Endoscopic Treatment of Vesicoureteral Reflux with Autologous Chondrocytes: Postoperative Sonographic Features

The American Urological Association convened the Pediatric Vesicoureteral Reflux Guidelines Panel to analyze the literature regarding available methods for treating vesicoureteral reflux diagnosed following a urinary tract infection in children and to make practice policy recommendations based on the treatment outcomes data insofar as the data permit. The panel searched the MEDLINE data base for all articles from 1965 to 1994 on vesicoureteral reflux and systematically analyzed outcomes data for 7 treatment alternatives: 1) intermittent antibiotic therapy, 2) bladder training, 3) continuous antibiotic prophylaxis, 4) antibiotic prophylaxis and bladder training, 5) antibiotic prophylaxis, anticholinergics and bladder training, 6) open surgical repair and 7) endoscopic repair. Key outcomes identified were probability of reflux resolution, likelihood of developing pyelonephritis and scarring, and possibility of complications of medical and surgical treatment. Available outcomes data on the various treatment alternatives were summarized in tabular form and graphically, and the relative probabilities of possible outcomes were compared for each alternative. Treatment recommendations were based on scientific evidence and expert opinion. The panel concluded that only a few recommendations can be derived purely from scientific evidence of a beneficial effect on health outcomes. For most children the panel recommended continuous antibiotic prophylaxis as initial treatment. Surgery was recommended for children with persistent reflux and other indications, as specified in the document.

We investigated the safety and clinical effects of a new biocompatible, biodegradable treatment, the Deflux system (dextranomer microspheres in sodium hyaluronan solution), for the endoscopic treatment of grades III and IV vesicoureteral reflux. In preclinical safety studies in pigs histopathological examination demonstrated excellent tolerance. Two weeks after submucous implantation in the pig bladder early ingrowth of fibroblasts and recently generated collagen were noted at the implantation sites. At 14 weeks of followup this ingrowth had slightly increased. Long-term followup in rats showed that the volume of subcutaneous implants was slightly reduced (23%) 1 year after implantation. In a clinical study we investigated the implantation technique and the short (3 months) and long-term (1 year) effects of Deflux implantation in 75 children (101 ureters) with grades III and IV vesicoureteral reflux. We report data from up to 3 months of followup. Implant volumes of 0.4 to 1.0 ml. were sufficient to create distinct boluses and crescent-like ureteral orifices. Although viscous, due to its viscoelastic properties the substance was easy to inject in a well controlled manner. At cystography 3 months later reflux had resolved in 68% of implants, was reduced to grades I and II in 13% of implants and was unchanged in 19% of treated ureters (grades III and IV reflux). No signs of ureteral obstruction or adverse reactions were noted. Results from 1 year of followup will be reported later. Our results indicate that the dextranomer microspheres act as micro-carriers that promote ingrowth of fibroblasts and generate new collagen. We conclude that the Deflux system may represent a new, safe, simple alternative to endoscopic treatment of vesicoureteral reflux in children.

Thirteen girls with grade III-V vesicoureteric reflux were treated by endoscopic injection of Teflon paste behind the intravesical ureter. Fourteen of the 18 treated ureters showed complete absence of reflux after one injection of Teflon. Three ureters required a second injection of Teflon for successful treatment of the reflux. One ureter with grade IV reflux was converted to grade II reflux. Properly carried out, this procedure corrects reflux. It takes less than 15 minutes, may be done as a day procedure, and avoids open surgery. There have been no complications.