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Evaluation of results in distant terms after endoscopic treatment of vesicoureteral reflux

V.N. Lisovoj, I.A. Turenko, A.N. Dubinina
Kharkiv National Medical University
Kharkiv Regional Clinical Center of Urology and Nephrology named after V.I. Shapoval
The article concerns the problems of optimization treatment of vesicoureteral reflex in children. With the help of endoscopic treatment, that was performed using endourological system of "Storz" company by means of submucous periurethral implantation of hydrophilic gel. In distant terms after endoscopic treatment of vesicoureteral reflux using proposed method we reached summary positive effectiveness of first and second operations in 95 % cases.
Key words: vesicoureteral reflux, endoscopic treatment, peri-urethral implantation, children.

Vesicoureteral reflux (VUR) is one of the most common diseases of lower urinary tract in children. Term VUR reflects pathogenetic process of retrograde urine flow from bladder to upper urinary tracts due to disturbances in valvular mechanism in vesicoureteral segment [1, 2] Prinicipal reasons for function disturbance in vesicoureteral segment are various abnormalities of lower ureter development: short intra-mural department, development abnormalities in infra-vesical zone and bladder muscle wall, and bladder function neurogenic disturbances [3]. At that retrograde urine flow leads to increase in intra-ureter and intra-pelvical pressure, inhibition of urethra and pelvis contractual activity, and vesicoureteral reflux [4]. In 25–40 % of cases VUR causes start and relapsing course of pyelonephritis, which in future in 60–70 % cases may lead to renal structure and function disturbances, reflux nephropathy development with local or generalized scars in kidney parenchyma, chronic renal insufficiency (23 %) and arterial hypertension (10–20 %) [1, 3]. Pyelonephritis against VUR background is especially severe in new-borns and in small babies, where it is often accompanied by stomach function disturbances, febrile temperature, "meningism" manifestations. Older children exhibit stable pyuria [5]. Till present in VUR treatment there was no alternative to open surgery. Notwithstanding development of large number of surgery procedures all they do not exclude disease relapse risk, and apart from that have several significant drawbacks – during their application possible are traumatization, prolonged rehabilitative period, various complications [6]. Cardinal progress in VUR treatment in children was achieved after introduction of subtrigonal endoscopic correction (injection), proposed by E. Matoushek (1981). At that, as various fixators to be injected under urethra orifice the following substances were used at various technology development stages: Teflon paste, silicon, hyaluronic acid preparations. The majority of these substances appeared dangerous due to various complications possibility: preparation vascular migration, urethra stenosis in injection zone, immune reactions [4, 7]. Now "golden standard" in implantation materials to be  used for VUR endoscopic treatment is polymeric hydrogels group that is actually inert by its proper characteristics, which leads to low risk of undesirable effects and immune reactions. This method advantage is little invasiveness, short rehabilitation period and high efficiency, which by various authors data reaches 95% - at that up to 85% of patients are cured from VUR after first operation [8, 9]. However, until now there are absent universal criteria and objective methodical algorithm, which allows clear surgeon orientation for any individual VUR correction method, which would be the preferable among many analogs for each concrete patient. All this is the ground for further problem studying. Materials and methods. From the moment of implementation into practice of endoscopic VUR correction technology in Pediatric Department of Kharkiv Oblast Clinical Center of Urology and Nephrology (2006) such operation was completed in 46 children aged from 1.5 to 17 years (from 1 to 2 years – 31 patients, from 2 to 5 years – 12, from 5 to 17 – 3 patients), including 28 patients with unilateral VUR of І – ІV st., 15 –- with bilateral VUR of І–ІІІ st., 3 patients with congenital abnormality in upper urinary tract, – duplication of kidneys. Method essence was restoration of disturbed urethra anti-reflux function by injection under its orifice of inert polymer – Nubiplant hydrogel [10, 11]. Operation was completed using "Storz" endourological system (diam. Ch11–13), Germany, and special catheter needle (Fig. 1).

 

Fig. 1. Method of gel injection under urethra orifice

 

Polymer was injected in volume of 1.5–2.0 ml, at distance 4–5 mm lower urethra orifice, in avascular zone, on 5, 6 or 7 m endoscopic watches, till its complete closure.

At that superior wall of formed submucosal prominence, which serves as fixed basis for urethra, lying closely to lower wall secures valvular anti-reflux function of vesiculoureteral segment. Bladder drainage was completed with urethral catether Foley during 24 hours. In 1-2 days after manipulation control ultrasound of kidneys and bladder was completed (Fig. 2). Patients were discharged from hospital on day 2-3. Control cystography was completed after 6 months [12, 13].

 

Fig. 2. Bladder ultrasound in 2 days after bilateral vesicoureteral reflux correction. "Prominence" in projections of left and right urethra orifices (а) and on the right after vesicoureteral reflux correction (6)

 

Results. To complete valuation of results in distant terms after endoscopic treatment of vesicoureteral reflux we examined control group of 40 patients. 34 patients (85 %) showed a complete recovery after single endoscopic gel injection. Among them 24 patients had VUR of І–ІV st. (Fig. 3), 9 – bilateral VUR of І–ІІІ sy. (Fig. 4), and one patient – urinary system development abnormality (duplication of kidneys). Only 10 % patients demanded repeated VUR endoscopic corrective injection for stable positive effect. In 95 % cases we registered complete clinical recovery. Reflux persistence after repeated endoscopic treatment was noted in 5 % (2 patients).

 

Fig. 3. Cystogram of girl-patient M., 5 years old. VUR of ІV st. (а), control cystogram 6 months after VUR endoscopic correction (б)

 

Fig. 4. Cystogram of boy-patient N., 17 years old. Bilateral VUR of ІІІ st. (а), control cystogram 6 months after VUR endoscopic correction (б)

Special interest should be given to treatment results in patients with IV st. of VUR. In recent past such a diagnosis was a direct indication to open surgery, which was not a complete cure-all. After patients treatment, which included four patients with VUR of IV st., we registered healing in one patient – after single correction; in two patients – after repeated endoscopic treatment, which allowed presuming procedure efficiency even in severe urinary system disturbances. This fact is encouraging, but it demands further profound studies.

Conclusion

High refluxes incidence amount urological pathologies, open anti-reflux surgeries shortcomings allow regarding endoscopic technologies as relatively safe choice that is able to improve treatment results in vesiculoureteral reflux and patients life quality. Practical implementation in our Pediatric Department of Regional Clinical Center of Urology and Nephrology of endoscopic correction demonstrated this medical technology high effectiveness in urethral segment restoration and vesiculoureteral reflux liquidation that objectively decreased need for open surgeries.

 

Literature
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VALUATION OF RESULTS IN DISTANT TERMS AFTER ENDOSCOPIC TREATMENT OF VESICOURETERAL REFLUX
V.N. Lisovoj, I.A. Turenko, A.N. Dubinina
The article concerns the problems of optimization treatment of vesicoureteral reflex in children. With the help of endoscopic treatment, that was performed using endourological system of "Storz" company by means of submucous periurethral implantation of hydrophilic gel. In distant terms after endoscopic treatment of vesicoureteral reflux using proposed method we reached summary positive effectiveness of first and second operations in 95 % cases.






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