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Endoscopic treatment of Vesico-ureteric reflux in Children

Endoscopic treatment of Vesico-ureteric reflux in Children. Dr. Beatrice Wong. Paediatric Surgical Centre Kowloon Central & East Cluster Hospital Authority, Hong Kong SAR. Vesico-ureteric reflux (VUR). Flap-valve mechanism at UVJ

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Endoscopic treatment of Vesico-ureteric reflux in Children

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  1. Endoscopic treatment of Vesico-ureteric reflux in Children Dr. Beatrice Wong Paediatric Surgical Centre Kowloon Central & East Cluster Hospital Authority, Hong Kong SAR

  2. Vesico-ureteric reflux (VUR) • Flap-valve mechanism at UVJ • Retrograde flow of urine from the bladder back up the ureters • Primary Vs Secondary

  3. Primary VUR • 1% of children in normal population • M: F= 1:5 • 30-50% of children with UTI • Major cause of end stage renal failure in children and young adults • Siblings of children with VUR have a much higher incidence of VUR

  4. The International Reflux Classification B C A A: Grade I reflux B: Grade II reflux C: Grade III reflux D: Grade IV reflux E: Grade V reflux. D E

  5. Complications of VUR • Recurrent UTI with pyelonephritis  Renal scars  Atrophic kidneys  Hypertension  Renal insufficiency  Renal failure

  6. Acute Renal Damage after First UTI • 57 neonates (8 weeks) (114 kidneys) VCUG findings Normal DMSA Focal scars VUR 20 19 No VUR 50 25 Total 70 (61%) 44 (39%) Cascio S, Puri P, Kelleher J. et al, Pediatr Nephrol 17: 503-505, 2002

  7. Acute renal damage in male infants with high grade VUR after First UTI • 141 male infants (3 w – 1 yr) (1984-2000) • 236 refluxing ureters • Renal parenchymal damage in 44% • 204male infants (1984-2003) • 343 refluxing ureters • Renal parenchymal damage in 39%Italkid ProjectMarra et al, J Pediatr 144:677-81, May 2004 Cascio S, Puri P, J Urol 168: 1708-1710, 2002

  8. Management • Two principles: • Determine primary Vs secondary VUR • Prevent UTIs • Treat the underlying causes • Medical/ Surgical + Surveillance

  9. TreatmentofPrimary VUR • General measures • Perineal hygiene • Adequate hydration/ Treat constipation • Bladder training • Drug therapy • Continuous antibiotic prophylaxis • Intermittent antibiotic therapy for breakthrough UTI • Anticholinergics (oxybutynin) • Open ureteric reimplantation • ENDOSCOPIC TREATMENT

  10. Analysis of Observationtherapyin high grade VUR Persistence of VUR at 5 years Development of new renal scars • Birmingham Reflux study51%5% • Toronto Sick Children 60% 8% • International Reflux Study (IRSC) 91% (bilateral) 12% 61% (unilateral) 7%

  11. OBSERVATION THERAPY (at 5 years) 90% Grade I 80% Grade II 60% Grade III 45% Grade IV unilateral 9.9% Grade IV bilateral SURGICAL THERAPY(n=8061 ureters) 99% Grade I 99.1% Grade II 98.3% Grade III 98.5% Grade IV 80.7% Grade V Reflux resolution(AUA, 1997)

  12. Obstruction rate after ureteric reimplantation requiring reoperationAUA, 1997(33 studies) 0.3 to 9.1%

  13. Endoscopic treatment of Vesico-ureteric reflux STING March 1984 P. Puri, B. O’ Donnell

  14. Endoscopic treatment of Vesico-ureteric reflux

  15. Technique of STING

  16. Endoscopic treatment of VURusing PTFE: multicenter survey1984-1996 • 53 paediatric urologist & paediatric surgeons at 41 centres worldwide • 8332 patients (1921 boys, 6411 girls) • Mean age 4.5 years (ranging 3m-14 years) • Follow-up 1-13years • 12251 refluxing ureters Claudio and Puri, J Urol 1998; 160: 1007-1011

  17. Endoscopic treatment of VURusing PTFE: Multicenter survey • Grade I 407 (3.3%) • Grade II 3832 (31.2%) • Grade III 5213 (42.5%) • Grade IV 2218 (18.1%) • Grade V 581 (4.7%) • USG& VCUG at 3 m, 1, 3 years

  18. Endoscopic treatment of VUR INITIAL RESULTS IN 12251 URETERS

  19. Endoscopic treatment of VUR LONG-TERM RESULTS IN 11510ureters • >90% ureters followed up for > 2 years • 182 (1.7%) endoscopically corrected refluxing ureters lost FU or refused VCUG • Resolution of VUR 11184 (95.6%) • Recurrence of VUR 326 (2.8%) • Ureteric obstruction requiring reop 41 (0.33%) • No clinically untoward effects in all patients

  20. Tissue-augmenting substances • Teflon (Polytetrafluroethylene,PTFE) • Migration to CNS, lungs VUR recurrence • Potential granuloma formation • Bovine cross-linked collagen • Polydimethysiloxane • Deflux (Dextranomer in sodium hylauronan) • Introduced in 1995 • Approved by FDA • Introduced into HK in 2003

  21. DEFLUX® • Dextranomer microspheres 80 to 250 µm in 1% sodium hyaluronic acid solution • Biodegradable, non-immunogenic properties, no potential for malignant transformation

  22. Endoscopic Treatment of VUR using Deflux® (2001-2004)(n=396) • 273 girls & 123 boys • Median age 2.1 yrs (Ranged 3 m to 13.6 yrs) • Bilateral(n=228); Unilateral (n=168) • 41 (6.6 %) duplex systems • 624 refluxing ureters (Grade II-IV) P Puri et al, J Urol. Oct 2003; 170: 1541-4

  23. Follow Up • Outpatient procedure • Voiding cystourethrography at 3 months • Renal and bladder ultrasound at 3 months and annually • Median follow-up: 24 months ( range 6 months – 42 months)

  24. Endoscopic treatment of Grade II-V VUR using Deflux624 URETERS

  25. 3.5 YEAR FOLLOW UPn=396 • 10 patients presented with UTI • No evidence of VUR on VCUG • USG: no evidence of delayed VUJ obstruction or any change in the sonographic appearance of Deflux® implant

  26. Deflux implantation for VUR: randomized comparison with antibiotic prophylaxis • Grade II-IV • Deflux group (n=40) Vs Observation therapy (n=21) • VUR resolution at 1 year • Deflux® group 69% • Observation therapy 38% • No adverse events in either group • Parenchymal damage • Deflux group 1 patient Vs observation group3 patients Capozza and Caione. J Pediatrics 140:230;2002

  27. Treatment of VUR: a new algorithm based on Parental preference • Parents questioned (n=100) • 80 % preferred endoscopic treatment • 5 % antibiotic prophylaxis • 2 % open surgery • 13 % undecided Capozza et al BJU Inter 92(3): 285-8, 2003

  28. Our early experience • Deflux® employed in 7 patients with Grade III-IV VUR (2003-2004) • 5 unilateral; 2 bilateral • Mean follow-up: 8 months • Complete resolution after single injection in all • Prospective randomised control study on Deflux® injection Vs antibiotic prophylaxis

  29. Conclusion • Endoscopic subureteric injection of tissue-augmenting substances has become an established alternative to long-term antibiotic prophylaxis and open surgery in the management of VUR in children • Deflux® seems to be a promising agent but long-term results are awaited

  30. THANK YOU

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