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Vesico-ureteral Reflux in Paediatric Patients – Update on Treatment
than 17% at 12–18 hours.
10,11
The increased risk of bacterial Table 1: One-year Results of Different Treatment
resistance must also be considered.
Options for Grade 3–4 Vesico-ureteral Reflux
UTIs may occur in up to 42% of children in antimicrobial prophylaxis,
Treatment Options Cure Rate (%)
and after five years 22% have febrile UTIs. Moreover, VUR tends to
Antibiotic prophylaxis 33
Open surgery 98
disappear slowly over time: after one year of prophylaxis, the
Deflux:
disappearance rate was calculated as 37% in grade 2 VUR, 33% in
One injection 71
grade 3 VUR and close to 0% in grade 4 VUR.
12
In a multicentre study
Two injections 84
in children by the International Reflux Study Group,
13
the spontaneous
cure rate of grade 3–4 VUR was less than 20% after five years of
Table 2: Vesico-ureteral Reflux Treatment Options –
prophylaxis and about 52% after 10 years.
14
Repeated voiding
Parental Preference
cystourethrograms are required during conservative treatment,
increasing the concern about the invasiveness of the procedure.
Treatment Preference (%)
Endoscopic treatment 80
Open Surgery Repairs
Antibiotic prophylaxis 5
A large number of highly effective open surgical repairs of VUR have Open surgery 2
been proposed and adopted, beginning with the original description No determined opinion 13
by Guy Laedbetter. The Leadbetter-Politano technique was effective On 100 patients with grade 3–4 vesico-uteral reflux (VUR) after six to 12 months of
but presented a significant rate of late upper urinary tract
antibacterial prophylaxis.
obstruction, and is no longer used.
15
Figure 4: Rate of Different Therapeutic Options for
Treatment of Vesico-ureteral Reflux Over 30 Years
The most common intravesical repair was proposed by Joseph
Cohen in 1975:
16
the ureteral hiatus remains the same and the ureter
is re-implanted in a transtrigonal submucosal tunnel (‘transtrigonal
ureteroneocystostomy’). The success rate is very high (95.9% of
ureters and 95.1% patients across 86 surveys).
8
However, the Cohen technique requires 60–90 minutes of surgery, a
few days of hospitalisation with antalgic treatment and bladder
catheterisation. A moderate amount of dysuria and frequency is
common, and children will miss school and sporting activities for
about one month. A failure rate of 3–5% can be expected. In this
anatomical position, it is difficult or even impossible to perform
retrograde ureteral catheterisation or ureteroscopy, procedures that
are significantly more common in the adult population.
1970 1980 1990 2000
In the Lich and Gregoir extravesical approach,
17,18
the bladder
Antimicrobial Open surgery Endoscopy
muscular wall is incised to expose the mucosa and a longer (3–4cm)
prophylaxis
submucosal tunnel is created. It may cause minor bladder Different therapeutic options for vesico-ureteral (VUR) treatment at our institution over
dysfunction and urinary retention, expecially when the procedure is
the last three decades. Endoscopic treatment has gained popularity versus long-term
antimicrobical prophylaxis and open surgery.
performed bilaterally. A partial and transient denervation occurring
around the ureteral hiatus is the suggested reason for this migration of non-biodegradable particles. Similar problems were
complication. More recently, there has been interest in performing experienced with Macroplastique
®
(Uroplastique, Bruxelles,
this technique laparoscopically.
19
Although successful in skilled Belgium). Cross-linked bovine collagen was a valid alternative for
hands, the utility of this approach remains in question given the some years, but it presented a high resorption rate and a risk of
cost–benefit ratio. immunogenic reactions. In our experience, adverse reactions have
never occurred with this agent.
22
Endoscopic Treatment
Injection of bulking agents under the refluxing ureteral orifice by The only agent currently approved by the US Food and Drug
cystoscopy was first described by Matouscheek in 1981
20
and Administration (FDA) for this purpose – and widely adopted in
pointed out by O’Donnell and Puri from 1984.
21
Teflon
®
paste was Europe – is Deflux
®
(dextranomer/hyaluronic acid copolymer, Q-
initially adopted and the technique was named ‘STING’ (subureteral Medd, Uppsala, Sweden), a slowly biodegradable injectable agent
Teflon injection), alluding to the mosquito puncture. The technique that is non-immunogenic and not animal-derived. We adopted
consists of a subureteric implant of a biomaterial, acting as a bulking Deflux in 1995.
12
The experience in our department is 2,400 treated
agent, that increases and stabilises the intravesical length of the patients and 4,000 ureteral units. Our success rate is about 90%
distal ureter. A paediatric cystoscope (8–14F) with a operating (96% in grade 2 VUR, 91% in grade 3 VUR and 81% in grade 4 VUR).
channel and a rigid or semi-rigid cannula are required. Grade 5 VUR has been also treated by Deflux subureteric and/or
intra-ureteric injection, with a success rate of approximately 67%,
The agent used has changed over time in the search for the ideal. although a number of children may require two or even three
Polytef was not accepted in the US due to the risk of long-distance treatments.
22
The increased efficacy of endoscopic treatment in
EUROPEAN UROLOGICAL REVIEW 87
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