Endoscopic Treatment of Vesicoureteral Reflux



Endoscopic Treatment of Vesicoureteral Reflux


ANGELA M. ARLEN

ANDREW J. KIRSCH



Vesicoureteral reflux (VUR) is the retrograde flow of urine from the bladder to the upper urinary tract and is one of the most common urologic diagnoses affecting children, with an estimated prevalence of 0.4% to 1.8% in the general pediatric population and 30% in those with a history of febrile urinary tract infection (UTI) (1,2). VUR is a risk factor for pyelonephritis, which can lead to renal scarring and subsequent complications such as hypertension, proteinuria, and even chronic kidney disease (3). VUR is one of several modifiable risk factors in the development of UTI. The goal of VUR treatment is to prevent pyelonephritis and preserve renal function. Management options include observation with or without continuous antibiotic prophylaxis and surgical correction via endoscopic, open, or laparoscopic/robotic approaches. Surgical intervention may be necessary in children with persistent reflux, renal scarring, or recurrent febrile UTIs. An individualized risk-based approach that takes into consideration a multitude of demographic, radiographic, and clinical factors should guide management (4).

Endoscopic treatment of VUR is an outpatient procedure associated with decreased morbidity compared to ureteral reimplantation. Endoscopic injection for VUR was introduced in 1981 as an investigational method with the first clinical experience published in 1984 (5,6). Over the past three decades, both injection techniques and bulking agents have significantly improved, which has resulted in higher treatment success rates (7,8). The success rate of outpatient endoscopic treatment of VUR approaches that of open ureteral reimplantation and offers considerable advantages to patients including limited morbidity, fewer complications, and reduced cost. Endoscopic injection has become an increasingly common method of correcting VUR because of its minimal invasiveness and high success rates (9).




INDICATIONS FOR SURGERY

Spontaneous resolution of primary reflux is common secondary to remodeling of the ureterovesical junction (UVJ), elongation of the intravesical ureter, and stabilization of bladder voiding dynamics. Reflux resolution depends on multiple factors including initial grade of reflux, gender, age, voiding dysfunction, presence of renal scarring, and timing of VUR on VCUG (4,12). Management should therefore be individualized and based on patient age, health, VUR grade, clinical course, presence of renal scarring, and parental preference. Surgical intervention may be necessary in children with persistent reflux, renal scarring, or recurrent febrile UTIs.


While open ureteral reimplantation may be a good treatment option after failed injection therapy, endoscopic treatment has also been successfully employed after failed ureteral reimplantation (Table 93.1). Current evidence suggests that either antireflux surgery or continuous antibiotic prophylaxis reduces the incidence of new renal scarring when compared to observation alone (17); however, no study has demonstrated a reduction in the incidence of end-stage renal disease. Valuable goals of VUR treatment are to prevent UTIs, particularly pyelonephritis, to avoid long-term antibiotic prophylaxis, and to reduce the need for distressing VCUGs and radiation exposure. Proponents of the endoscopic approach argue that decreasing the incidence of febrile UTIs is the main goal of therapy. Recurrence, while possible, may occur in the absence of symptoms and be viewed as subclinical, similar to an individual with VUR diagnosed after a sibling screen or for fetal hydronephrosis. Proponents of the open surgical approach comment that ureteral reimplantation provides a permanent cure and is worth the increased morbidity to achieve this goal.

In terms of reducing the risk of UTI, endoscopic treatment may achieve this goal as well as or better than open surgery (8,16,18). Indications for surgical correction of VUR via open, robot-assisted laparoscopic, or endoscopic approach include moderate- to high-grade reflux (grades III to V), low probability of spontaneous resolution, renal scarring, recurrent pyelonephritis, breakthrough febrile UTI while on continuous antibiotic prophylaxis, and parental preference (19,20). While endoscopic injection has focused on the treatment of primary VUR, it was initially largely avoided for cases of complex VUR (i.e., VUR associated with functional or anatomic abnormalities such as neurogenic bladder or megaureters). In general, endoscopic treatment is emerging at many centers as the firstline surgical treatment modality of choice for VUR, whereas ureteral reimplantation remains reserved for cases of failed injection therapy, significant anatomic abnormalities (i.e., large paraureteral diverticula, ectopic ureters, megaureters), and surgeon or parental preference.








TABLE 93.1 SUCCESS RATES OF ENDOSCOPIC TREATMENT FOR PRIMARY AND COMPLEX VESICOURETERAL REFLUX









































































































































































































Reference


Indication


Bulking agent


Volume (mL)


Ureters


Follow-up (months)


Success (%)


Elder JS et al., 2006


Various


Various


0.2-1.7


8,101


Variable


85


Capozza N et al., 2004


Various


Various


0.2-2.2


1,694


12-204


77


Kirsch AJ et al., 2004


Various


Dx/HA


0.5-1.5


119


3-12


92


Kirsch AJ et al., 2006


Various


Dx/HA


0.8-2.0


139


3-18


93


Van Capelle JW et al., 2004


Primary


PDMS


0.2-2.0


311


3-110


75


Kajbafzadeh AM et al., 2006


Primary


Ca hydroxylapatite


0.4-0.6


364


6


69


Yu RN et al., 2006


Primary


Dx/HA


1.0


162


2-26


93


Puri P et al., 2006


Various


Dx/HA


0.2-1.5


1101


3-46


96


Lorenzo AJ et al., 2006


Various


PDMS



351


72


72


Pinto KJ et al., 2006


Primary


Dx/HA



86


3


84


Perez-Brayfield M et al., 2004


Neurogenic bladder


Dx/HA


0.4-2.0


9


3


78


Läckgren G et al., 2007


Voiding dysfunction


Dx/HA



74


12


83


Elmore JM et al., 2006


Failed initial injection


Dx/HA


1.0-1.5


53


3


89


Perez-Brayfield M et al., 2004


Failed reimplantation


Dx/HA


0.4-2.0


19


3


88


Kitchens D et al., 2006


Failed reimplantation


Dx/HA


0.7-3.8


20


19


83


Campbell JB et al., 2006


Renal transplantation


Dx/HA



11



55


Molitierno JA et al., 2007


Duplicated ureter


Dx/HA


0.8-2.8


63


1.3


85


Cerwinka WH et al., 2007


Paraureteral diverticulum


Dx/HA


0.8-1.8


20


6.6


81


Chertin B et al., 2007


Ureterocele


Various



44


1-21


91


Routh JC et al., 2010


Various


Dx/HA



7303


Variable


77


Hacker FM et al., 2011


Various


Dx/HA



174


18-100


98


Kaye JD et al., 2011


Primary


Dx/HA


Mean 1.3


521


12-36


90


Kalisvaart et al., 2011


Primary


Dx/HA


0.8-2.7


82


13-27


93


Meta-analysis by Elder JS et al. (25) summarizes results until 2003. Routh et al. (28), 2010, is a meta-analysis of Dx/HA studies published through 2008.


Success after one or several treatments in some studies.


Dx/HA, dextranomer/hyaluronic acid; PDMS, polydimethylsiloxane.

Only gold members can continue reading. Log In or Register to continue

Apr 24, 2020 | Posted by in UROLOGY | Comments Off on Endoscopic Treatment of Vesicoureteral Reflux
Premium Wordpress Themes by UFO Themes