Vesicoureteral reflux of a solitary kidney treated with endoscopic injection therapy comprising tandem injections administered with the assistance of a ureteral guidewire in a young girl

Abstract

We present the case of a 12-year-old girl with vesicoureteral reflux (VUR) of a solitary kidney treated using a modified hydrodistention implantation technique. A needle was set parallel to the ureteral guidewire inserted through the ureteral orifice before performing injections to correct VUR. Multi-site tandem injections were administered along the wire, which confirmed the direction and length of the ureteral tunnel. The mounds were aligned without ureteral kinking. A reduced volume of dextranomer-hyaluronic acid copolymer (Deflux®) was required to construct an effective anti-reflux tunnel. A voiding cystourethrogram confirmed VUR resolution. This technique avoided complications associated with a solitary kidney.

Highlights

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The hydrodistention implantation technique is a new option for vesicoureteral reflux.
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VUR of a solitary kidney was safely treated with a modified HIT.
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The modified HIT included a ureteral guidewire to assist with tandem injections.

1 Introduction

Anti-reflux endoscopic injection therapy, such as that comprising the hydrodistention implantation technique (HIT) with Deflux®, is a new option for children with vesicoureteral reflux (VUR). ^, We have demonstrated that this therapy is effective and safe for postpubertal patients with a dilated ureteral orifice. Selecting the appropriate site and applying an adequate volume of Deflux® are important because overloading may be accompanied by the risks of hydronephrosis and ureteral strictures. We present a case of VUR of a solitary kidney that was safely and successfully treated with a reduced injection volume and a modified HIT involving a ureteral guidewire to assist with tandem injections.

2 Case presentation

A 12-year-old girl with repeated febrile urinary tract infections was referred to our hospital for the correction of VUR of her solitary kidney. A voiding cystourethrogram (VCUG) revealed grade III VUR in the left kidney during the voiding phase ( Fig. 1 a) . Computed tomography revealed acute focal nephritis, and dimercaptosuccinic acid scintigraphy demonstrated multiple renal scars; however, uptake on the right side was not observed ( Fig. 1 b and c). Because the patient requested minimally invasive treatment, endoscopic injection therapy was conducted using Deflux®. Ethics committee approval and written informed consent from the patient and the patient’s parents were obtained before surgery.

The left ureteral orifice was positioned laterally and resembled a golf hole ( Fig. 2 a). Furthermore, an evaluation involving hydrodistension revealed that the orifice was slightly open, preventing a full view of the intraluminal ureter , and it was therefore classified as grade H2 ( Fig. 2 b).

Initially, the hydrodistention injection therapy (HIT) was attempted, but visibility within the tunnel was compromised during the injection due to decreased water flow caused by the needle inserted into the scope’s channel. Using a ureteral guidewire, the roof of the ureteral tunnel was elevated, improving visibility in our current H2 case with a small-sized ureteral orifice. The needle was set parallel to the guidewire, thus confirming the direction and length of the tunnel; then, injections were performed ( Fig. 2 c and d). Endoscopic injections were performed using the HIT with a guidewire. During insertion of the ureteral guidewire, Deflux® was injected at the most proximal site using an 8.5-Fr pediatric cystourethroscopy ( Fig. 3 a). A second injection was performed at a slightly distal and lateral site where tissue softness was confirmed by the test injection ( Fig. 3 b). A third injection was performed near the ureteral orifice using the original HIT, thereby aligning these three injected points and forming a long anti-refluxed ureter ( Fig. 3 c). A fourth injection was performed using the subureteral injection method. Finally, the mound shape formed a volcano-like configuration ( Fig. 3 d). The total volume of these four injections was 1.5 ml.