Advertisement

Current Urology Reports

, 20:49 | Cite as

Ureteral Obstruction After Endoscopic Treatment of Vesicoureteral Reflux: Does the Type of Injected Bulking Agent Matter?

  • Florian FriedmacherEmail author
  • Prem Puri
Pediatric Urology (D Weiss, Section Editor)
  • 8 Downloads
Part of the following topical collections:
  1. Topical Collection on Pediatric Urology

Abstract

Purpose of Review

Endoscopic injection of bulking agents for the treatment of vesicoureteral reflux (VUR) has become a therapeutic alternative to antibiotic prophylaxis and ureteral reimplantation. Although considered as a safe and efficient procedure, several studies have reported cases of ureteral obstruction (UO) after endoscopic correction of VUR. This review article evaluates the present VUR literature to estimate the incidence of UO following endoscopic injection of different substances, while also discussing the impact of injection technique and implant volume.

Recent Findings

Twenty-five publications were identified that provided detailed information on 64 females and 32 males (age range, 7 months–48 years) that developed UO after endoscopic treatment of VUR using dextranomer/hyaluronic acid (Dx/HA), polyacrylate polyalcohol (PP), polydimethylsiloxane (PDMS), calcium hydroxyapatite (CaHA), polytetrafluoroethylene (PTFE), or collagen. There was some variation in the reported incidence of UO among these materials: Dx/HA (0.5–6.1%), PP (1.1–1.6%), PDMS (2.5–10.0%), CaHA (1.0%), and PTFE (0.3%). Postoperative UO was described following subureteric transurethral injection (STING), intraureteric hydrodistension implantation technique (HIT), combined HIT/STING and double HIT. The injected volume ranged widely, also depending on the type of bulking agent: Dx/HA (0.3–3.0 mL), PP (0.3–1.2 mL), PDMS (1.0–2.2 mL), CaHA (0.4–0.6 mL), and PTFE (1.5–2.0 mL). The timing of UO varied from immediately after the procedure to 63 months. Over half of patients showed asymptomatic hydroureteronephrosis on follow-up imaging, whereas the remaining presented with symptoms of acute UO or fever.

Summary

UO remains a rare complication after endoscopic correction of VUR, generally reported in less than 1% of treated cases, which appears to be independent of the injected substance, volume, and technique. However, long-term follow-up is recommended as asymptomatic or delayed UO can occur, potentially leading to deterioration of renal function.

Keywords

Vesicoureteral reflux Ureter Endoscopy Ureteral obstruction Deflux Vantris 

Notes

Compliance with Ethical Standards

Conflict of Interest

Florian Friedmacher and Prem Puri each declare no potential conflicts of interest.

Human and Animal Rights and Informed Consent

This review article does not contain any studies with human participants or animals performed by the author.

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Williams G, Fletcher JT, Alexander SI, Craig JC. Vesicoureteral reflux. J Am Soc Nephrol. 2008;19:847–62.CrossRefGoogle Scholar
  2. 2.
    Sargent MA. What is the normal prevalence of vesicoureteral reflux? Pediatr Radiol. 2000;30:587–93.CrossRefGoogle Scholar
  3. 3.
    Diamond DA, Mattoo TK. Endoscopic treatment of primary vesicoureteral reflux. N Engl J Med. 2012;366:1218–26.CrossRefGoogle Scholar
  4. 4.
    Sung J, Skoog S. Surgical management of vesicoureteral reflux in children. Pediatr Nephrol. 2012;27:551–61.CrossRefGoogle Scholar
  5. 5.
    Cara-Fuentes G, Gupta N, Garin EH. The RIVUR study: a review of its findings. Pediatr Nephrol. 2015;30:703–6.CrossRefGoogle Scholar
  6. 6.
    Peters CA, Skoog SJ, Arant BS Jr, Copp HL, Elder JS, Hudson RG, et al. Summary of the AUA guideline on management of primary vesicoureteral reflux in children. J Urol. 2010;184:1134–44.CrossRefGoogle Scholar
  7. 7.
    Hayn MH, Smaldone MC, Ost MC, Docimo SG. Minimally invasive treatment of vesicoureteral reflux. Urol Clin North Am. 2008;35:477–88.CrossRefGoogle Scholar
  8. 8.
    Routh JC, Inman BA, Reinberg Y. Dextranomer/hyaluronic acid for pediatric vesicoureteral reflux: systematic review. Pediatrics. 2010;125:1010–9.CrossRefGoogle Scholar
  9. 9.
    Puri P, Kutasy B, Colhoun E, Hunziker M. Single center experience with endoscopic subureteral dextranomer/hyaluronic acid injection as first line treatment in 1,551 children with intermediate and high grade vesicoureteral reflux. J Urol. 2012;188:1485–9.CrossRefGoogle Scholar
  10. 10.
    Hsieh MH, Madden-Fuentes RJ, Lindsay NE, Roth DR. Treatment of pediatric vesicoureteral reflux using endoscopic injection of hyaluronic acid/dextranomer gel: intermediate-term experience by a single surgeon. Urology. 2010;76:199–203.CrossRefGoogle Scholar
  11. 11.
    Läckgren G, Wåhlin N, Sköldenberg E, Stenberg A. Long-term follow-up of children treated with dextranomer/hyaluronic acid copolymer for vesicoureteral reflux. J Urol. 2001;166:1887–92.CrossRefGoogle Scholar
  12. 12.
    Ormaechea M, Ruiz E, Denes E, Gimenez F, Dénes FT, Moldes J, et al. New tissue bulking agent (polyacrylate polyalcohol) for treating vesicoureteral reflux: preliminary results in children. J Urol. 2010;183:714–7.CrossRefGoogle Scholar
  13. 13.
    Vandersteen DR, Routh JC, Kirsch AJ, Scherz HC, Ritchey ML, Shapiro E, et al. Postoperative ureteral obstruction after subureteral injection of dextranomer/hyaluronic Acid copolymer. J Urol. 2006;176:1593–5.CrossRefGoogle Scholar
  14. 14.
    Kirlum HJ, Stehr M, Dietz HG. Late obstruction after subureteral collagen injection. Eur J Pediatr Surg. 2006;16:133–4.CrossRefGoogle Scholar
  15. 15.
    Mevorach RA, Hulbert WC, Rabinowitz R, Kennedy WA, Kogan BA, Kryger JV, et al. Results of a 2-year multicenter trial of endoscopic treatment of vesicoureteral reflux with synthetic calcium hydroxyapatite. J Urol. 2006;175:288–91.CrossRefGoogle Scholar
  16. 16.
    Al-Hunayan AA, Kehinde EO, Elsalam MA, Al-Mukhtar RS. Outcome of endoscopic treatment for vesicoureteral reflux in children using polydimethylsiloxane. J Urol. 2002;168:2181–3.CrossRefGoogle Scholar
  17. 17.
    Puri P, Granata C. Multicenter survey of endoscopic treatment of vesicoureteral reflux using polytetrafluoroethylene. J Urol. 1998;160:1007–11.CrossRefGoogle Scholar
  18. 18.
    Perović S, Smoljanic Ž, Šćepanović D, Vukadinović V. Ureteral obstruction caused by subureteral Teflon injection. Pediatr Surg Int. 1991;6:283–6.CrossRefGoogle Scholar
  19. 19.
    Snodgrass WT. Obstruction of a dysmorphic ureter following dextranomer/hyaluronic acid copolymer. J Urol. 2004;171:395–6.CrossRefGoogle Scholar
  20. 20.
    •• Papagiannopoulos D, Rosoklija I, Cheng E, Yerkes E. Delayed obstruction with asymptomatic loss of renal function after dextranomer/hyaluronic Acid copolymer (Deflux) injection for vesicoureteral reflux: a close look at a disturbing outcome. Urology. 2017;101:63–6 A series of 3 cases where Deflux was used in off-label fashion, resulting in delayed UO and loss of renal function.CrossRefGoogle Scholar
  21. 21.
    Rubenwolf PC, Ebert AK, Ruemmele P, Rösch WH. Delayed-onset ureteral obstruction after endoscopic dextranomer/hyaluronic acid copolymer (Deflux) injection for treatment of vesicoureteral reflux in children: a case series. Urology. 2013;81:659–62.CrossRefGoogle Scholar
  22. 22.
    Zemple RP, Potretzke AM, Kryger JV. Delayed onset ureteral obstruction following Deflux® injection for vesicoureteral reflux. J Pediatr Urol. 2012;8:e23–6.CrossRefGoogle Scholar
  23. 23.
    Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Open Med. 2009;3:e123–30.PubMedPubMedCentralGoogle Scholar
  24. 24.
    Serrano Durba A, Bonillo García MA, Moragues Estornell F, Domínguez Hinarejos C, Sanguesa C, Martínez Verduch M, et al. Vesicoureteric reflux endoscopic treatment complications in childhood. Actas Urol Esp. 2006;30:170–4.CrossRefGoogle Scholar
  25. 25.
    Alizadeh F, Mazdak H, Khorrami MH, Khalighinejad P, Shoureshi P. Postoperative ureteral obstruction after endoscopic treatment of vesicoureteral reflux with polyacrylate polyalcohol copolymer (Vantris®). J Pediatr Urol. 2013;9:488–92.CrossRefGoogle Scholar
  26. 26.
    García-Aparicio L, Rodo J, Palazon P, Martín O, Blázquez-Gómez E, Manzanares A, et al. Acute and delayed vesicoureteral obstruction after endoscopic treatment of primary vesicoureteral reflux with dextranomer/hyaluronic acid copolymer: why and how to manage. J Pediatr Urol. 2013;9:493–7.CrossRefGoogle Scholar
  27. 27.
    Alenezi H, Alhazmi H, Trbay M, Neel KF. Endoscopic correction of vesicoureteral reflux in children with a solitary kidney: the risk of obstruction. J Pediatr Urol. 2013;9:1166–9.CrossRefGoogle Scholar
  28. 28.
    Şencan A, Yıldırım H, Özkan KU, Uçan B, Karkıner A, Hoşgör M. Late ureteral obstruction after endoscopic treatment of vesicoureteral reflux with polyacrylate polyalcohol copolymer. Urology. 2014;84:1188–93.CrossRefGoogle Scholar
  29. 29.
    •• Ben-Meir D, Bahouth Z, Halachmi S. Late-onset Uretero-vesical Junction obstruction following endoscopic injection of bulking material for the treatment of vesico-ureteral reflux. Urology. 2017;101:60–2 A retrospective review of nine patients who developed late-onset UO following endoscopic treatment of VUR. The proposed mechanisms are gradual increase in ureterovesical junction resistance and ineffective peristalsis.CrossRefGoogle Scholar
  30. 30.
    • Okawada M, Murakami H, Tanaka N, Ogasawara Y, Lane GJ, Okazaki T, et al. Incidence of ureterovesical obstruction and Cohen antireflux surgery after Deflux® treatment for vesicoureteric reflux. J Pediatr Surg. 2018;53:310–2 A retrospective series of 339 patients with VUR who received endoscopic Deflux treatment. UO was detected in eight cases suggesting that this complication may be more frequent than previously reported.CrossRefGoogle Scholar
  31. 31.
    •• Chertin B, Mele E, Kocherov S, Zilber S, Gerocarni Nappo S, et al. What are the predictive factors leading to ureteral obstruction following endoscopic correction of VUR in the pediatric population? J Pediatr Urol. 2018;14:538.e1–7 A retrospective study of 2495 patients who underwent endoscopic correction of VUR. There were no differences in incidence of UO and histopathological changes between Deflux and Vantris.CrossRefGoogle Scholar
  32. 32.
    Seifert HH, Mazzola B, Zellweger T, Ruszat R, Muller A, Burkhalter F, et al. Ureteral obstruction after dextranomer/hyaluronic acid copolymer injection for treatment of secondary vesicoureteral reflux after renal transplantation. Urology. 2006;68:203.e17–9.Google Scholar
  33. 33.
    Onol FF, Tarcan T, Tinay I, Kotiloğlu E, Simşek F. Kidney loss due to periureteral fibrosis and ureteral obstruction secondary to migration of subureterically injected calcium hydroxylapatite. J Pediatr Urol. 2006;2:503–8.CrossRefGoogle Scholar
  34. 34.
    Zaccara A, Castagnetti M, Beniamin F, Rigamonti W. Late onset ureteric obstruction after endoscopic subureteric injection of calcium hydroxyapatite for primary vesicoureteric reflux. Urology. 2007;70:811.e1–3.CrossRefGoogle Scholar
  35. 35.
    Arlen AM, Pakalniskis BL, Cooper CS. Asymptomatic chronic partial obstruction of a normal ureter following dextranomer/hyaluronic acid copolymer (Deflux®) injection for grade I vesicoureteral reflux. J Pediatr Urol. 2012;8:e27–30.CrossRefGoogle Scholar
  36. 36.
    Abbo O, Bouali O, Beauval JB, Moscovici J, Galinier P. Distal and late ureteral obstruction: a rare complication following dextranomer/hyaluronic acid injection for vesicoureteral reflux in children. Prog Urol. 2012;22:192–4.CrossRefGoogle Scholar
  37. 37.
    Nseyo U, Mancini JG, Wiener JS. Symptomatic bilateral delayed partial ureteral obstruction after bilateral endoscopic correction of vesicoureteral reflux with dextranomer/hyaluronic acid polymer. Urology. 2013;81:184–7.CrossRefGoogle Scholar
  38. 38.
    Aaronson DS, Siddiqui SA, Reinberg Y, Baskin LS. Relative contraindication to endoscopic subureteral injection for vesicoureteral reflux: congenital refluxing megaureter with distal aperistaltic segment. Urology. 2008;71:616–9.CrossRefGoogle Scholar
  39. 39.
    Kempf C, Winkelmann B, Roigas J, Querfeld U, Müller D. Severe complications after endoscopic injection of polydimethylsiloxane for the treatment of vesicoureteral reflux in early childhood. Scand J Urol Nephrol. 2010;44:347–53.CrossRefGoogle Scholar
  40. 40.
    Mazzone L, Gobet R, González R, Zweifel N, Weber DM. Ureteral obstruction following injection of dextranomer/hyaluronic acid copolymer: an infrequent but relevant complication. J Pediatr Urol. 2012;8:514–9.CrossRefGoogle Scholar
  41. 41.
    Chung JM, Park CS, Lee SD. Postoperative ureteral obstruction after endoscopic treatment for vesicoureteral reflux. Korean J Urol. 2015;56:533–9.CrossRefGoogle Scholar
  42. 42.
    O’Donnell B, Puri P. Treatment of vesicoureteric reflux by endoscopic injection of Teflon. Br Med J. 1984;289:7–9.CrossRefGoogle Scholar
  43. 43.
    Kirsch AJ, Perez-Brayfield M, Smith EA, Scherz HC. The modified sting procedure to correct vesicoureteral reflux: improved results with submucosal implantation within the intramural ureter. J Urol. 2004;171:2413–6.CrossRefGoogle Scholar
  44. 44.
    Kirsch AJ, Arlen AM. Evaluation of new Deflux administration techniques: intraureteric HIT and Double HIT for the endoscopic correction of vesicoureteral reflux. Expert Rev Med Devices. 2014;11:439–46.CrossRefGoogle Scholar
  45. 45.
    Baybikov R, Sizonov V, Bondarenko S, Dolgov B, Dubrov V, Kagantsov I, et al. Do the type of bulking agents and injection method have any influence on the incidence of ureteral obstruction by endoscopic treatment of reflux? European Society for Paediatric Urology. 2015. https://www.espu.org/members/previous-events-abstracts. Accessed 20 Apr 2019.
  46. 46.
    Kirsch AJ, Perez-Brayfield MR, Scherz HC. Minimally invasive treatment of vesicoureteral reflux with endoscopic injection of dextranomer/hyaluronic acid copolymer: the Children’s Hospitals of Atlanta experience. J Urol. 2003;170:211–5.CrossRefGoogle Scholar
  47. 47.
    Sorensen MD, Koyle MA, Cowan CA, Zamilpa I, Shnorhavorian M, Lendvay TS. Injection volumes of dextranomer/hyaluronic acid are increasing in the endoscopic management of vesicoureteral reflux. Pediatr Surg Int. 2010;26:509–13.CrossRefGoogle Scholar
  48. 48.
    Routh JC, Ashley RA, Sebo TJ, Vandersteen DR, Slezak J, Reinberg Y. Histopathological changes associated with dextranomer/hyaluronic acid injection for pediatric vesicoureteral reflux. J Urol. 2007;178:1707–10.CrossRefGoogle Scholar
  49. 49.
    Stenberg A, Larsson E, Läckgren G. Endoscopic treatment with dextranomer-hyaluronic acid for vesicoureteral reflux: histological findings. J Urol. 2003;169:1109–13.CrossRefGoogle Scholar
  50. 50.
    Palagiri AV, Dangle PP. Distal ureteral calcification secondary to deflux injection: a reality or myth? Urology. 2011;77:1217–9.CrossRefGoogle Scholar
  51. 51.
    Noe HN. Calcification in a Deflux bleb thought to be a ureteral calculus in a child. J Pediatr Urol. 2008;4:88–9.CrossRefGoogle Scholar
  52. 52.
    • Friedmacher F, Colhoun E, Puri P. Endoscopic Injection of dextranomer/hyaluronic acid as first line treatment in 851 consecutive children with high grade vesicoureteral reflux: efficacy and long-term results. J Urol. 2018;200:650–5 A prospective study of 851 patients who underwent endoscopic correction of high-grade VUR with no cases of postoperative UO. CrossRefGoogle Scholar
  53. 53.
    Ben-Meir D, Morgenstern S, Sivan B, Efrat R, Livne PM. Histology proved malpositioning of dextranomer/hyaluronic acid in submucosal ureter in patients after failed endoscopic treatment of vesicoureteral reflux. J Urol. 2012;188:258–61.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.National Children’s Research CentreOur Lady’s Children’s HospitalDublinIreland
  2. 2.Department of Pediatric SurgeryThe Royal London HospitalLondonUK

Personalised recommendations