INTRODUCTION
Primary vesicoureteral reflux (VUR) is the most common urological anomaly in children and has been reported in 30 to 50% of those who present with urinary tract infection (UTI). The association of VUR, UTI and renal parenchymal damage is well known. Reflux nephropathy is the cause of endstage renal failure in 3–25% of children and 10–15% of adults. There has been no consensus regarding when medical or surgical therapy should be used. A num- ber of prospective studies have shown low probabil- ity of spontaneous resolution of high grade of reflux during conservative follow-up. Furthermore, all of these studies revealed that observation therapy does carry an ongoing risk of renal scarring. Open surgery is the standard treatment for VUR when indicated.
Although ureteral reimplantation is effective, this op- eration is not free of complications.
Since its introduction endoscopic correction of VUR has become an established alternative to long- term antibiotic prophylaxis and open surgical treat- ment. Recently, we published our data regarding
long-term effectiveness of endoscopic STING (sub- ureteral injection of polytetrafluoroethylene) for VUR in 258 patients, and its success was confirmed in our 17-year follow-up. Our study as well as long-term studies from others have not shown any clinical untoward effects with the use of polytetrafluoroethy- lene for the treatment of vesicoureteral reflux.
Recently, a number of other tissue augmenting substances have been used endoscopically for sub- ureteral injection. Dextranomer microspheres in so- dium hyaluronic acid solution (Deflux) is a recently developed organic substance comprising 80 to 250 µm microspheres. It has been reported that dex- tranomer/hyaluronic acid copolymer is biodegrad- able, has no immunogenic properties and has no po- tential for malignant transformation. Dextranomer microspheres in sodium hyaluronic acid solution consist of microspheres of dextranomers mixed in a 1% high molecular weight sodium hyaluronan solu- tion. Each millilitre of the system contains 0.5 ml so- dium hyaluronan and 0.5 ml microspheres.
Prem Puri
Figure 47.2
The disposable Puri catheter for injection (Storz) is a 4-Fr nylon catheter onto which is swaged a 21-gauge needle with 1 cm of the needle protruding from the
catheter. Alternatively, a rigid needle can be used. A 1-
ml syringe filled with Deflux paste is attached to the
injection catheter.
Typ I Typ II Typ III Typ IV Typ V
Figure 47.2
Figure 47.4a–c
For the subureteric injection technique the patient should be placed in a lithotomy position. The cysto- scope is passed and the bladder wall, the trigone, bladder neck and both ureteric orifices inspected. The bladder should be almost empty before proceeding with injection, since this helps to keep the ureteric or- ifice flat rather than away in a lateral part of the field.
The injection of Deflux paste or any other tissue augmenting substance should not begin until the op- erator has a clear view all around the ureteric orifice.
Under direct vision through the cystoscope the nee- dle is introduced under the bladder mucosa 2–3 mm below the affected ureteric orifice at the 6 o’clock po- sition. In children with grade IV and V reflux with wide ureteral orifices, the needle should be inserted not below but directly into the affected ureteral ori- fice. It is important to introduce the needle with pin- point accuracy. Perforation of the mucosa or the ure- ter may allow the paste to escape and may result in failure.
The needle is advanced about 4–5 mm into the lamina propria in the submucosal portion of the ure- ter and the injection started slowly. As the paste is in-
jected a bulge appears in the floor of the submucosal ureter. During injection the needle is slowly with- drawn until a “volcanic” bulge of paste is seen. The needle should be kept in position for 30–60 s after in- jection to avoid extrusion. Most refluxing ureters re- quire 0.3–0.6 ml Deflux to correct reflux.
A correctly placed injection creates the appear- ance of a nipple on the top of which is a slit-like or in- verted crescentic orifice. If the bulge appears in an incorrect place, e.g., at the side of the ureter or proxi- mal to it, the needle should not be withdrawn, but should be moved so that the point is in a more fa- vourable position. The non-injected ureteric roof re- tains its compliance while preventing reflux.
Post-operative urethral catheterization is not nec-
essary. The majority of patients are treated as day
cases. Co-trimoxazole is prescribed in prophylactic
doses for 3 months after the procedure. Micturation
cystography and renal ultrasonography are per-
formed 3 months after discharge. A follow-up mictu-
rating cystogram and renal and bladder ultrasono-
graphic scan are obtained 12 months after endoscop-
ic correction of reflux.
Figure 47.4a–c
a b c
Chertin B, DeCaluwe D, Puri P (2003) Endoscopic treatment of primary grades IV and V vesicourteral reflux in children with subureteral injection of polytetrafluoroethylene. J Urol 169 : 1847–1849
Puri P (2000) Endoscopic correction of vesicoureteral reflux.
Curr Opin Urol 10 : 593–597
Puri P (2001) Endoscopic treatment of vesicoureteral reflux.
In: Gearhart JP, Rink RC, Mouriquand PDE (eds) Pediatric urology. WB Saunders Philadelphia, pp 411–422
Puri P, Chertin B, Velayudham M et al (2003) Treatment of ves- icoureteral reflux by endoscopic injection of dextrano- mer/hyaluronic acid copolymer: preliminary results J Urol 170 : 1541–1544
