Endoscopic Treatment of Reflux

Vesicoureteral reflux (VUR) is the abnormal retrograde flow of urine from the bladder into the ureter and possibly the kidney.

VUR is one of the most common urinary tract anomalies of children. VUR is secondary when high pressure bladder cases a break down of the normal antireflux mechanism of the ureterovesical junction, which may occur in children with posterior urethral valves or neurogenic bladders. Secondary reflux also occurs in children who have complete ureteral duplication. Primary reflux is a congenital anomaly of the UVJ wherein a deficiency of the longitudinal muscle of the intravesical ureter results in an inadequate valvular mechanism.

The goal of treating children with VUR is prevention of recurrent pyelonephritis and subsequent renal scaring.

What are the symptoms of vesicoureteral reflux?

The following are the most common symptoms of vesicoureteral reflux. However, each child may experience symptoms differently. Symptoms may include:

• urinary tract infection (urinary tract infections are uncommon in children younger than 5 years and unlikely in boys at any age, unless VUR is present)
• trouble with urination including:
  • urgency 
  • dribbling
  • wetting pants
• an abdominal mass may be detected from a swollen kidney
• poor weight gain
• high blood pressure

Diagnose

VUR can often be detected by ultrasound before a child is born. If there is a family history of VUR, but your child has no symptoms, your child's physician may elect to perform a diagnostic test to rule out VUR. Diagnostic procedures for VUR may include:

• voiding cystourethrogram (VCUG) - a specific x-ray that examines the urinary tract. A catheter (hollow tube) is placed in the urethra (tube that drains urine from the bladder to the outside of the body) and the bladder is filled with a liquid dye. X-ray images will be taken as the bladder fills and empties. The images will show if there is any reverse flow of urine into the ureters and kidneys.
• renal ultrasound - a non-invasive test in which a transducer is passed over the kidney producing sound waves which bounce off the kidney, transmitting a picture of the organ on a video screen. The test is used to determine the size and shape of the kidney, and to detect a mass, kidney stone, cyst, or other obstruction or abnormalities.
• blood tests

The main treatment options are administration of prophylactic antibiotics, open surgery and endoscopic submucosal biomaterial injection.

Endoscopic treatment of primary or secondary VUR is indicated at any of the following conditions when conservative treatments (e.g., prophylactic antibiotics and clean intermittent catheterization) have failed:

• Lower grades of reflux (grades I to III); or
• Recurrent, poorly controlled febrile urinary tract infections; or
• Persistent reflux in post-pubertal female members; or
• Deterioration of renal parameters regardless of reflux severity; or
• Children who have had a previously unsuccessful ureteral reimplantation; or
• Children whose reflux is associated with a thick-walled neuropathic bladder; or
• Children who have stopped taking their medication as a result of drug intolerance or parental non-compliance.

The long-term requirement of prophylactic antibiotic therapy and the occasional complications of surgery techniques led to the development of endoscopic treatment of  VUR in the early 1980s. Since then, many foreign materials, such as polytetrafluroethylene, polydimethylsiloxane and bovine collagen have been used for subureteral injections with cure rates ranging from 60% to 80%.

Silicon has been associated with autoimmune reactions, and its migration has also been reported. Injection of bovine collagen has the additional draw back of presenting a foreign protein to immune system, which may elicit an anaphylactic reaction, and because of act digestion, early recurrence is reported consequently, new alternative substances have been proposed, including dextranomer, Deflux and urocol. Our preferred method for treatment of VUR is open surgery (Gilvernet antireflux technique). However in recent four years  Gilvernet antireflux technique  was done laparoscopically on 40 patients. In our Center patients with previously failed operation were candidated for Endoscopic treatment of VUR. In our institute from 2000 a totally of 130 patient underwent this procedure.

Procedure

With the patients under general anesthesia routine cystoscopy is performed and the ureteral urifice shape and location and trigone and bladder well trabecollation are observed. A storz cystoscopic injection needle consisting of a 10mm long, 2 gauge, 3fr needle connects to a 30cm length plastic tube is advanced through the working channel of a miniature wolf neonatal cystoscopic. The needle tip is inserted at the 6 oclock position into the subureteral space approximately 1 to 2mm distal to the ureteral orifice and is advanced proximally. An average of 0.4 to 0.6 cc bulking material is injected slowly until a volcano bulge obliterates the ureteral orifice (fig 1). The needle is kept in position for 2 to 3 minutes before it is with drawn to minimize extravasation of injected material through the needle track. Renal and bladder ultrasound will be obtained at 1week and to assess outcome, follow up VCUG will be performed 6 months after injection.

Fig 1: The original technique of endoscopic injection therapy. Arrow points at needed position in relation to ureteral orifice (middle).

Fig 2 : Endoscopic images demonstrate ureteral orifice (arrow) (a) prior to and (b) following chondrocyte injection. Postinjection image show