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Re: Postoperative Ureteral Obstruction after Endoscopic Treatment of Vesicoureteral Reflux with Polyacrylate Polyalcohol Copolymer (Vantris®)
1408
PEDIATRIC UROLOGY
I had been in the habit of discharging boys and girls following endocopic correction of reflux if the postoperative ultrasound was normal. I may need to modify this approach. The convenience of the endoscopic approach may be less attractive if long-term surveillance for possible obstruction becomes necessary. Douglas A. Canning, MD
Re: Long-Term Incidence of Urinary Tract Infection after Ureteral Reimplantation for Primary Vesicoureteral Reflux C. P. Nelson, K. C. Hubert, P. J. Kokorowski, L. Huang, M. M. Prasad, I. Rosoklija and A. B. Retik Department of Urology, Children’s Hospital Boston, Boston, Massachusetts J Pediatr Urol 2013; 9: 92e98.
Abstract available at http://jurology.com/ Editorial Comment: The authors studied 1,076 children who underwent ureteral reimplantation for primary vesicoureteral reflux (VUR) to identify the risk of pyelonephritis after ureteral reimplantation. Four preoperative variables predicted a statistically increased incidence of postoperative pyelonephritis, namely VUR grade III or higher, female gender, breakthrough urinary tract infection and renal scarring. Postoperative infection was rare. Pyelonephritis-free existence ranged from 99.6% for males with grade I to II reflux to 72.3% for females with dilating VUR. The International Reflux Study in Children suggested that antireflux surgery helps decrease the incidence of febrile urinary tract infection.1,2 This more recent review reassures us that pyelonephritis is vanishingly rare following antireflux surgery. Douglas A. Canning, MD 1. Jodal U, Koskimies O, Hanson E et al: Infection pattern in children with vesicoureteral reflux randomly allocated to operation or long-term antibacterial prophylaxis. The International Reflux Study in Children. J Urol 1992; 148: 1650. 2. Jodal U, Smellie JM, Lax H et al: Ten-year results of randomized treatment of children with severe vesicoureteral reflux. Final report of the International Reflux Study in Children. Pediatr Nephrol 2006; 21: 785.
Re: Postoperative Ureteral Obstruction after Endoscopic Treatment of Vesicoureteral Reflux with Polyacrylate Polyalcohol Copolymer (VantrisÒ) F. Alizadeh, H. Mazdak, M. H. Khorrami, P. Khalighinejad and P. Shoureshi Isfahan Urology and Kidney Transplantation Research Center, Isfahan University of Medical Sciences, Al-Zahra Hospital, Isfahan, Iran J Pediatr Urol 2013; 9: 488e492.
Abstract available at http://jurology.com/ Editorial Comment: The authors observed 8 children with obstruction, 4 early and 4 late, following injection of polyacrylate polyalcohol copolymer for vesicoureteral reflux (VUR). Of the 4 patients with early obstruction 2 had right flank pain only a few hours after the injection. These cases resolved almost immediately with no residual evidence of hydronephrosis by postoperative day 1. Two additional patients had renal colic 2 to 3 days postoperatively. Of these patients hydroureteronephrosis resolved after 3 months in 1. Although pelviureterectatsis was persistent in the other, furosemide renography showed a T1/2 of less than 10 minutes and no further treatment was required. Of the children with late onset obstruction 3 (4 ureters) had onset of ureterovesical obstruction 1 month or later following surgery. One of these children had high volume bilateral VUR preoperatively. She manifested bilateral dilatation 1 month postoperatively and a febrile urinary tract
PEDIATRIC UROLOGY
1409
infection 1 month later. She required open bilateral ureteral reimplantation. The second patient, a 7-year-old boy, had bilateral grade III reflux and no voiding dysfunction. His ureters developed fullness 10 months after injection. One side was managed by a ureteral stent, and on the other side the implant was incised and irrigated away. The stent was left indwelling for 6 weeks and subsequently removed with only mild residual hydronephrosis. Mild renal fullness developed in the third patient, which persisted. I believe most parents will opt for the more traditional open or laparoscopic ureteral reimplant when faced with the risk, however small, of future ureteral obstruction following endoscopic injection for VUR. Douglas A. Canning, MD
Re: Delayed-Onset Ureteral Obstruction after Endoscopic Dextranomer/Hyaluronic Acid Copolymer (Deflux) Injection for Treatment of Vesicoureteral Reflux in Children: A Case Series € sch P. C. Rubenwolf, A. K. Ebert, P. Ruemmele and W. H. Ro Department of Pediatric Urology, Clinic St. Hedwig, University Medical Centre Regensburg, Regensburg, Germany Urology 2013; 81: 659e662.
Abstract available at http://jurology.com/ Editorial Comment: These authors report on 4 additional patients with upper urinary tract obstruction identified at 1, 7, 28 and 63 months after dextranomer/hyaluronic acid copolymer injection for vesicoureteral reflux. Histopathological evaluation of ureteral segments revealed extensive foreign body formation in all cases. These cases, added to the 2 preceding reports, lend credence to the concern that delayed obstruction is not as uncommon as we thought following dextranomer/hyaluronic acid copolymer injection and suggest that additional followup beyond the immediate postoperative period is important. Douglas A. Canning, MD
Re: Endoscopic Correction of VUR Using Vantris as a New Non-Biodegradable Tissue Augmenting Substance: Three Years of Prospective Follow-up B. Chertin, W. A. Arafeh, A. Zeldin, I. A. Ostrovsky and S. Kocherov Department of Pediatric Urology, Hebrew University, Jerusalem, Israel Urology 2013; 82: 201e204.
Abstract available at http://jurology.com/ Editorial Comment: The authors present information on another product for endoscopic correction of vesicoureteral reflux. VantrisÒ is a polyacrylate polyalcohol bulking copolymer. The results of this study, nearly 93% success after a single injection with low injection volumes (mean 0.7 ml, range 0.2 to 1.1), suggest that a relatively small volume of this implant can be used with good success. Unfortunately the recent reports documenting the threat of early and late obstruction with Vantris and dextranomer/hyaluronic acid copolymer may temper our enthusiasm for this substance as well as for others as time goes on. Douglas A. Canning, MD
PEDIATRIC UROLOGY
I had been in the habit of discharging boys and girls following endocopic correction of reflux if the postoperative ultrasound was normal. I may need to modify this approach. The convenience of the endoscopic approach may be less attractive if long-term surveillance for possible obstruction becomes necessary. Douglas A. Canning, MD
Re: Long-Term Incidence of Urinary Tract Infection after Ureteral Reimplantation for Primary Vesicoureteral Reflux C. P. Nelson, K. C. Hubert, P. J. Kokorowski, L. Huang, M. M. Prasad, I. Rosoklija and A. B. Retik Department of Urology, Children’s Hospital Boston, Boston, Massachusetts J Pediatr Urol 2013; 9: 92e98.
Abstract available at http://jurology.com/ Editorial Comment: The authors studied 1,076 children who underwent ureteral reimplantation for primary vesicoureteral reflux (VUR) to identify the risk of pyelonephritis after ureteral reimplantation. Four preoperative variables predicted a statistically increased incidence of postoperative pyelonephritis, namely VUR grade III or higher, female gender, breakthrough urinary tract infection and renal scarring. Postoperative infection was rare. Pyelonephritis-free existence ranged from 99.6% for males with grade I to II reflux to 72.3% for females with dilating VUR. The International Reflux Study in Children suggested that antireflux surgery helps decrease the incidence of febrile urinary tract infection.1,2 This more recent review reassures us that pyelonephritis is vanishingly rare following antireflux surgery. Douglas A. Canning, MD 1. Jodal U, Koskimies O, Hanson E et al: Infection pattern in children with vesicoureteral reflux randomly allocated to operation or long-term antibacterial prophylaxis. The International Reflux Study in Children. J Urol 1992; 148: 1650. 2. Jodal U, Smellie JM, Lax H et al: Ten-year results of randomized treatment of children with severe vesicoureteral reflux. Final report of the International Reflux Study in Children. Pediatr Nephrol 2006; 21: 785.
Re: Postoperative Ureteral Obstruction after Endoscopic Treatment of Vesicoureteral Reflux with Polyacrylate Polyalcohol Copolymer (VantrisÒ) F. Alizadeh, H. Mazdak, M. H. Khorrami, P. Khalighinejad and P. Shoureshi Isfahan Urology and Kidney Transplantation Research Center, Isfahan University of Medical Sciences, Al-Zahra Hospital, Isfahan, Iran J Pediatr Urol 2013; 9: 488e492.
Abstract available at http://jurology.com/ Editorial Comment: The authors observed 8 children with obstruction, 4 early and 4 late, following injection of polyacrylate polyalcohol copolymer for vesicoureteral reflux (VUR). Of the 4 patients with early obstruction 2 had right flank pain only a few hours after the injection. These cases resolved almost immediately with no residual evidence of hydronephrosis by postoperative day 1. Two additional patients had renal colic 2 to 3 days postoperatively. Of these patients hydroureteronephrosis resolved after 3 months in 1. Although pelviureterectatsis was persistent in the other, furosemide renography showed a T1/2 of less than 10 minutes and no further treatment was required. Of the children with late onset obstruction 3 (4 ureters) had onset of ureterovesical obstruction 1 month or later following surgery. One of these children had high volume bilateral VUR preoperatively. She manifested bilateral dilatation 1 month postoperatively and a febrile urinary tract
PEDIATRIC UROLOGY
1409
infection 1 month later. She required open bilateral ureteral reimplantation. The second patient, a 7-year-old boy, had bilateral grade III reflux and no voiding dysfunction. His ureters developed fullness 10 months after injection. One side was managed by a ureteral stent, and on the other side the implant was incised and irrigated away. The stent was left indwelling for 6 weeks and subsequently removed with only mild residual hydronephrosis. Mild renal fullness developed in the third patient, which persisted. I believe most parents will opt for the more traditional open or laparoscopic ureteral reimplant when faced with the risk, however small, of future ureteral obstruction following endoscopic injection for VUR. Douglas A. Canning, MD
Re: Delayed-Onset Ureteral Obstruction after Endoscopic Dextranomer/Hyaluronic Acid Copolymer (Deflux) Injection for Treatment of Vesicoureteral Reflux in Children: A Case Series € sch P. C. Rubenwolf, A. K. Ebert, P. Ruemmele and W. H. Ro Department of Pediatric Urology, Clinic St. Hedwig, University Medical Centre Regensburg, Regensburg, Germany Urology 2013; 81: 659e662.
Abstract available at http://jurology.com/ Editorial Comment: These authors report on 4 additional patients with upper urinary tract obstruction identified at 1, 7, 28 and 63 months after dextranomer/hyaluronic acid copolymer injection for vesicoureteral reflux. Histopathological evaluation of ureteral segments revealed extensive foreign body formation in all cases. These cases, added to the 2 preceding reports, lend credence to the concern that delayed obstruction is not as uncommon as we thought following dextranomer/hyaluronic acid copolymer injection and suggest that additional followup beyond the immediate postoperative period is important. Douglas A. Canning, MD
Re: Endoscopic Correction of VUR Using Vantris as a New Non-Biodegradable Tissue Augmenting Substance: Three Years of Prospective Follow-up B. Chertin, W. A. Arafeh, A. Zeldin, I. A. Ostrovsky and S. Kocherov Department of Pediatric Urology, Hebrew University, Jerusalem, Israel Urology 2013; 82: 201e204.
Abstract available at http://jurology.com/ Editorial Comment: The authors present information on another product for endoscopic correction of vesicoureteral reflux. VantrisÒ is a polyacrylate polyalcohol bulking copolymer. The results of this study, nearly 93% success after a single injection with low injection volumes (mean 0.7 ml, range 0.2 to 1.1), suggest that a relatively small volume of this implant can be used with good success. Unfortunately the recent reports documenting the threat of early and late obstruction with Vantris and dextranomer/hyaluronic acid copolymer may temper our enthusiasm for this substance as well as for others as time goes on. Douglas A. Canning, MD