic procedural shift toward minimally invasive techniques for all providers and probable delayed intervention in a substantive number of cases until endoscopic treatment was freely accessible between 2002-2004. CONCLUSION: Our patient-driven model respects current lite-rature and clinical experience, while acknowledging that our understanding is still currently in evolution. As our knowledge grows, from well-designed prospective study, we adopt new techniques and retire archaic practices. At this point in time, however, we find evidence lacking to support adoption of a procedure-driven algorithm in the care of VUR.
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OBJECTIVES: Although vesicoureteral reflux (VUR) is a very frequent pathology in the pediatric age and represents an important part of the activity of pediatricians, pediatric urologists, nephrologists, and radiologists, yet there is controversy about its global management both in diagnosis and treatment. The objective of this paper is to perform an update in the use of different imaging techniques in the diagnosis and follow-up of VUR and to propose a work up protocol.METHODS: We describe the imaging techniques: VCUG, ultrasound, intravenous urography, bladder-ultrasound, DMSA, MRI, and their role in the evaluation and follow-up of VUR. We performed a bibliographic review about the topic and present the experience of our working group on VUR.RESULTS: The bibliographic review shows a clear evolution of the concepts of VUR and also the management algorithms. The concepts of congenital renal lesion without urinary tract infection (UTI) or acquired lesion after UTI are clearly differentiated in the most recent reviews. Reflux is passing from being the center of the problem to a secondary phenomenon in relation to UTI, and this is leading to a change of diagnostic strategy, less and less invasive.CONCLUSIONS: VCUG has been to date the first and indisputable technique for the management of VUR, mainly in the diagnostic phase, but technological advances in the area of ultrasound (ultrasound contrasts, harmonic image, etc.) have converted ultrasound in the first imaging technique for the management of VUR in pediatric age. On the other hand, work-up algorithms have changed due to the great impact prenatal diagnosis is having in the management of urinary tract anomalies.
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OBJECTIVES: The primary objective of this studyis to perform a systematic review of the therapeutic manage-ment of primary VUR in pediatric urology.METHODS: A systematic review of the articles published inall of the available databases has been performed, includingscientific evidence-based medicine criteria. Inclusion criteriaconcerning basic quality of the articles were considered es-sential, as well as exclusion criteria to be able to reject thearticles.RESULTS: A critic reading of selected articles, and statisticalstudy of grouped data was performed according to the type oftreatment and benefits contributed by each treatment, and alsoto their undesirable effects.CONCLUSIONS: The following Conclusions were drawnfrom the results obtained and from the analysis of the texts.Both medical and surgical treatment present similar effective-ness concerning resolution of gra-des I, II and III VUR, andthe former one is the recom-mended initial treatment following diagnosis. Endosco-pic treatment is exactly as effective asopen surgery for grades I, II and III with fewer undesirablesecon-dary effects. There are no differences concerning theefficacy of the different injected substances. Not enough evi-den-ces exist for degrees IV and V that may recommend or ad-vise against any of the treatments. In any degree of VUR, opensurgical treatment is superior as far as medi-cal treatment isconcerned only regarding the number of acute pyelonephritisepisodes during follow-up. This con-clusion cannot be appliedon endoscopic treatment
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Vesicoureteral reflux remains one of the most controversial subjects in paediatric urology. The flooding of publications on reflux makes the understanding of this anomaly and its treatments quite opaque. Evidence Based Medicine might be a helpful tool to clarify the various approaches of reflux reflected in 6.715 publications found on Medline with the key-words “vesicoureteral reflux” and “vesicoureteric reflux”. These articles were critically reviewed and graded according to EBM scorings, with regard to their methodological designs. It appears clearly after this review of literature concerning VUR that most of our beliefs are based on low evidence publications and that EBM has not sufficient arguments to establish recommendations for diagnostic and treatment of VUR. It appears yet that antenatal dilatation of the urinary tract and symptomatic UTIs justify looking for VUR. Surgery should be discussed in recurrent UTIs or deterioration of renal function. There is no consensus in the case of persistent asymptomatic VUR, indication and duration of antibioprophylaxis, and choice of radical treatment.
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OBJECTIVES: Vesicoureteral reflux (VUR) has been associated, since the old times, with chronic renal failure (CRF). Nevertheless, some functional parameters may be altered before glomerular filtration rate deteriorates, such as maximum urinary osmolality (Uosm) and urinary excretion of microalbumin.METHODS: We retrospectively studied the records of 77 children (37 males and 14 females; 48% and 52% respectively) with the diagnosis of VUR that were cured at the time of the study and were two years old or older (6.28+- 3.75; range: 2-16 years). In addition to Uosm and urinary excretion of microalbumin, the grade of VUR, creatinine levels, GFR, and morphological anomalies detected in 99Tc dimercaptosuccinate gammagrams (DMSA) were collected.RESULTS: Only four patients had moderate CRF. No differences in Uosm values were observed according to VUR grade. All children with grade I and II VUR had a normal renal concentration test. A long-term concentration defect was observed in 15 children, six with grade III, 8 with grade IV, and 1 with grade V. Only 2 patients with normal DMSA had reduced Uosm. Uosm had a direct correlation with GFR (r = 0.6; p<0.001). Regarding urinary excretion of microalbumin, elevated values were found in 11 children, one with grade II, four with grade III, and six with grade IV. Only four patients with normal DMSA showed microalbumin values over the normal range. A negative correlation between osmolality levels and microalbumin/creatinine quotient was observed (r = - 0.37; p<0.001). In comparison with patients with normal DMSA, patients with bilateral scars showed significantly lower values of Uosm and GFR.CONCLUSIONS: At the end of the follow-up period we observed a defect on concentration capacity in 19.5% and increase of microalbuminuria in 14.3% of the children with the diagnosis of VUR. The frequency of CRF in our series is very low (5.1%). The observed renal tubular function deterioration is more in relation with the loss of renal parenchyma than the initial grade of VUR.
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OBJECTIVES: Various papers differentiating neonatal vesicoureteral reflux (VUR) with severe renal damage from other predominant group of newborns with neonatal VUR without renal lesions and those diagnosed in older ages, generally in relation with urinary tract infection (UTI), have been published over the last decade. From the standpoint that VUR is part of a broad spectrum both in clinical expression as in pathogenesis, with different theories described to explain the existence of this type of congenital VUR in males. The existence of a fetal vesicourethral dysfunction, presenting after birth as a high risk bladder, which is defined by urodynamic tests in the first trimester, explains the appearance of severe fetal VUR with functional deterioration of one or both renal units at the time of birth; this entity must be diagnosed to establish the adequate therapeutic management. This clinical picture is named Valve like syndrome or male uncoordinated fetal voiding.
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OBJECTIVES: To update the classification of vesicoureteral reflux in children.METHODS: Videourodynamics.RESULTS: We categorize the different types of vesicoureteral reflux in children.CONCLUSIONS: The usefulness of the classification is demonstrated, with the introduction of some modifications necessary for its continuous updating.
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OBJECTIVES: 30-50% of pediatric patients with the diagnosis of lower urinary tract infection (UTI) have vesi-coureteral reflux (VUR). The endoscopic treatment of VUR has become one of the main therapeutic tools and its success has been traditionally related to the grade of VUR. Nevertheless, in each of the VUR grades different grades of ureteral dilation may be observed. The aim of the study is to evaluate the influence of ureteral dilation rate in the cure rate after endos-copic treatment.METHODS: From a total of 632 renal units with reflux treated endoscopically, we review the first four years (1996-1999). After discarding patients with secondary VUR (neurogenic bladder, ureteral duplication) 70 patients enter the study (a total of 105 renal units with reflux). Voiding cystourethrograms (VCUG) were evaluated by means of a double blind study, grading ureteral dilation of all patients in three grades: mild-normal, moderate and severe. We performed comparisons between the cure rates of first endoscopic injection in the three grades of ureteral dilation.RESULTS: After the evaluation of VCUG in the double blind study, from 105 renal units with reflux in the study, three had grade I VUR, 12 grade II, 64 grade III, and 26 grade IV. After grading ureteral dilation there were 45 with mild-normal grade, 44 moderate and 16 severe. The comparison of cure rates for grade III and IV VUR without considering the grade of ureteral dilation did not show statistical significance. Never-theless, we found statistically significant differences between the cure rates of each grade of ureteral dilation: when consi-dering all renal units with reflux treated, considering all grade III and IV VUR, and considering only grade III reflux.CONCLUSIONS: The international classification of VUR as a prognostic factor for the success of endoscopic treatment does not considered differences between same degree refluxes. The results observed demonstrate that grade of ureteral dila-tion must be evaluated in conjunction with grade of reflux at the time of making prognosis about the success of endoscopic treatment of VUR.
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OBJECTIVES: To present a methodology of pe-rioperative evaluation of lower urinary tract function in patients with primary VUR. To describe the most frequent urodynamic patterns in patients with primary VUR and their treatment. To show the results of a lower urinary tract evaluation in a pros-pective study in a pediatric population of 63 patients, with persistent primary VUR, with the aim to help to a better unders-tanding of the natural history of VUR.METHODS: The study includes a pediatric population of 63 patients with primary grade II-V VUR, 28 girls and 35 boys, with ages between six months and 15 years (mean age 5.9 yr.). In the study protocol for the systematic study of primary vesicoureteral reflux we perform a non invasive screening for lower urinary tract dysfunction, which select patients that will benefit from a complete cystomanometry. Study variables: age, gender, VUR side and grade, and renal function, in relation with the lower urinary tract function at the time of recruitment. The results of urodynamics have been evaluated in relation to urinary symptoms and history of lower urinary tract infection.RESULTS: Differential characteristics of the study population: high mean age (overall 5.9 yr.; 7.7 in girls), high percentage of high grade VUR (59%), renal damage (52%) and lower urinary tract dysfunction (86%) without significant differences between boys and girls. Statistically significant associations between: VUR grade and renal damage; presence of lower urinary tract dysfunction and bilateral VUR; female gender and lower urinary tract dysfunction; and normal lower urinary tract function and absence of renal damage. The voiding dysfunc-tion pattern was predominant in females and bladder hype-ractivity in males. Urinary symptoms did not differ between the various patterns of urodynamic abnormalities. The incidence of UTI shows significant differences between the various uro-dynamic patterns, being more frequent in girls with type 4 urodynamic pattern (dysfunctional voiding).CONCLUSIONS: The performance of a non invasive scree-ning of lower urinary tract function by medical history, urine analysis, ultrasound and post void residual ultrasound evalua-tion enabled the selection of patients who would benefit from a complete urodynamic study. If there are symptoms or signs of lower urinary tract dysfunction it is recommended to per-form a complete urodynamic study. Pediatric cystomanometry provides precise data about bladder filling and voiding pha-ses, facilitating the specific treatment of the lower urinary tract dysfunction. The urodynamic study has a special significance in the prognosis of the urological malformation associated in children with VUR. With this systematic study of the lower urinary tract function early diagnosis and treatment of patients in risk may be achieved, as well as adequate selection of patients that will benefit from pharmacotherapy and/or urothe-rapy, with the aim to prevent renal damage progression and to potentiate definitive cure of VUR.
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OBJECTIVES: To perform a bibliographic review on the topic of vesicoureteral reflux (VUR) in children with myelomeningocele.METHODS: PubMed search using the terms: vesicoureteral reflux and myelomeningocele.RESULTS: Between 1981 and 2007 340 articles were found, 61 of which were considered adequate, and 48 were used as references for this monographic issue. We discuss the pathogenesis of VUR in neurogenic bladder, the efficacy of conservative treatment with clean intermittent catheterization and anticholinergic drugs, as well as the indications and efficacy of various surgical procedures including ureteral reimplantation, subureteral injection of various agents, bladder augmentation, cutaneous vesicostomy, urethral dilation, transureteral-ureterostomy and botulin toxin injection.CONCLUSIONS: Vesicoureteral reflux plays an important role in the development of renal damage in infants and children with congenital myelomeningocele. Nephropathy may be prevented with adequate evaluation and follow-up and timely therapeutic intervention. Renal failure in these patients always reflects the failure of medical care or social/socioeconomic conditions.
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Vesicoureteral reflux is a commonly encountered condition in pediatric urology. The treatment of vesicoureteral reflux is debated in all patients. Much controversy exists regarding the need to reimplant refluxing ureters at the time of bladder augmentation, particularly in those patients with neuropathic bladders. In patients with neuropathic bladders, reflux may be the result of elevated detrusor pressure, recurrent/persistent urinary tract infections and/or a neuropathic dysfunction at the ureterovesical junction and the trigone. Treatment of VUR in patients undergoing bladder augmentation varies and includes routinely reimplanting all refluxing ureters, selectively reimplanting ureters with high-grade reflux or avoiding anti-reflux surgery in all patients regardless of the grade of reflux. We review the literature and our experience with the treatment of vesicoureteral reflux in patients that have undergone augmentation cystoplasty.
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Two kinds of elimination disorders can be associated with Vesico Ureteral Reflux (VUR): pure bladder elimination disorders or combination of bladder and bowel elimina- tion disorders. An elimination disorder is always a factor which worsens the prognosis of VUR, as it increases the risk of infectious complications and thus presents a threat for the upper urinary tract. Regarding pure bladder elimination disorders, a chronic urine residue is observed in four clinical situations: the syndrome megacystismega ureter; the mega bladder without mega ureter, but with VUR; high grade massive VUR without a mega bladder; organic obstructions of the urethra (such as posterior urethral valves.). VUR associated with urine and fecal elimination disorders cover functional pelvi perineal dyscoordination, bladder sphincter dysynergia, disturbances of visceral motricity and anal sphincter function. The most characteristic type is represented by the neuropathic detrusorsphincter dysfunction; also enter in this category neurogenic non-neurogenic bladders (Hinman’s syndrome); However the vast majority of urine and fecal elimination disorders is represented by non neuropathic perineal dyscoordination associating at various degrees: voiding postponement, lack of sphincter relaxation during micturation, interrupted voiding, and constipation. The diagnosis of elimination disorders associated with VUR is based on non invasive investigations such as anamnesis and drinking/voiding chart in children and adolescents, and “four observation test” in infants. Ultrasound and uroflowmetry are also useful tools. Invasive investigations include mainly voiding cystourethrography and urodynamics, ideally combined in video urodynamic studies. The management of urinary and intestinal elimination disorders is based on the prevention of infections, the suppression of the post voiding residual urine and the treatment of an associated constipation. If surgical treatment of VUR is needed, it must be associated to the management of elimination disorders in the peri operative period. In many instances, an appropriate treatment of elimination disorders often leads to the VUR resolution.
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OBJECTIVES: To assess the efficacy of medical and surgical treatment of vesicoureteral reflux (VUR) in children using recurrence of urinary tract infectio-ns, renal scarring and renal function as end-points. METHODS/RESULTS: We performed a MEDLINE sear-ch for articles. We selected only randomized clinical trials and meta-analysis that analyzed medical versus sur-gical treatment of VUR in children. A total of 820 patients were included in all studies. We found no statistatically significant differences between surgically and medically treated patients in terms of scarring, kidney function or recurrence of urinary tract infections. There was only a significant decrease in the frequency of febrile UTI in patients who were surgically corrected, compared with those receiving antibiotics alone (RR 0.43). CONCLUSIONS: We found no clinically significant differences between surgical and medical treatment for VUR in terms of kidney function or renal scarring. We suggest that a child with UTI and VUR should be treated conservatively at first.
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OBJECTIVES: To assess the efficacy of antibiotic prophylaxis for prevention of urinary infections and renal parenchymal damage in children with primary vesicoureteral reflux (VUR). METHODS/RESULTS. A search based on MEDLINE and The Cochrane Library was performed selecting those cli-nical trials and meta-analysis which compared antibiotic prophylaxis (either continuous or intermittent) and place-bo or no treatment at all in children with primary VUR. Three systematic reviews were chosen for assessing the efficacy of prophylaxis of urinary infections including trials with a predominant paediatric population without known VUR. Results showed that the use of antibiotics decreased the risk of urinary infection. The quality of the trials was, however, insufficient and therefore of questionable results. We also selected two randomized controlled trials in children with reflux: one had limited information as the degree of reflux was not stated; the second assessed the results in a population of 113 children with VUR grade I to III (55 receiving prophylaxis and 58 not) fo-llowing acute pyelo- nephritis. There were no differences with regard to the risk of urinary infection or the risk of renal parenchymal damage. CONCLUSIONS. There is not enough evidence supporting generalized use of antibiotics to prevent urinary infections. No benefit in prophylaxis has been proven for VUR grades I to III. There is no data for high grade VUR. It will be necessary to perform more trials in order to establish more accurate recom- mendations on prevention of urinary infections in the presence of VUR.
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OBJECTIVES: Vesicoureteral reflux (VUR) is a frequent pathology, with an incidence of 29/50% in children studied for urinary tract infection (UTI) and 20% of newborns with the diagnosis of prenatal hydronephrosis. Over the years, the treatment has been the subject of many meetings, many research studies, and continues being a topic under discussion. The number of candidates for surgical treatment increased with the development of minimally invasive endoscopic techniques by subureteral injection of bulking agents. We present the results of the surgical treatment of VUR between 2001 and 2006.METHODS: We performed a retrospective study of the endoscopic treatment of VUR by subureteral injection of Dextranomer and hyaluronic acid copolymer (Copol-Dx/AH). All children undergoing treatment between July 1st 2001 and December 30th 2006 were included in this study. Treatment was performed in children with VUR grade II or greater. All patients presenting no reflux or grade I VUR on control VCUG were considered cured; stopping antibiotic prophylaxis was proposed in these cases.RESULTS: 661 children underwent treatment, 607 endoscopic and 54 with the Cohen technique. Among children treated endoscopically, 437 where females and 170 males. VUR was bilateral in 37.7% of the cases, with grade II being the most frequent (40% in males and 57% in females). Overall success rate was 70% after first treatment, 75% after second treatment and increased to 78% after the third.CONCLUSIONS: Subureteral injection of dextranomer and hyaluronic acid copolymer is an effective treatment in children with VUR, independently of the grade. It is a simple, safe, well tolerated procedure with low associated morbidity. Currently, it is the surgical treatment of choice in most patients with VUR.
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OBJECTIVES: To assess the feasibility and results of the endoscopic treatment of vesicoureteral reflux (VUR) after a failed ureteral reimplantation.METHODS: From January 1996 to October 2006, 28 patients underwent endoscopic treatment for VUR grade II to V persisting after open ureteral reimplantation. VUR was bilateral in 11 patients, for a total of 39 ureteral units (UU) treated. The endoscopic treatment was performed 1 to 7 years after surgery (average 2.5 years). Dextranomer/Hyaluronic acid Copolymer (Dx/HA) was used as injectable material. The amount of injected material ranged from 0.5 to 2.8 ml (average: 1.2 ml). Some technical refinements were required to increase the success of the procedures. Patients were followed up from 2.5 to 17 years. Voiding cystourethrogram (VCUG) was performed at 6 months and MAG3 renal scan with voiding phase at 24 months. Results were compared with the outcome of the endoscopic treatment in patients treated by the same surgeons for primary VUR, matched for grade (control group). RESULTS: All treatments were performed as one-day procedure. No complications were observed. Success was achieved in 22/28 patients (78.5%) and in 30/39 UU (76.9 %) after failed ureteral reimplantation. No significant difference in success rate was found from the control group (p= ns). CONCLUSIONS: Endoscopic treatment of VUR after a failed reimplantion can be a challenging procedure, for a skilled endoscopists. Nonetheless it can achieve successful results in a high percentage of patients with minimal morbidity and a minimal invasiveness; it should thus be recommended for these patients.
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OBJETIVE: Over the past 20 years endoscopic treatment (ET) of vesicoureteral reflux (VUR) has changed the algorithm of reflux management. We describe a modification of the standard subureteral injection (STING) that has contributed to the increased success rate of this procedure.METHODS: Between January 2006 and December 2006 192 children, 5 months to 10 years old (mean age 2.8 years) underwent endoscopic treatment for VUR, with injection of dextranomer/hyaluronic acid copolymer (Dx/HA). Standard STING procedure was used in 165 patients (235 ureters). A modified STING procedure, here described as “ureteral repositioning and injection” (URI) was used in 27 patients (38 ureters). In the URI technique, the needle was inserted as for standard STING; subsequently the distal part of the ureter was raised and levered towards the lumen of the bladder; Dx/HA was then injected. Renal/bladder ultrasound was performed 1 month after treatment and a voiding cystourethrogram (VCUG) at 4-6 months.RESULTS: After a single injection the VCUG showed no reflux in 203 ureters of STING group (86%) and in 34 ureters of URI group (91%). Mean injected volume of Dx/HA was 0.7 ml (0.3 - 1.8 ml) for STING and 0.4 ml (0.3 - 0.8 ml) for URI.CONCLUSION:The modified STING we have proposed, presents some advantages. It is very easy to perform and needs less material to inject. The ureteral repositioning into the bladder, with the support of the implanted material, may reconstruct a true flap-valve mechanism, without the risk of ureteral obstruction.
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OBJECTIVES: Vesico-ureteric reflux (VUR) is a common cause of urinary tract infections in children, being less commonly diagnosed in adults. Several anti-reflux plasties have been used successfully for the treatment of such condition, such as Politano-Leadbetter, Cohen and Gregoir-Lich techniques, the latter being our preferred approach in open procedures. Here we describe our experience with laparoscopic Gregoir-Lich anti-reflux plasty (LGLP) in children and adults.METHODS: The LGLP was used for the treatment of VUR in 15 patients (7 adults and 8 children). Four adults and 5 children had bilateral disease and both sides were treated at the same procedure. Data was collected prospectively and we analysed age at treatment, laterality, degree of VUR, previous anti-reflux procedures, operative time, number of detrusor stitches used in each side, intra-operative and post-operative complications, success rate and follow-up.RESULTS: A total of 23 ureteral units were treated. VUR was graded as I in one unit, II in 4 units, III in 10 units, IV in 7 units and 1 unit was not classified, as it was diagnosed by radioisotopic cystography. Two children had failed previous endoscopic procedures. There were no open conversions. Two muccosal perforations occurred during the procedure and were successfully treated laparoscopically. Nineteen out of 21 ureteral units (90%) presented no VUR at the cystographic control, and no bladder dysfunction was identified on follow-up.CONCLUSIONS: The LGLP is a feasible, minimally invasive alternative for VUR that reproduces the open procedure. It has an excelent success rate and is not associated to bladder disfunction, even in bilateral procedures.
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Biodegradable injectable bulking agents of animal origin present a fast rate of bio-reabsorption and may cause an allergic reaction. Biodegradable elements of synthe-tic origin have a high rate of reabsorption after a year. Non-biodegradable agents of synthetic origin lead to the formation of a fibrotic capsule, giving stability and long-term permanen-ce. VANTRIS® is categorized into this last group; it belongs to the family of Acrylics, particles of polyacrylate polyalcohol copolymer immersed in a glycerol and physiological solution carrier. Molecular mass is very high. When injected in soft tissues, this material causes a bulkiness that remains stable through time.The carrier is a 40% glycerol solution with a pH of 6. Once in-jected, the carrier is eliminated by the reticular system through the kidneys, without metabolizing. Particles of this polyacrylate polyalcohol with glycerol are highly deformable by compres-sion, and may be injected using a 23-gauge needle. The ave-rage of particles size is 320 mm. Once implanted, particles are covered by a fibrotic capsule of up to 70 microns. Particles of this new material are anionic with high superficial electronegativity, thus promoting a low cellular interaction and low fibrotic growth.The new polyacrylate polyalcohol copolymer with glycerol was tested for biocompatibility according to ISO 10993-1:2003 in vitro, showing that they are not mutagenic for the Salmone-lla T. strains analyzed. The extract turned out to be non-cyto-toxic for cell lines in culture and non-genotoxic for mice. In in vivo studies, acrylate did not cause sensitization in mice. The macroscopic reaction of tissue irritation was not significant in subcutaneous implants and in urethras of rabbits. Seven female dogs were injected transurethrally with VANTRIS® to evaluate short and long-term migration (13 weeks and 12 months res-pectively).No particles or signs of inflammation or necrosis are observed in any of the organs examined 13 weeks and 12 months after implantation. To conclude, this new material meets the condi-tions of ideal tissue bulking material.
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OBJETIVES: Vesicoureteral reflux (VUR) is the most common urologic anomaly in childhood, affecting 1% of the pediatric population. Endoscopic treatment of VUR is accepted as the first therapeutic option and various injectable materials have been used since its implantation. We present our experience in the endoscopic treatment of VUR with various substances which we have been employing since we started performing the procedure.METHODS: We have performed a retrospective descriptive study including 445 patients that underwent endoscopic treatment for vesicoureteral reflux in our centre between 1988 and 2004. We treated a total of 568 ureters, and we analyze results depending on the material employed, grade of reflux and associated pathology.RESULTS: Among 569 ureters with vesicoureteral reflux undergoing treatment 457 were single VUR (79%), 76 (15%) were part of a double renal system, 24 (4%) were associated with neurogenic bladder, and 12 (2%) were secondary VUR after antireflux open surgery. We use three types of materials, with predominance of polytetrafluorethylene in 257 ureters, followed by hyaluronic acid dextranomer in 159, and finally polydimethylsiloxane in 153. In the cases of single VUR global cure rate was 88% (381 ureters), with significant improvement of the grade of reflux in 7% (51 ureters), and 5.5% of the cases (25 patients) requiring a Cohen type reimplantation. We observed a lower success rate and greater need of repeated injections in grade IV and V refluxes. In VUR associated with duplication results are worse, with less successes and greater need of procedures for its resolution. We cured 59 ureters (77%) out of 76 treated, 13 (19%) improved, and 4% required Cohen type reimplantation. In cases of VUR associated with neurogenic bladder 20 ureters were cured (83%). There was significant improvement in two ureters (8%); there were two failures (8%), requiring Cohen type reimplantation to avoid progressive deterioration of the kidney. In the cases of VUR after open surgical reimplantation all 12 ureters treated were cured (100%). Among 8 single ureters, reflux was solved with 1 procedure in 6 and 1 required 2 procedures. The total number of cured ureters has been 496(87%), and 51(9%) have improved. 22 ureters underwent surgery (4%). 68% of the cases were cured after 1 injection, 16.5% after 2 , and 1& after 3. There have been 5 complications (0,8%): 1 case of hemorrhagic cystitis which resolved spontaneously in two days, and 4 pyelonephritis which received the appropriate antibiotic therapy following antibiogram. We did not have any case of recurrent lower urinary tract infections. Follow-up has range it from 1.5 to 15 years.CONCLUSIONS: It seems that both polydimethylsiloxane and hyaluronic acid dextranomer are good and safe materials, and do not have the risk of distant migration of polytetrafluorethylene.
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OBJECTIVES: To know the results, complications and outcomes of eight patients with the diagnosis of neurogenic bladder (NB) who underwent vesicoureteral reflux surgery by subureteral injection of inert substances, trying to precise its indication in the therapeutic scheme for neurogenic bladder dysfunction.METHODS: Retrospective review of the results and complications recorded during follow-up in eight pediatric patients with NB secondary to various pathologies and the diagnosis of VUR treated by subureteral injection of Teflon paste (1 case),polydimethylsiloxane (6) and dextranomer/hyaluronic acid copolymer (1).RESULTS: In 8 (72.7%) of the 11 ureters treated VUR was cured after first injection. VUR stopped after second endoscopic treatment in 2 of the 3 ureters with persistent VUR. The efficacy of endoscopic treatment after second injection achieved 90.9%. In 2 unilateral cases we observed contralateral VUR, which cured in one case after endoscopic treatment and the other one followed a conservative scheme. Over the follow-up period (Mean FU time 51.8+/- 28.5 months) 4 cases presented complications. VUR recurred in two: in one contralateral VUR was detected 19 months after first treatment, the other one presented bilateral ureterohydronephrosis with recurrent urinary tract infections and required augmentation cystoplasty.CONCLUSIONS: Endoscopic treatment is an effective option when choosing surgical treatment for VUR in a patient with neurogenic bladder. It is necessary to follow the long-term outcome of patients after surgery, mainly those with abnormal bladder capacity and compliance and active or dyssynergic urethra due to the possibility of recurrence of the VUR.
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OBJECTIVES: Our aim is to know the results of Endoscopic Treatment (ET) in infants with recurrent pyelonephritisand high grade (G) Vesicoureteral Reflux (VUR).METHODS: Inclusion criteria: infants 2-12 months old with G III-V VUR and at least 2 pyelonephritis, one of them during antibioticprophylaxis (AP). N=27 infants: 19 males (70%) and 8 females. VUR was primary in 17 (63%) and secondary in 10. VUR Grade was III in 12 ureters (U) (32%), IV 16 (42%) and V 10 (26%). Polydimethylsiloxane, Hydroxiapatite and Dextranomer/ Hyaluronic Acid (DAH) were the bulking agents employed. Results Classification: Solved: G 0-I.; Improved: GII (control without AP); Persistence: III-V. Open Surgery (OS) or repeated ET (1-2) was done depending on cystoscopic findings.RESULTS: 34 ureters are available for final results; 1 G III, 2 G IV and 1 G V are waiting for a new injection. G III 11 U: 11 first and 4 second injections (1.36 Injections / ureter): Solved 9 (81.8%), Improved 1, OS 1 (9%). G IV 14 U: 14 first 3 second and 1 third injection (1.28 injections / ureter): Solved 10 (71.4%), Improved 4. No OS. G V: 9 U: 9 first, 4 second and 1 third injections (1.55 injections / ureter): Solved 5 (55.6 %), Improved 1, OS 3 (33.3%). Overall results: Solved:24 U (70.58 %), Improved: 6 (17.6%), OS 4 (11.8%). OS avoided 30 (88.2%): G III 91%, IV 100% and V 66.7%. Results of G III are better than G V. The only complication was 1 ureteral obstruction treated successfully with open surgery.CONCLUSIONS: ET can be considered the first therapeutic option in infants with G III-V VUR and pyelonephritis in spite of PA, because ET has solved VUR in 70.58% and avoided OS in 88.2% with a minimally invasive procedure and low incidence of complications.
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OBJECTIVES: To analyze our series of primary congenital diverticula (PCD) and their association with vesicoureteral reflux.METHODS: We have taken care of 23 children with PCD. Eleven of them had big diverticula (> 2 cm) and twelve small. In the first group, 4 children had vesicoureteral reflux and 5 in the second group. In group A, ureteral reimplantation was performed at the time of diverticulum excision. Nor diverticula neither refluxes were operated in group B.RESULTS: We analyze separately results in both groups. Group A: Patients were operated including diverticulum excision. There were not recurrences except in one case with Ehler-Danlos Syndrome. No reimplanted ureter showed postoperative reflux. Nevertheless, one case with multiple bladder diverticula without reflux presented reflux after the excision of several diverticula without reimplantation. Group B: Small diverticula did not undergo surgery. Spontaneous outcome of reflux was similar to that of the general population without diverticula.CONCLUSIONS: Bladder diverticula are frequently associated with vesicoureteral reflux. The presence of reflux is not an absolute condition for surgical or endoscopic treatment. When diverticula are big in size (Group A) the indication for surgery comes from recurrent infection or voiding disorders, not from reflux. If they undergo surgery, ureteral reimplantation is performed in the case they had reflux or for technical reasons like bladder wall weakness. When diverticula are small (Group B) the presence of reflux does not condition treatment, being the rate of spontaneous resolution similar to the general population.
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OBJECTIVES: The VUR is one of the most fre-quent pathologies in pediatric urology. Classically it has been managed with medical or surgical treatment depending on age, grade, and other variables. Over the last years, urolo-gists have started to perform endoscopic treatment with various substances, surgery but minimally invasive. The objective of this work is to evaluate our results with this method.METHODS: Between 1996 and 2004 we performed endos-copic treatment on 41 patients (70 ureters) using different substances. We analyze VUR grade and side, improvement with one or more injections, post-operative follow-up with clinical evaluation, bladder ultrasound and voiding cystourethrogram (VCUG), and compare the long-term results of the different substances used, mainly with the evaluation of recurrences and/or urinary tract infections.RESULTS: 41 patients entered the study; collagen was injected in 13 cases, Macroplastique® in 14, and Deflux® in 14. Twenty-nine patients underwent bilateral injection, adding up to a total of 70 injected ureters. Collagen injection had a success rate of 53% with the first injection and 77% with the second, Macroplastique® success rate was 83% with the first injection and 91% with the second, and Deflux® 84% on first injection and 88% with the second. Mean post-operati-ve follow-up was 44 months, with a range of 18-86 months. 18% of the patients presented post operative UTI, they were treatment failures. There are no UTI episodes in patients after successful treatment.CONCLUSIONS: Endoscopic treatment is a useful tool in the long-term management of VUR, both as definitive treatment or as an alternative to conventional medical management, with better results when using Macroplastique® and Deflux®.
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OBJECTIVES: To analize results and late complications in patients with vesicoureteral reflux, treated by endoscopic treatment and with several substances.METHODS: In a long bibliographic review we analize results, recurrences and late complications with this treatment using different substances.RESULTS/CONCLUSIONS: In spite of the prescribed substance, VUR may recur several years af-ter treatment. These cases are of low grade and most disappear after a new session of ET. VUR can also appear in the other side, not knowing in fact why this happens. Grade IV -V reflux, and also VUR secondary to organic and functional pathology, can be resolved by endoscopic treatment, although the percentage of good results is lower. Parents have to be informed, in detail, of the three therapeutic options for reflux, (medical, en-doscopic, and open surgery), and participate in the final decision. Parents use to prefer ET. According to the number of patients treated by ET and the number of follow-up years that possible side effects have been observed, most authors consider that ET is a safe treatment, and it is currently the treatment of choice for patients with reflux.
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OBJECTIVES: To evaluate the rate of seconda-ry or complicated vesicoureteral reflux (VUR) among the total number of VUR cases treated in our institution. To determine the efficacy of the endoscopic treatment in secondary or compli-cated VUR depending on etiology and grade.METHOD: We review our experience with endoscopic treat-ment for VUR from 1992 to 2006. We have used three diffe-rent materials: polytetrafluoroethylen (Teflon®), polydimethyls iloxane(Macroplastique®) and dextranomer/hyaluronic acid copolymer (Deflux®). 479 ureters with VUR were treated in 402 patients ; 124 patients and 142 ureters of them were se-condary or complicated VUR cases. All patients were followed up with urinary tract ultrasound and radiological or isotopic voiding cystogram. Success is defined as VUR disappearance or improvement to grade I VUR without urinary infection after removing antibiotic prophylaxis.RESULTS: The success rate has been 71.13% after the first injection, 85.92% after the second injection and 90.14% after the third injection. Mean subureteral dose has been 0.65 ml. The complications rate has been 0%.CONCLUSIONS: The endoscopic treatment in secondary or complicated VUR is a minimally invasive procedure. It seems to be more difficult than in primary VUR cases, but its low mor-bidity and efficacy indicate this may be a proper first option in selected patients. In cases of VUR secondary to neurogenic bladder dysfunction it seems to be less successful, probably because of a worse control of the high bladder pressure.
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OBJECTIVES: We report the outcome and inci dence of urinary retention after bilateral extravesical reimplant in patients with primary vesicoureteral reflux. METHODS: We retrospectively evaluated the chart of 127 pa tients, 92 females and 35 males, who underwent correction of primary vesicoureteral reflux using the extravesical approach. Mean patient age at surgery was 3.93 years. Postoperatively the urethral catheter was removed after 24 to 72 hours and a voiding trial was done. Surgical outcomes were analyzed specifically for perioperative complications and resolution of reflux on postoperative VCUG. RESULTS: Mean follow-up was 4.01 years. Postoperative VCUG showed resolution of reflux in 122 (96%) patients. Uri nary retention developed in 7/127 patients (5.5%). In 57 patients in whom the surgery was done from 06-1998 to 01- 2001, urinary retention developed in 5/57 (8.7%) for 1 day (1), 2 days (1), 5 days (2) and 4 weeks (1). In 70 patients in whom the surgery was done from 02-2001 to 10-2006, urinary retention developed in 2/70 (2.85%) for 1 day (2). CONCLUSIONS: Bilateral extravesical vesicoureteral reim plant can be associated with temporary urinary retention. In the last 5 years, with a careful and limited dissection close to the distal ureter and used of bipolar cautery when necessary, we were able to decreased the risk of postoperative urinary retention.
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We present the case of a child presenting vesicoureteral reflux after ureteral reimplantation and endoscopic treatment. In a second cistoscopy to repeat endoscopic treatment a new orifice in the medium third of the tunnel of the previous ureteral reimplantation was discovered. This orifice acted as a shunt and maintained reflux. The patient was treated by further occlusion of the orifice with another injection of “Dextranómero/Nasha”.
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OBJECTIVES: The endoscopic treatment (ET) of vesicoureteral reflux (VUR) is considered by many urologic and pediatric surgeons as the first treatment option in the event of being required, because it is a minimally invasive procedure, of short duration, ambulatory in many cases, with good results and few complications. Ureteral obstruction is the most serious but less frequent complication. The objective is know the incidence, treatment and evolution of patients with ureteral obstruction as complication of the ET of VUR. METHODS: Evaluation of the medical literature using Pubmed and Ovid. Revision of the clinical report of children (CH) under ET of VUR between March of 1998 and July of 2007, to find those cases that presented ureteral obstruction after ET. RESULTS: A total of 377 children (CH) with VUR in 598 ureters (U), were treated with TE, during the mentioned period of 9 years, between March 1998 and July 2007. Only 2 U (0.33%), in 2 CH (0.5%) presented Ureteral Obstruction with dilatation of the upper urinary tract that need open surgical ureteral reimplantation, with good results in both patients.CONCLUSION: The risk of ureteral obstruction after ET of VUR is low, less than 0.5% of U. The treatment of this complication can be endoscópic or by open surgery both of them with good results.
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OBJECTIVES: To know the incidence of new contralateral VUR and its evolution in children with primary uni-lateral vesicoureteral reflux (VUR) managed with endoscopic treatment (ET). METHODS: During 7.5 years a total of 228 children with primary VUR underwent endoscopic implantation of bulking material, 90 of them (39,5%) have been unilateral. The inclu-sion criterion was: unilateral primary VUR managed with ET, without previously contralateral VUR. Collected data included: patient age, gender, indications for surgery, number of preope-rative cystourethrograms, preoperative and new contralateral postoperative VUR grades, nephropathy in the ipsilateral or contralateral sides, type and volume of bulking material used, and VUR outcome. An update bibliographic review with me-thanalysis is also performed to compare results.RESULTS: Six children (6,7%) developed new contralateral VUR. Mean age was 3.3 years. Four patients were females and 2 males. The bulking material used was polydimethylsi-loxane in one and Dextranomer/Non animal stabilished hya-luronic acid in 5. The initial grades of primary VUR were: II in 1 case, III in 3, and IV in 2. Four patients had previous history of bladder dysfunction. The new contralateral VUR was II in 5 and III in one. In 5 patients initial VUR persisted, always of lower grade than previously, and new contralateral VUR ap-peared. In one patient initial VUR disappeared and appeared in the contralateral side. Five patients were reinjected and VUR was cured, except one who is waiting for a new endoscopic procedure. One patient with grade II contralateral VUR is un-der observation. In the metanalysis performed nine issues have been found with an incidence of 8,2%.CONCLUSION: Contralateral VUR is a relatively frequent complication in unilateral primary VUR treated by endosco-pic procedures (6.7%), but not enough as to perform bilateral endoscopic treatment in all unilateral VUR. Contralateral VUR etiology is not clear but bladder dysfunction can be an impor-tant factor.
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OBJECTIVES: We analyze the frequency of vesi- coureteral reflux and the factors that favor its appearance after kidney transplantation in pediatric patients. METHODS: This retrospective analysis examined the preva- lence of posttransplant vesicoureteral reflux in a total of 201 kidney transplants performed in children at our centre between 1978 and 2006. In patients who required corrective surgery for this problem, we analyzed pretransplant residual diuresis, pretransplant pathology and posttransplant problems related to vesicoureteral reflux. We also analyzed the form of presenta- tion, whether reflux was to the graft or to the native kidney, degree of reflux, and surgical technique used to correct reflux. RESULTS: Twelve patients (5.9%) needed surgery to correct reflux to the graft (10 children) or to the native kidney (2 chil- dren). Reflux presented as urinary tract infection in 11 children and progressive graft failure in 1. Urethrovesical disorders that favoured vesicoureteral reflux were present in 10 patients (noncompliant bladder, detrusor overactivity, posterior urethral valves, urethral stenosis). Lengthening the submucosal tunnel stopped urinary tract infections in all 12 patients, whereas 6-month voiding cystourethrograms showed resolution in 10 patients and reduction in the degree of reflux in 2. CONCLUSION: The high percentage of posttransplant vesi- coureteral reflux in pediatric patients was related with higher frequency of vesicourethral pathology in children who recei- ved the transplant. In children with pretransplant urethrovesical anomalies we recommend an initial technique which utilizes a longer submucosal tunnel during implantation, such as the Lich-Gregoir.
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Primary vesicoureteral reflux is defined as the dysfunction of the vesicoureteral junction in the absence of any other bladder pathology. Most works in the literature focus on pediatric vesicoureteral reflux, paying little attention to reflux in adults. There is not much knowledge about the real incidence of this pathology in adults and there are few published papers about what are the situations in which we should suspect, per- form a diagnostic work up and treat reflux in adult patients. It is article we perform a bibliographic review on topics as important as epidemiology, diagnosis and treatment of reflux in adults. The objective of this article is to transmit what are the clinical manifestations in front of which we should look for adult reflux and when to treat when it is diagnosed.
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OBJECTIVES: There is a general opinion about that vesicoureteral reflux (VUR) rarely produces symptoms during adulthood. But it is possible to find active VUR over 20 years of age. A case report of a woman 28 years old with symptomatic VUR is presented with description of the “Reflux Pain” by herself. The objective of this article is to study the clinical aspects of symptomatic VUR in an adult woman with impairment in her quality of life.METHODS/RESULTS: She was a 33 years old female patient, with chronic and febrile breakthrough urinary tract infections (UTI) since she was 28 years of age. Then an unknown bilateral VUR was diagnosed. It was grade III in an incompletely duplicated right side and grade II in the left one. She recived antibiotic prophylaxis (AP) for 4 years, in spite of it she had a temperature over 37o, with frequent peaks over 38o, and she lost 8 KG of weight. She also had lumbar pain and “Reflux Pain”, which was described by the patient as: “acute, intense, excruciating, ascending, located in the ureters and kidneys, beginning some minutes before urinating and finishing some minutes later. During these 4 years many others pathologies were ruled out looking for other etiology of the temperature of “unknown origin”. Finally she was sent to urology for treatment of VUR. Bilateral Endoscopic Treatment (ET) with non animal stabilized Hyaluronic acid/ Dextranomer (DX/NASHA) gel was performed, with good result after the first injection. “Reflux Pain” disappeared few days after ET and after one month the temperature was under 37o. She remains asymptomatic after 4 years of follow up.CONCLUSIONS: VUR can produce symptoms during adulthood, with a very typical pain easy to identify, chronic pyelonephritis with temperature and progressive deterioration.ET can eliminate VUR, stop the symptoms and improve quality of life.
