The fate of implant after endoscopic injection of dextranomer/hyaluronic acid in vesicoureteral reflux: time to partial reabsorption and stabilization
Introduction
Vesicoureteral reflux (VUR) is a common urological disease, which affects 1% of the pediatric population, and it potentially leads to renal damage, scars, and eventually, end-stage renal disease [1]. Recently, shared goals of treatment are the prevention of urinary tract infections (UTIs), the avoidance of long-term antibiotics use and the reduction of radiation exposure. Endoscopic treatment is well tolerated in children, it has reduced costs compared with other treatment modalities, and it effectively achieves the first two goals [2]. These reasons warrant endoscopic treatment as an emerging treatment of choice for VUR. Despite guidelines recommendations, which still suggest postoperative voiding cystourethrograms (VCUG), many authors nowadays deem VCUG superfluous in favor of an adequate ultrasonographic (US) follow-up [3]. However, few studies exist on implant changes at follow-up and even fewer on the US appearance.
In the present study, the authors evaluated US appearance of mounds in children undergone endoscopic injection of dextranomer/hyaluronic acid (Dx/HA) for VUR treatment. The final aim was the identification of a new parameter, which could be useful to determine the success rate both intra-operatively and during the follow-up to reduce the need for VCUG. Mound heights were recorded during the postoperative visits and compared with intra-operative measures to calculate reabsorption rate. Secondary endpoints were considered the evaluation of the time needed to reach stabilization of implants and cut-off heights to ensure the success of the procedure.
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Materials and methods
The authors considered all consecutive patients referred to the authors Urologic Outpatient Clinic between April 2015 and March 2016 for primary VUR. The study included children with recurrent febrile upper UTI and either primary reflux grade 3 to 5 confirmed by pre-operative VCUG or grade 2 in presence of contralateral high-grade reflux; eligible patients under 1 years of age were initially managed conservatively and thereafter re-evaluated. Exclusion criteria were grade 1 VUR, presence of
Results
A total of 30 consecutive patients, 47 ureters, matching the inclusion criteria, underwent Dx/HA injection with IO-US monitoring and attended the planned postoperative assessment. Five patients were excluded from the analysis as they did not attend all the postoperative assessment (Table 1). Of the 30 patients, 16 were females. VUR was unilateral in 13 (27.7%) and bilateral in 34 (72.3%) children. The average age at surgery was 37 ± 23 months, ranging from 14 months to 7 years. Of the 47 renal
Discussion
Management options available for pediatric VUR include watchful waiting, medical treatment with continuous antibiotics prophylaxis and various surgical alternatives [6]. Among those, endoscopic treatment is widely considered an optimal choice compared with ureteroneocystostomy in terms of reduced morbidity (less pain, no scars), shorter hospitalization, reduced costs, and increased patients’ preference.
Owing to inadequate intra-operative indicators and variable success rate, international
Conclusions
The present study demonstrates a strong correlation between mound height and result after endoscopic injection of Dx/HA in children intra-operatively and lasting for months. The authors could furthermore report a total reabsorption of 21–23% of implants and a stabilization of the mound around 6 months after surgery. These results highlight how mound height measured by US could overcome the need for routine VCUG following endoscopic injection for non-complicated VUR.
Ethical approval
The Local Ethics Committee approved the study protocol.
Funding
None declared.
Competing interest
None declared.
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