[Our experience using various injectable materials for the endoscopic treatment of vesicoureteral reflux].
OBJECTIVE
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 ofter 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.
Cabezalí Barbancho
Daniel
D
Sección de Urología, Servicio de Cirugía Pediátrica, Hospital Universitario 12 de Octubre, Madrid, España. dcabezali@yahoo.es
Gómez Fraile
Andrés
A
López Vázquez
Francisco
F
López Díaz
María
M
Aransay Bramtot
Adolfo
A
D000293:Adolescent; D000328:Adult; D002648:Child; D002675:Child, Preschool; D003558:Cystoscopy; D003911:Dextrans / Q000008:administration & dosage; D004129:Dimethylpolysiloxanes / Q000008:administration & dosage; D006801:Humans; D006820:Hyaluronic Acid / Q000008:administration & dosage; D007223:Infant; D007267:Injections; D011138:Polytetrafluoroethylene / Q000008:administration & dosage; D012189:Retrospective Studies; D018666:Ureteroscopy; D014718:Vesico-Ureteral Reflux / Q000628:therapy*
D003911:Dextrans; D004129:Dimethylpolysiloxanes; C487487:dextranomer-hyaluronic acid copolymer; C013830:baysilon; D011138:Polytetrafluoroethylene; D006820:Hyaluronic Acid