Endoscopic Treatment

CHAPTER 47 Endoscopic Treatment of Vesicoureteral Reflux Prem Puri INTRODUCTION Primary vesicoureteral reflux (VUR) is the most common urological anomaly in children and has been reported in 30 to 50% of those who present with urinary tract infection (UTI). The association of VUR, UTI and renal parenchymal damage is well known. Reflux nephropathy is the cause of endstage renal failure in 3–25% of children and 10–15% of adults. There has been no consensus regarding when medical or surgical therapy should be used. A number of prospective studies have shown low probability of spontaneous resolution of high grade of reflux during conservative follow-up. Furthermore, all of these studies revealed that observation therapy does carry an ongoing risk of renal scarring. Open surgery is the standard treatment for VUR when indicated. Although ureteral reimplantation is effective, this operation is not free of complications. Since its introduction endoscopic correction of VUR has become an established alternative to longterm antibiotic prophylaxis and open surgical treatment. Recently, we published our data regarding long-term effectiveness of endoscopic STING (subureteral injection of polytetrafluoroethylene) for VUR in 258 patients, and its success was confirmed in our 17-year follow-up. Our study as well as long-term studies from others have not shown any clinical untoward effects with the use of polytetrafluoroethylene for the treatment of vesicoureteral reflux. Recently, a number of other tissue augmenting substances have been used endoscopically for subureteral injection. Dextranomer microspheres in sodium hyaluronic acid solution (Deflux) is a recently developed organic substance comprising 80 to 250 µm microspheres. It has been reported that dextranomer/hyaluronic acid copolymer is biodegradable, has no immunogenic properties and has no potential for malignant transformation. Dextranomer microspheres in sodium hyaluronic acid solution consist of microspheres of dextranomers mixed in a 1% high molecular weight sodium hyaluronan solution. Each millilitre of the system contains 0.5 ml sodium hyaluronan and 0.5 ml microspheres. 494 Prem Puri Figure 47.1 Vesicoureteric reflux is classified into five grades. The indications for endoscopic therapy for VUR include: í High grade primary VUR (grades III–V) í VUR in duplex renal systems í í í 47 VUR secondary to neuropathic bladder and posterior urethral valves VUR in failed reimplanted ureters VUR into ureteral stumps Figure 47.2 The disposable Puri catheter for injection (Storz) is a 4-Fr nylon catheter onto which is swaged a 21-gauge needle with 1 cm of the needle protruding from the catheter.Alternatively, a rigid needle can be used.A 1ml syringe filled with Deflux paste is attached to the injection catheter. Chapter 47 Endoscopic Treatment of Vesicoureteral Reflux 495 Figure 47.1 Typ I Typ II Typ III Typ IV Typ V Figure 47.2 496 Prem Puri Figure 47.3 All cystoscopes available for infants and children can be used for this procedure. The injection catheter can be introduced through a 9.5F, 11F or 14F Storz cysto47 scope, or a 9.5F Wolf cystoscope, or a 9.5F or 11.5F angled Wolfe cystoscope. Figure 47.4a–c For the subureteric injection technique the patient should be placed in a lithotomy position. The cystoscope is passed and the bladder wall, the trigone, bladder neck and both ureteric orifices inspected. The bladder should be almost empty before proceeding with injection, since this helps to keep the ureteric orifice flat rather than away in a lateral part of the field. The injection of Deflux paste or any other tissue augmenting substance should not begin until the operator has a clear view all around the ureteric orifice. Under direct vision through the cystoscope the needle is introduced under the bladder mucosa 2–3 mm below the affected ureteric orifice at the 6 o’clock position. In children with grade IV and V reflux with wide ureteral orifices, the needle should be inserted not below but directly into the affected ureteral orifice. It is important to introduce the needle with pinpoint accuracy. Perforation of the mucosa or the ureter may allow the paste to escape and may result in failure. The needle is advanced about 4–5 mm into the lamina propria in the submucosal portion of the ureter and the injection started slowly. As the paste is injected a bulge appears in the floor of the submucosal ureter. During injection the needle is slowly withdrawn until a “volcanic” bulge of paste is seen. The needle should be kept in position for 30–60 s after injection to avoid extrusion. Most refluxing ureters require 0.3–0.6 ml Deflux to correct reflux. A correctly placed injection creates the appearance of a nipple on the top of which is a slit-like or inverted crescentic orifice. If the bulge appears in an incorrect place, e.g., at the side of the ureter or proximal to it, the needle should not be withdrawn, but should be moved so that the point is in a more favourable position. The non-injected ureteric roof retains its compliance while preventing reflux. Post-operative urethral catheterization is not necessary. The majority of patients are treated as day cases. Co-trimoxazole is prescribed in prophylactic doses for 3 months after the procedure. Micturation cystography and renal ultrasonography are performed 3 months after discharge. A follow-up micturating cystogram and renal and bladder ultrasonographic scan are obtained 12 months after endoscopic correction of reflux. Chapter 47 Endoscopic Treatment of Vesicoureteral Reflux 497 Figure 47.3 Figure 47.4a–c a b c 498 Prem Puri CONCLUSION Endoscopic treatment is a simple, safe and effective procedure in the management of all grades of reflux. Procedure-related complications are rare. The only significant complication with this procedure has been failure. This may be initial failure, i.e., the reflux is not abolished by the injection, or recurrence, where initial correction is not maintained. About 15–20% of refluxing ureters require more than one endoscopic injection of paste to correct the condition. Apart from failure to correct reflux, vesicoureteric junction obstruction is the only other reported complication following STING. A recent multicentre survey of STING procedures in 12,251 ureters in 8,332 patients revealed vesicoureteric junction obstruction in 41 ureters (0.33%) requiring reimplantation of ureters. 47 SELECTED BIBLIOGRAPHY Chertin B, DeCaluwe D, Puri P (2003) Endoscopic treatment of primary grades IV and V vesicourteral reflux in children with subureteral injection of polytetrafluoroethylene. J Urol 169 : 1847–1849 Puri P (2000) Endoscopic correction of vesicoureteral reflux. Curr Opin Urol 10 : 593–597 Puri P (2001) Endoscopic treatment of vesicoureteral reflux. In: Gearhart JP, Rink RC, Mouriquand PDE (eds) Pediatric urology. WB Saunders Philadelphia, pp 411–422 Puri P, Chertin B,Velayudham M et al (2003) Treatment of vesicoureteral reflux by endoscopic injection of dextranomer/hyaluronic acid copolymer: preliminary results J Urol 170 : 1541–1544