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Year : 2016  |  Volume : 8  |  Issue : 6  |  Page : 135-145  

Vesico-ureteral reflux

Date of Web Publication26-Apr-2016

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How to cite this article:
. Vesico-ureteral reflux. Urol Ann 2016;8, Suppl S2:135-45

How to cite this URL:
. Vesico-ureteral reflux. Urol Ann [serial online] 2016 [cited 2020 Aug 8];8, Suppl S2:135-45. Available from: http://www.urologyannals.com/text.asp?2016/8/6/135/181208

A new technique of antireflux plasty

Bertrand Dore, Shwky El Abd, Adel Youssef, Saleh Mohalhel

Department of Urology, Riyadh Central Hospital, Riyadh, Saudi Arabia

All the techniques described until now to correct vesico renal reflux include dissection of the distal ureter. Avoiding this, the original technique described in 1984 by Prof. Gil-Vernet is based on anatomical investigations of the lower ureter with its intrinsic muscular fibers, the transmural part and the function of waldeyer sheath in preventing the reflux.

It was done not only for cases with megatrigone and ectopic ureteric orifices but also for all grades of reflux. The advancement increases the length of intramural ureter and the mucosal roof of both orifices. Although this is a brief report for five cases only but a very good result with 18 months follow up was seen.

It seems a safe and easy method. Furthermore, with the new procedures of uretero-renoscopy this technique allows easy catheterization and ureteroscopy of both ureteric orifices in the future a situation which is very difficult after the classic when antireflux advancement procedure.

Presented at the: 4 th Saudi Urological Conference

Riyadh Central Hospital

18 September 1986

Endoscopic submucosal teflon injection (STING): An alternative treatment of vesicoureteric reflux in children

T. Merdad, V. DeBoe, L. Merchx, F. Keuppens

Department of Urology and Pediatrics, Academic, Hospital of the Vrije Universiteit Brussels, Brussels, Belgium, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

Objectives: Vesicoureteric reflux is a common urological disorder in children. Those who do not need prompt surgical treatment are managed conservatively, with the focus of preventing UTI, this treatment is suitable for approximately 70% of those patients. We used STING, which is a simple noninvasive treatment, for the other 30%.

Materials and Methods: 100 Refluxing units in 68 children were treated with STING with a maximum follow up of five years. Indications were high grade reflux (III-V), persistence or progression of reflux despite conservative therapy, breakthrough urinary infection despite antibiotics prophylaxis and bad antibiotic compliance.

Results: Reflux was cured with a success rate of 75% after a single injection and 96% after two injections. Best results were obtained in low grade reflux (I-II). 60-70% success rate was obtained in high grade reflux (III-V). The main advantage of STING over open reimplantations lies with its noninvasiveness, simplicity and possibility of being repeated in case of failure.

Conclusion: The technique of the endoscopic approach to treat reflux has been popularized by O'Donnell in 1984, because of the simplicity and efficacy reported by several authors. This technique has been the first choice of treatment options in the department of urology at the VUB University in Brussels.

Presented at the: 10 th Saudi Urology Conference

King Fahad National Guard Hospital

26-28 November 1996

Immunologic changes in bacteriuric children with and without schistosomiasis

Shawky El Abd

Department of Urology, Riyadh Central Hospital, Riyadh, Saudi Arabia

The problem of UTI in children constitutes a worldwide problem that is furtherly augmented by bilharziasis in endemic areas. The work entailed assessment of the immunologic status in 30 infected children 20 of them had active schistosomiasis, compared to the control group. The efficiency of how antibilharzial drugs (Niridazol and Trichlorfone) plus their antibacterial and immunosuppressive effect was demonstrated. The antibiotic role was also observed.

The infested children were classified into four groups and the mean serum concentration of IgG, IgA and IgM were estimated by the immunodiffusion method. A follow up of these Igs two weeks after antibilharzial or antibacterial therapy was done.

Presented at the: 4 th Saudi Urological Conference

Riyadh Central Hospital

18 September 1986

A study on urinary tract infections in children seen at KFU

Khalid Al Umran

Department of Paediatrics, King Faisal University, Al Khobar, Saudi Arabia

This is a retrospective study on patients with urinary tract infections (UTI) seen in King Fahd Hospital of the University (KFHU) during the five year period from February 1988 to January 1993. Data of patients with confirmed UTI were obtained from laboratory and medical records and analysed. Of the 212 children (ages 0-12) 104 were females and 108 were males.

Clinical diagnosis of UTI confirmed by microbiological assay and its consequences by radiological and laboratory investigations including renal functions tests.

Urine specimens from all patients were subjected to culture and organisms isolated from all patients. All isolates were gram negative bacilli predominantly  Escherichia More Details coli. Of the cultures a few yielded mixtures of gram negative bacilli and gram positive organisms. Antibiotic susceptibility tests on gram negative organisms revealed resistance to ampicillin cotrimaxazole and tetracycline but sensitivity generally to gentamicin, augmenting, nalidixic acid, nitrofurantoin and others.

The study presents a clinical and microbiologic profiles of UTI in paediatric age group as seen in our hospital, reviews the methods of diagnosis and management of such cases and recommends specific treatment by antibiotics.

Presented at the: 8 th Saudi Urological Conference

King Fahd Military Medical Complex

9-10 November 1993

Urinary tract infection in children at K.F.M.M.C.: A four year audit

S. Egail, I. Al Oraifi, A. Al Dayel, M. Ezzibdeh, K. Lubkiewicz, M. A. Babiker

Department of Urology, King Fahd Military Medical Complex, Dhahran, Saudi Arabia

Urinary tract infection (UTI) is a common problem of childhood. We examined retrospectively the records of 192 patients who had confirmed UTI. Mean age of patients 12.8 months (range 0-120 months), and male to female ratio was 1:1.3.

122 (63.5%) children presented with febrile illness and 40 (20.85) had other symptoms. The commonest organism isolated from 243 cultures was E.coli (80.75), Klebsiella (9.9%), and other organisms (9.4%).

Diagnostic imaging studies, including KUB, ultrasound or IVU, were requested for 62 (32.3%) patients only. Abnormalities were detected in 27 patients.

As the results of this audit, we suggest radiological protocol for evaluation of all children with proven UTI.

Presented at the: 8 th Saudi Urological Conference

King Fahd Military Medical Complex

9-10 November 1993

Urinary tract infection in children with posterior urethral valves and bilateral refluxing ureters

C. Krishnappa, Akhileshwar Jha, Kuruvilla Zachariah, Zaid Roshdi, Mahmoud Murtaja, K. S. AbdulWahab

Department of Urology, King Fahd Central Hospital, Gizan, Saudi Arabia
"25 cases of Posterior Urethral Valves and Bilateral refluxing ureters treated in KFCH for last 5 years". The age of the patient ranged from 1 day to 4 years. Clinical presentation were (a) UTI, b) retention of urine, (c) failure to thrive, (d) secondary effects of obstruction like prolapse of rectum and vesical calculi. 20 patients were treated with Urethroscopy and fulguration of valves. 10 cases who had grade III & IV vesica-ureteric reflux were also submitted to Anti-reflux procedure along with fulguration of post ureteral valve. Other 10 cases had grade I & II reflux along with post urethral valve were submitted only for excision of PUV. The second group of patient, when they were discharged from hospital, their RFT was normal (serum creatinine), their urine was sterile at the time of discharge. These children were followed up at 3 months interval time. Most of the patients during the follow up time itself developed UTI and rising serum creatinine level. These children were not on chemoprophylaxis at the time of follow up.

Conclusion: After the clinical trial, it is concluded that the chemoprophylaxis should be integral part of follow up till the definitive anti-reflux procedure is done. In persistent, refluxing cases even in Grade I & II, we recommend PUV valve excision as well as anti-reflux procedure in cases where it is cystoscopically proved, evidence for organic lesion at vesica-ureteric junction.

Presented at the: 8 th Saudi Urological Conference

King Fahd Military Medical Complex

9-10 November 1993

Increasing prevalence of antimicrobial resistance among uropathogens causing urinary tract infections in children

T. M. Gebriel, T. Ben-Hamida, M. Aboshkiwa

Department of Medical Microbiology, Al-Fateh University of Medical Sciences, Tripoli, Libya

Objective: During childhood urinary tract infections considered an important cause of serious complications as chronic renal failure, guideline for the management of UTIs in children that recommended empiric therapy rely on the predictability of the agents causing the infections and knowledge of their antimicrobial susceptibility. In the present study, the frequencies of resistant uropathogens to the most commonly used antibiotics were retrospectively surveyed in Salah-Edden Hospital-Tripoli during the years 1992, 1995 and 1998.

Results: E.coli, Klebsiella pneumonaie and proteus sp. were the most common uropathogens, according for more than 70% of the total urine isolated studies. The prevalence of resistance among E.coli was more than 70% for ampicillin in each year studied. The prevalence of resistance to co-trimoxazole significantly rose from more than 49% in 1992 to more than 64% in 1998. Concerning Klebsiella pneumonaie the prevalence of resistance significantly rose from 0& to nalidixic acid; 0% to nitrofurantoin; 21% to augmentin and 32% to co-trimoxazole in 1992 to 16%; 16% 57% and 66% in 1998 respectively, while in case of proteus sp. the prevalence of resistance to co-trimoxazole significantly rose from 40% in 1992 to 100% in 1998.

Conclusion: There were statistically significant increase in the prevalence of antibiotic resistance from 1992 to 1998 among the most common uropathogens which leaves the physician with every few choices when treating UTIs without prior knowledge of the causative pathogens.

Presented at the: 13 th Saudi Urological Conference

Riyadh Armed Forces Hospital

14-17 February 2000 (09-12 Dhu Al Qa'dah 1420)

Clean intermittent catheterization in Saudi children: Suggestion for a common protocol

R. De Castro, K. A. Fouda Neel, A. M. Al Shammari, J. M. Abu Daia

Department of Urology, Division of Pediatric Urology, King Faisal Specialists Hospital and Research Centre, King Khalid University Hospital, Department of Urology, Division of Pediatric Urology, King Fahd National Guard Hospital, Riyadh, Saudi Arabia

Preface: The introduction and popularization of method, practice and philosophy of Clean Intermittent Catheterization (CIC) of the urinary bladder in the treatment of bladder dysfunctions by Lapides in 1970 was one of the most import modern steps in the progress of urological science. This is particularly true for Pediatric Urology. In the treatment of severe urinary incontinence in children secondary to great urological malformations (extrophyepispadias complex and bilateral single ectopic ureter) and to neurogenic congenital bladder dysfunction's very few were possible before the CIC era and very much can be done now, thanks to this technique.

Objective: CIC is widely utilized in the Kingdom of Saudi Arabia, as well as in all the countries with a good level of sanitary organization, but the materials and the methods in use are not always the most appropriate. We should try to improve the health service for the patients on CIC in the entire Kingdom, contributing to the diffusion of the right methods of CIC and making available the best quality materials.

Methods: The Pediatric Urology Staff of three hospitals in Riyadh felt it was appropriate to pursue the mentioned aims. We started comparing our different experiences with children on CIC in the Kingdom and outside. We analyzed the materials our hospitals supplied to our outpatients on CIC, the stock in trade already available in our hospitals for impatient use and new wares available in the Kingdom from the pharmaceutical companies. We analyzed many different catheters and their cost.

Results: As a result of our investigations, we prepared a list of the best available article we believe should be supplied for CIC and a list of article which should not be used for this purpose.

Conclusions: We will present our agreement about the methods and materials for CIC in children and we would like to compare and discuss it openly to finalize a common protocol for CIC for Saudi children, hoping to avoid some mistakes and improve the quality of life of these patients.

Presented at the: 12 th Saudi Urology Conference

Al Hada and Taif Armed Forces Hospitals Progam

23-25 February 1999 (7-9 Dhu Al Qa'dah 1419)

Extravesical ureteric reimplantation in children: Preliminary experience from KKUH

S. M Soliman, K. N. Fouda

Department of Urology, King Khalid University, Riyadh Saudi Arabia

Background: In the last decade there has been renewed interest in extravesical ureteric reimplantation (Extravesical detrusorrhaphy). This has been reported to be an effective technique for treating isolated VUR with avoiding the annoyances consequent to opening the bladder especially bladder spasms, yet its use especially in bilateral cases has been questioned because of a reported high incidence of voiding dysfunction thereafter. We reviewed our experience with extravesical ureteric reimplantation in the Paediatric Urological Service at KKUH in the last 2 years.

Patients and Methods: From 1998 through 2000, all patients with non-STINGable VUR who underwent extravesical ureteric reimplantation were reviewed. Patients were grouped into group A: undergoing unilateral reimplantation and group B: undergoing bilateral reimplantation. Preoperative voiding dysfunction was carefully searched for. Preoperative and postoperative radiological studies and signs of voiding dysfunction were reviewed and compared between both groups. Patients were judged to be catheter weaned when they were able to void at least half of their bladder volume. Those preoperative anticholinergic, CIC, or requiring concomitant open bladder surgery were excluded from the study.

Results: There were 11 patients with 16 refluxing units (8 boys, 3 girls, mean age 5.1 years), with a follow up range from 2-23 months: none showed preoperative signs of voiding dysfunction. Group A included 6 patients (7 refluxing units) one unit was nephrectomized due to nonfunction and group B included 5 patients (9 refluxing units). In both groups, none of the patients showed signs of remaining of D-novo VUR on postop VCUG. The average duration until patients were catheter weaned was 3 days in group A and none in this group developed any sign of voiding dysfunction on follow up. In group B, by contrast, it was 3.8 days and one developed significant daytime and night incontinence persisting 1 month after surgery.

Conclusion: Extraversical reimplantation is a highly successful technique in treating VUR, yet careful consideration should be given for cases with intended bilateral reimplantation, as this may be preceded by incomplete ability to empty the bladder and late voiding dysfunction, a complication that is seldom reported after intraversical reimplantation. Our preliminary experience with a limited number of patients suggests reverting to the "classical" intraversical techniques when it comes to reimplanting the ureters bilaterally and reserve the extraversical approach to unilateral cases.

Presented at the: 14 th Saudi Urological Conference

King Fahd Military Medical Complex- Dhahran

13-15 February 2001 (19-21 Dhu Al Qa'dah 1421)

Endoscopic correction of complicated yesicoureteric refluxin children

Khalid Fouda Neel

Department of Surgery, Division of Urology, King Khalid University Hospital, Riyadh, Saudi Arabia

Objective: Endoscopic treatment of vesicoureteric reflux (VUR) is a widely used intervention with high success rate, low morbidity, short hospital stay and cost effective. Treatment of complicated VUR [failed surgery, posterior urethral valves, neurogenic bladder, bladder dysfunction (NNBSD)] is still challenging. Here we review our experience at King Khalid University Hospital, Riyadh, with VUR endoscopic correction using macroplastique; in complicated VUR.

Materials and Methods: 18 patients, 11 female and 7 male, were treated endoscopically to correct their VUR from 1998-2000. 9 of them had "complicated VUR" 3 with failed previous surgery for the treatment of primary VUR, 1 with PUV and 5 with NNBSD. Of the 9 patients with complicated VUR, 6 had bilateral VUR, 3 had unilateral VUR. Endoscopic correction of VUR was done for all patients and a follow up micturating cystourethrogram was requested 3-6 months after treatment and renal ultrasound one month after treatment.

Results: Of 9 patients with complicated VUR, 7 were available for follow up. Out of the 12 ureters treated and came for follow up, 10 showed complete resolution of VUR and 2 with same pre injection grade of reflux. None of the patients with persistent reflux had a 2 nd attempt yet. Only one patient had pyelonephritis post injection, none had obstructive changes and none had allergic reaction to the material.

Conclusion: Early result of endoscopic correction of VUR for complicated VUR is encouraging, with an 84% success rate and 15% complication rate. We strongly recommended this line of treatment, as the first option, for this difficult group of patients when surgical correction of VUR is decided.

Presented at the: 14 th Saudi Urological Conference

King Fahd Military Medical Complex - Dhahran

13-15 February 2001 (19-21 Dhu Al Qa'dah 1421)

Variability of significance of nuclear medicine cystogram

K. Fouda Neel, J. F. Schillinger, G. H. Kiruluta

Division of Urology, King Khalid University Hospital, Riyadh,

Saudi Arabia, Department of Urology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada

Radionuclide cystography (RNC) is a widely used test in the diagnosis or as in indication of resolution, of vesicoureteric reflux (VUR). The recurrence (persistence) of reflux after one negative RNC has been previously reported. This prospective study further elaborates on this phenomenon.

85 patients with primary VUR, treated conservatively, between 1991 and 1996 having one negative RNC, were included in this study, 12 to 18 months after the negative study a repeat RNC was done. Two groups, those with and those without necurrence of reflux were identified and compared as to sex distribution, age of resolution, time between presentation and first negative RNC, change in grade between presentation and just before resolution, side of reflux at presentation and grade before resolution. The differences between both groups were statistically analyzed.

Of the 85 patients, 25 (29%) ha recurrence of reflux. Of these 18 (72%) patients had recurrence with grade two or greater and 15 (60%) of the 25 patients are still refluxing 12 months after the second positive RNC. There was no observed association between the two groups in any of the variables (p-values were greater than 0.05).

This study emphasizes the importance of a second negative RNC to indicate absence/resolution of reflux, as one negative RNC alone would have missed persistent reflux in 25 of 85 patients at one year and 15 of 85 patients at two years. Whether this is variability in the disease process or an unknown factor inherent in the test is unknown, in that there is no statistical difference in the parameters studied between the two groups.

Presented at the: 12 th Saudi Urology Conference

Al Hada and Taif Armed Forces Hospitals Program

23-25 February 1999 (7-9 Dhu Al Qa'dah 1419)

Augmentation ureterocystoplasty with ipsilateral renal presrvation

R. F. Talic

Department of Surgery, King Khalid University Hospital, Riyadh, Saudi Arabia

Introduction: Evaluate the role of ureterocystoplasty with ipsilateral renal preservation in the management of patients with neuroversical dysfunction and impaired renal function who failed conservative medical treatment.

Patients and Methods: Five patients with neuroversical dysfunction (2 male and 3 female) with a mean age of 6.2 years were recruited in this ongoing study starting June 1996. All patients have vesicoureteric reflux (VUR), impaired and deteriorating renal function. Symptoms, renal function and radiological evaluation are recorded both pre and post operatively. Urodynamic assessment was included in the post operative follow up. Operative reconstruction involved augmentation cystoplasty using the distal ureter of one renal unit and transuretero-ureterostomy. Neureterostomy for correction of VUR in the contralateral kidney was required in 4 patients.

Results: All patients were followed up with an average of 12 months. All patients showed symptomatic improvement and were dry by day and night. Two patients continue to have positive urine cultures but no symptomatic urinary tract infections. Three patients have stable renal function, improvement was noted 2 patients. VUR was corrected in 3 patients and improved in 2 patients. Hydroureteronephrosis and obstruction improved in all patients.

Conclusion: Early results of this operative intervention are satisfactory and promising in the management of this difficult group of patients in terms of symptomatic improvement and stabilization of the renal function. The long-term effect on the renal function will require long-term follow up.

Presented at the: 11 th Saudi Urology Conference

King Fahd Military Medical Complex - Dhahran

24-26 February 1998 (27-29 Shawwal 1418)

Ureteroneocystostomy with and without the use of an intravesical catheter. A prospective randomized study

A. Al Shammari, A. Bhatti, R. N. Kupchak, L. W. Mix, A. Decter, M. D. Leonard

Department of Urology, Children's Hospital, University of Manitoba and University of Alberta, Canada, Department of Urology, King Fahad National Guard Hospital, Riyadh, Saudi Arabia

Purpose: To objectively assess postoperative pain, analgesic requirement, bladder spasms, nosocomial urinary tract infections, length of hospital stay and the outcome of "no catheter" intravesical ureteric reimplantation compared to intravesical ureteric reimplantation with a bladder cathter.

Materials and Methods: Over a period of one year, 33 patients (24F, 9M) aged 3-14 years with primary vesicoureteric reflux were randomly assigned to a "no catheter" group or to a "catheter" group after meeting study selection criteria. Two standard procedures of intravesical ureteric reimplantation were utilized with intra-operative low dose caudal anesthesia. All patients were given intravenous morphine for pain control postoperatively, either by a continuous intravenous infusion or by patient control analgesia. Postoperative pain was assessed by a patient driven pain scale and by interviewing patients and their parents at least twice a day as regards pain control/bladder spasms. Urine cultures were performed on the day of the surgery and 1 st and 3 rd postoperative days. Patients were followed at 6 weeks with a renal ultrasound and at three months with a voiding cystogram or nuclear cystogram. Postoperative analgesic requirements, occurrence of bladder spasms, urinary tract infection rate, length of hospital and the outcome are reported. Student's paire test was used for evaluation of statistical significance.

Results: There was no difference in sex distribution, mean age, mean body weight, or nosocomial urinary tract infection between the two groups The postoperative intravenous morphine requirement was significantly lower (p < 0.05) in the "no catheter" group with a mean (+ 0.5) in the "catheter" group . Bladder spasms occurred in 80% of catheterized patients and only in 30% of non-catheterized patients. The length of hospital stay was significantly shorter (p < 0.05) in the "no catheter" group with a mean (+ SEM) of 87.2 hours (+ 19.4) compared to 109.1 hours (+ 20.9) in the "catheter" group. All evaluated patients had stable upper tracts by renal ultrasound at 6 weeks and cure of their reflux by cystogram at three months, regardless of catheter status.

Conclusion: Intravesical ureteroneocystotomy without a catheter is safe and well tolerated. Patients with "no catheter" reimplantation have significantly lower postoperative intravenous analgesic requirements, shorter hospital stay and subjectively fewer bladder spasms than patients with catheter post-reimplantation do. "No catheter" reimplantation did not alter the expected outcome. We therefore recommended this technique as a safe and effective addition to the urologic armamentarium.

Presented at the: 11 th Saudi Urological Conference

King Fahd Military Medical Complex - Dhahran

24-26 February 1998 (27-29 Shawwal 1418)

STING for treatment of VUR

Michael P. Leonard

Department of Urology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada

This lecture will briefly review the history of the STING procedure. A profile of the commonly used materials for STING, along with their clinical results and safety concerns will be examined. Finally a review of Deflux; as it applies to STING will be carried out. This will culminate with the review of a series of Deflux; STING as carried out at CHEO. At the completion of the lecture, the following objectives will be reached:

An understanding of how the STING was developed and evolved

An appreciation of the pros and cons of the varied materials used to effect the STING

Current clinical results with the use of Deflux; for STING, including the results of a series accumulated by the author.

Presented at the: 18 th Saudi Urological Conference

King Abdulaziz University Hospital

20-23 February 2006 (21-24 Muharram 1427)

Endoscopic treatment of vesicoureteral reflux in children with subureteral injection of duflex: The alberta children's hospitals experience

O. Bawazir, W. Hyndman

Department of Surgery, Alberta Children Hospital, Calgary, Canada

Purpose: Vesicoureteral reflux is a risk for progressive renal damage associated with urinary tract infection. Mild to moderate reflux is routinely treated with long-term antibiotic prophylaxis to prevent recurrent infections and open surgical reimplantation for breakthrough infections despite antibiotic therapy. Endoscopic subureteral injection of implant material is a therapeutic alternative to long-term prophylaxis and open surgery. We present our experience with the use of subureteral injection of dextranomer/hyaluronic acid (Dx/HA) in Alberta Children Hospital, Calgary, Canada.

Materials and Methods: Between October 2003 and October 2004, 22 patients 7 months to 10 years old (mean age 2.6 years) underwent subureteral injection of Dx/HA for complex VUR at our institutions. Dx/HA was injected submucosally within the intramural ureter (modified STING) in most cases. Hydrodistension was use to open the ureter orifices. The average volume of injected material was measured for each ureter. Renal sonography was performed to determine if hydronephrosis was present. At 6 weeks fluoroscopic voiding cystourethrograms were used to evaluate for the presence of VUR.

Results: A total of 40 ureters were treated in 19 girls and 3 boys. Reflux was corrected in 16 patients out of 22 (73%), repeated injection required in 2 patients with low grade reflux which resulted in complete resolution. STING failed to correct reflux in 4 patients (18%) or 8 ureters (20%), which were managed by ureteral reimplantation.

Conclusions: Submucosal intraureteral implantation with Dx/HA corrected complex (STING) is a simple, safe and effective outpatient procedure for vesicouretral reflux. The use of the modified STING technique optimizes ureteral cooptation and improves the success rate.

Presented at the: 18 th Saudi Urological Conference

King Abdulaziz University Hospital

20-23 February 2006 (21-24 Muharram 1427)

Comparative study between subureteral injection of dextronomer-hyaluronic acid copolymer and extravesical reimplantation in low grade VUR in children

Osama Kamhawy

Department of Urology, Faculty of Medicine, Zagazig University, Zagazig, Egypt

To compare the results of extravesical ureteral reimplantation to endoscopic subureteral injection of dextranomer hyaluronic acid co-polymer (Deflux, Q-Med Ab, Uppsola, Sweden) in the treatment of low grade vesicoureteral reflux in children, 20 children (30 ureters) underwent subureteral injection of the aforementioned material and 26 children (39 ureters) underwent extravesical ureteral reimplantation. Low grade reflux meant 1 to 3. Mean patient age at the time of surgery in the injection and reimplantation groups was 6 (range 2-13) and 5 (range 2-14) years respectively. The mean follow up period was 12 (range 7-29) and 14 (range 6-27) months respectively. Of the patients who underwent single injection, 80% were cured of reflux at 3 months and 83.3% were cured at the last follow up while in the reimplantation group 94.8% were cured at 3 months and improved to 97.4% at the last follow up. There was a significant difference in the cure rate between the two groups of the study at 3 months and last follow up. No complications were recorded in the injection group, while in the reimplantation group contralateral reflux was seen in 3 cases (23%) at 3 months postoperatively and persist in only one case (7.7%) at the last follow up, UTI was recorded in 3 cases (11.5%), and urine retention in 2 cases (7.7%).

We can conclude that in spite of lower success rate of injection than reimplantation, the lower morbidity, the ease of a second injection or reimplantation when indicated makes subureteral injection therapy a viable option in treating low grade vesicoureteral reflux in children when medical treatment fails.

Presented at the: 18 th Saudi Urological Conference

King Abdulaziz University Hospital

20-23 February 2006 (21-24 Muharram 1427)

Are postoperative studies necessary after ureteral reimplantation? Study of single center

Al Qahtani Saeed, Al Mudhin Fayez, A. Al Shammari

Division of Urology, King Fahad National Guard Hospital, Riyadh, Saudi Arabia

Purpose: We evaluated the usefulness of postoperative imaging studies after ureteric reimplantation.

Materials and Methods: Records of 196 patients who had undergone simple or reconstructive ureteric reimplantation from 1994 to 2004 were reviewed retrospectively and 111 patients who fit the criterion. Study inclusion criterion was primary reflux with at least 1 year of postoperative follow up. Grades I to III reflux were defined as low and grades IV and V were defined as high. All patients were on prophylactic antibiotics. Evaluation included ultrasound in 6 weeks and a nuclear cystourethrogram 3 months postoperatively, and if reflux persisted the studies were repeated at 12 months.

Results: A total of 111 patients underwent simple or reconstructive ureteral reimplantation. At 3 months the procedure was successful in 90.1% of patients, and at 12 months the success rate increased to 98.2% of patients. There were 7 cases that were persistent refluxing and 4 with down grade at 3 months. At 12 months reflux resolved spontaneously in all of 11 patients and 2 needed redo. Those needed redo were high grade preoperatively with elimination syndrome. There was no statistically significant difference in the success rate at 1 year between high versus low grade reflux. Elimination syndrome significantly affects the success rates. Worsening hydronephrosis was noted in 0% at 6 weeks and at 12 months too.

Conclusions: Ureteral reimplantation is successful in treating vesicoureteral reflux. Postoperative cystourethrogram should be reserved for high grade reflux and those with elimination syndromes. Limiting these studies will help reduce patient discomfort and the cost of treatment.

Presented at the: 18 th Saudi Urological Conference

King Abdulaziz University Hospital

20-23 February 2006 (21-24 Muharram 1427)

Can prophylactic antibiotics safely be discontinued in children with vesicoureteric reflux?

Ahmed J. Al Sayyad, John G. Pike, Michael P. Leonard

Division of Pediatric Urology, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada

Purpose: To review the outcome of stopping prophylactic antibiotics in children with persistent VUR.

Materials and Methods: Retrospective review of patients with VUR off antibiotics over the past 12 years. Selection criteria: Children 4 years or older who were toilet trained, could verbalize and had a normal voiding pattern. Exclusion criteria: PUV, ectopic ureter, neurogenic bladder or severe voiding dysfunction. Outcome measures: Age of stopping antibiotics, duration on and off antibiotics, grade of reflux at the time of stopping antibiotics, the occurrence of UTIs and new renal scarring. All patients were followed with renal ultrasound.

Results: 78 patients [67 F (85%), 11 M (14.1%)] included. Bilateral VUR was present in 36 patients (46.2%), left VUR in 29 (37.2%) and right VUR in 13 (16.7%). Reflux grade ranged from I-III (I = 16.7%, II = 75.6%, and III = 7.7%). Mean age when taken off antibiotics was 5.74 years. Period on antibiotics prior to discontinuance ranged from 0-84 months, mean 26.2 months. Period off antibiotics ranged from 5-138 months, mean 37.7 months. 9 female patients (11.5%) developed UTI. 8 had cystitis (10.2%) and 1 had pyelonephritis (1.3%). Period off antibiotics in this group ranged from 5-60 months, mean 21.1 months. None of our patients, including those with UTI, developed new scarring of their kidneys by renal ultrasound.

Conclusion: Discontinuing prophylactic antibiotics in selected school age children is safe practice. The risk of significant upper tract infection is low, and the development of new renal scars unlikely.

Presented at the: 18 th Saudi Urological Conference

King Abdulaziz University Hospital

20-23 February 2006 (21-24 Muharram 1427)

Do infants with low grade antenatal hydronephrosis benefit from screening for vesicoureteric reflux?

M. Al Assiri, N. Al Said, J. P. Capolicchio, R. Jednak, P. Forbrs, J. L. Pipi Salle

Department of Urology, The Montreal Children's Hospital, Montreal, Quebec, Canada

Introduction: The natural history of undiagnosed vesicoureteric reflux (VUR) in children with low grade antenatal hydronephrosis (LAHN); SFU__-__, is unknown, therefore screening infants with LAHN for VUR might be unjustified. We present a cohort of patients with LAHN who were managed without VCUG or long-term antibiotic prophylaxis and compare outcomes to similar group who were screened and given prophylaxis.

Methods: The charts of 262 consecutive children with LAHN seen from 1999-2001 were reviewed. Patients with ureteral dilation or other renal/bladder anomalies were excluded. Patients were subdivided into 2 groups: one group managed with prophylactic antibiotics and a screening cystogram (VCUG), while the other group was not. Urinary tract infection (UTI) was the main outcome measure.

Results: One hundred and forty-four with LAHN met our inclusion criteria, with a mean follow up of 20 months. Ninety-nine patients (80 males) underwent screening VCUG. Of those, 24 males (30%) were circumcised, 9 (9%) had VUR and were kept on prophylaxis. In addition, only 2 patients (2%) developed symptomatic UTI; both of them uncircumcised males without VUR. The other group; 45 patients (31 males), were managed without VCUG or prophylactic antibiotics. None developed UTI, 12/31 (39%) males were circumcised.

Conclusion: Our data suggest that patients with LAHN do not benefit from VCUG screening of prophylactic antibiotics. A prospective randomized study is required to confirm the long-term safety of this approach.

Presented at the: 17 th Saudi Urological Conference

King Fahd Military Medical Complex

8-10 March 2005

Endoscopic treatment of vesicoureteral reflux with dextranomer/hyaluronic acid copolymer. Impact of voiding dysfunction on the overall treatment success

Hisham El Shawaf

Department of Urology, Ain Shams University, Cairo, Egypt

Purpose: Endoscopic injection of destranomer/hyaluronic acid (Dx/HA) copolymer has become an increasingly accepted treatment for primary vesicoureteral reflux (VUR) in children. Because some patients with VUR also experience voiding dysfunction, this prospective analysis was performed to assess the efficacy of that treatment for VUR of different etiologies together with evaluation of the impact of voiding dysfunction on endoscopic treatment outcome.

Materials and Methods: A total of 37 patients of both sex (male = 18 & female = 19) with VUR of different etiologies and grades (grade II to V), were included after failure of minimum course of 6 months of antibiotic prophylaxis and underwent endoscopic treatment with Dx/HA copolymer for VUR. Follow up consisted of pelviabdominal ultrasonography at one & 12 months visit and voiding cystourethrography 3, 6 and 12 months after injection. Of the 37 patients 9 were re-treated with dextranomer/hyaluronic acid copolymer because of persistent reflux (grade II or greater). The first implantation technique was recorded on videotaper. Voiding cystourethrography and micturition details were recorded at the 3 to 6 months follow up visit and compared with baseline measurements. Positive response was defined as reflux grade 0 or 1. As many as 2 repeat injections were offered to nonresponders, and those with persistent reflux (grade II or greater) were referred for open surgery. Clinical follow up was continued for a minimum of 1 year.

Results: The overall success rate was 75.7% (28/37) in all patients included in the study at 3 months follow up. Preoperative reflux according to the International Reflux Study Classification was grade II in 17 (39.5%), III in 15 (34.8%), IV in 10 (23.2%) and V in 1 (2.3%) ureteral renal units. We subsequently stratified our treatment results into 2 groups according to the etiology with 22 patients having primary VUR (affecting 25 renal units) and 15 patients with secondary VUR (affecting 18 renal units) of different etiologies. A positive response was observed in 81.8% of children with primary VUR, with 9.1% of patients requiring open surgery. While, among patients with secondary VUR the response rate was 66.6% and open surgery was performed in (13.3%). In all patients a positive response to treatment was sustained throughout the follow up period. The treatment was well tolerated, with no complications associated with the procedure. At baseline 15 patients had known controlled voiding dysfunction. Of the 9 patients (24.3%) who required re-treatment, the initial implant was correctly positioned in all patients included according to the videotape. Endoscopic observation at the time of re-treatment revealed that the implant was displaced in 5 patients, missed in one and remained correctly positioned in 3 patients. Of the retreated patients 2 had misdiagnosed voiding dysfunction, had not received any anticholinergic therapy and had a displaced implant.

Conclusions: Endoscopic treatment with Dx/HA copolymer appears to be an effective and well tolerated alternative to open surgery for first line treatment of VUR of either primary or secondary origin. Uncontrolled voiding dysfunction contributed to endoscopic treatment failure with dextranomer/hyaluronic acid copolymer because of implant displacement in this study.

Therefore, we suggest that patients with voiding dysfunction should be controlled with anticholinergics and/or micturition rehabilitation before endoscopic therapy.

Presented at the: 16 th Saudi Urological Conference

King Faisal Specialist Hospital and Research Centre

2-4 March 2004 (11-13 Muharram 1425)

Can the "STING" change the paradigm of management in vesicoureteric reflux combined with pelviureteric junction obstruction?

Sherif Soliman

Department of Urology, King Khalid University Hospital, Riyadh, Saudi Arabia

Objective: To evaluate the possibility of one stage, double level correction in children with vesicoureteric reflux (VUR) combined with pelviureteric junction obstruction (PUJO).

Patients and Methods: Seven children (age range 10-48, median 15 months) having VUR (1 grade 3, 5 grade 4, 1 grade 5) along with established PUJ obstruction diagnosed by persistent hold up in washout diuretic renogram with a catheter in bladder, underwent simultaneous endoscopic correction of VUR by Dextranomer/Hyaluronic Acid Copolymer (DefluxΒ΢) with Anderson-Haynes dismembered pyeloplasty drained with a nephrostomy tube. Two patients had solitary functional renal units. In the first 3 patients a nephrostogram was performed 7-10 days postoperatively to confirm upper and lower tract potency before extubation. In the following, the nephrostomy tube was clamped on day 3 postoperative for 24 hours and if the child shows no evidence of obstruction or leakage it was removed. Patients were followed clinically and sonographically at 2, 4, 8 and 12 months. An MCUG was performed at 4 months to confirm or deny the disappearance of VUR.

Results: None of the patients had any evidence of obstruction or leakage. PUJO was successfully corrected in all patients as evidenced by reduction in their hydronephrosis. All but 1 boy (grade 5) had their VUR resolved. The latter needed a formal open reimplant after 2 redo injections to correct his VUR.

Conclusion: In children with VUR associating PUJO, endoscopic correction of the former can allow addressing the problem in one operative session away from the proposed effect of devascularizing the ureter if operated upon conventionally at its two poles simultaneously.

Presented at the: 17 th Saudi Urological Conference

King Fahd Military Medical Complex

8-10 March 2005

Histopathological findings post dextranomer/hyaluronic acid implants in children with vesicoureteral reflux

M. Al Mandil, A. Murphy, M. Souab, A. E. Khoury

Department of Urology, The Hospital for Sick Children, Toronto, Ontario, Canada

Aim of the Work: Dextranomer/hyaluronic acid (Deflux) is being widely used as an implant for the treatment of vesicoureteral reflux as an alternative to other implants material. The literature is still lacking or deficient in documenting histopathological changes in humans after implants.

Patients and Methods: A retrospective review of patients undergoing ureteroneocystostomy after failed dextranomer/hyaluronic acid implants to capture demographic and clinical data of those patients. In addition, histopathological specimen review with further testing of excised ureteral segments looking at inflammatory changes of the surrounding tissue was conducted. Histopathological changes were correlated with the clinical findings looking at volume, duration of implant and degree of reflux.

Results: A total of 10 patients, (13 ureters) were eligible for the study. Mean age at implants 53 months, mean age at ureteroneocystostomy was 60 months. Mean time from implant injection to excision was 7 months. All ureters showed giant cell reaction with variable severity, all were encapsulated, all showed the presence of mast cells range (6-26 by HPF) and eosinophils range (1-30 by HPF). Atypia was not present in any specimen, marked to moderate fibrosis was present in all ureters. There was no correlation between the histopathological and clinical findings in regard to volume and degree of reflux. No sign of nuclear atypia or high turnover was noted.

Conclusions: Dextranomer/hyaluronic acid is stable and safe after 5 to 39 months of follow up of intra/subureteral injection. No signs of nuclear atypia or high nuclear turn over were noted. There is no correlation between volume of implant used and degree of inflammation.

Presented at the: 20 th Saudi Urological Conference

King Fahad Hospital of the University - Tabuk

18-20 March 2008

Double blind prospective randomized study to explore the effectiveness of prophylactic preoperative tolterodine on the success rate of endoscopic treatment of primary vesicoureteric reflux

M. Salem, K. Fouda, H. Al Hazmi, A. Gomha

Department of Urology, King Khalid University Hospital, King Saud University, Department of Surgery, Division of Pediatric Urology, Riyadh, Saudi Arabia

Objective: To study whether the prophylactic use of Tolterodine for patients with primary vesicoureteric reflux (VUR) and stable bladder can enhance the success rate of endoscopic treatment (ET) of VUR.

Patients and Methods: All patients with primary VUR, in need of ET, were divided to two groups: those with element of bladder dysfunction (Dysfunctional Voiding Symptoms Score DVSS >6 in females and >9 in males) and those with "stable bladder". The "stable bladder" group were randomized at their clinic follow up visit to two subgroups: subgroup A who were not started on Tolterodine, and subgroup B who were started on a prophylactic dose of Tolterodine one week before the procedure, and continued for a month after that. In the group with bladder dysfunction, classical management of the bladder was given, and the procedure was done on an improved bladder. Group one and subgroup A and B were compared and statistically analyzed.

Results: 44 patients (18 males and 26 females) with mean age of 5.2 (range 3-10) with VUR were included in the study. In group one (15 patients, 8 with bilateral VUR) had symptoms of bladder dysfunction, 14 (60%) out of 23 refluxing ureters showed complete resolution. In group two, 29 patients were randomized. In subgroup A (15 patients), 18 (83%) out of 24 ureters showed resolution of VUR, and in the second subgroup B (14 patients), 17 (74%) out of 23 refluxing ureters showed complete resolution. The overall success rate was 70% in all groups with 70 refluxing renal units. No statistical difference was found between the 3 groups in success rate (P0.464), nor between the two main groups (P0.254) nor between subgroup A and B (P0.365) in the success rate.

Conclusion: We did not find a close correlation between voiding dysfunction and the success rate of ET of VUR with the use of a prophylactic dose of Tolterodine in patients with stable bladder. It did not enhance the success rate of ET. Thus we cannot conclude that the assumed subclinical voiding dysfunction can affect the outcome of ET of VUR.

Presented at the: 21 st Saudi Urological Conference

North West Armed Forces Hospital - Tabuk

14-16 April 2009


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