Efficacy of dextranomer hyaluronic acid and polyacrylamide hydrogel in endoscopic treatment of vesicoureteral reflux: A comparative study

Abstract

Introduction: Various bulking agents are available for vesicoureteral reflux (VUR) endoscopic treatment, but their inconsistent success rates and costs are concerns for urologists. Recently, polyacrylamide hydrogel (PAHG) has been shown to have a good overall success rate, which seems comparable to dextranomer hyaluronic acid (Dx/HA), currently the most popular bulking agent. Our objective was to compare the short-term success rate of PAHG and Dx/ HA for VUR endoscopic treatment in children. Methods: We performed a prospective non-randomized study using PAHG and Dx/HA to treat VUR grades I to IV in pediatric patients. All patients underwent endoscopic sub-ureteric injection of PAHG or Dx/HA, using the double-HIT technique, followed by a 3-month postoperative renal ultrasound and voiding cystourethrogram. Treatment success was defined as the absence of de novo or worsening hydronephrosis and absence of VUR. Results: A total of 90 pediatric patients underwent an endoscopic injection: 45 patients (78 ureters) with PAHG and 45 patients (71 ureters) with Dx/HA. The mean injected volume of PAHG and Dx/ HA was 1.1 mL and 1.0 mL, respectively. The overall success rate 3 months after a single treatment was 73.1% for PAHG and 77.5% for Dx/HA. Postoperatively, 1 patient in each group presented with acute pyelonephritis and 2 patients in the Dx/HA group developed symptomatic ureteral obstruction. Conclusion: Success rates of PAGH and Dx/HA in endoscopic injections for VUR treatment were comparable. The rate of resolution obtained with Dx/HA was equivalent to those previously published. The lower cost of PAHG makes it an interesting option.

Vesicoureteral reflux: From prophylaxis to surgery

“…Finally, only few published series are available on PAHG. [32][33][34] The success rate with this bulking agent appears promising, but more trials are needed prior to extensive use.…”

Proprietary non-animal stabilized hyaluronic acid/dextranomer gel (NASHA/Dx) for endoscopic treatment of grade IV vesicoureteral reflux: Long-term observational study

“…Our study predated development of the hydrodistention implantation technique (HIT) and 'double HIT'. These techniques have been reported superior to STING [36,37], although there has been some variability in their success rates in grade IV VUR [16,38,39]. Cross-study comparisons should always be interpreted with caution e apparent differences in response could be related to variations between the study populations, assessment methods or duration of follow-up, aside from the injection technique and physician experience.…”

Management of Vesicoureteral Reflux: What Have We Learned Over the Last 20 Years?

“…Polyacrylate-polyalcohol copolymer has been associated with risks of periureteral fibrosis (potentially complicating subsequent ureteral reimplantation) and obstruction of the vesicoureteral junction (116,121). Comparative studies suggest that polyacrylatepolyalcohol copolymer, polyacrylamide hydrogel and small-size dextranomer/hyaluronic acid copolymer are at least as effective as NASHA/Dx in resolving VUR (106,(121)(122)(123)(124). Only one of these studies was a prospective, randomized trial; the results showed comparable efficacy with NASHA/Dx and polyacrylatepolyalcohol copolymer (121).…”

“…Only one of these studies was a prospective, randomized trial; the results showed comparable efficacy with NASHA/Dx and polyacrylatepolyalcohol copolymer (121). The only other prospective study (non-randomized) also reported similarity between the two agents being compared (NASHA/Dx and polyacrylamide hydrogel) (123). The remaining comparisons of recently developed materials vs. NASHA/Dx were retrospective, limiting the robustness of the results.…”

“…Intra-operative costs were highest with endoscopic injection, but the total cost (intra-operative plus post-operative hospitalization costs) was highest with the Cohen procedure (€8201), and similar with endoscopic treatment and laparoscopic reimplantation (€3283 and €3211, respectively). Observations regarding lower product costs with polyacrylamide hydrogel and small-size dextranomer/hyaluronic acid copolymer vs. NASHA/Dx have been made in some publications ( 88 , 123 , 129 ). Simple comparisons of product costs do not provide a complete pharmacoeconomic picture: formal studies that include the total long-term costs of patient management (influenced by long-term safety and efficacy of the treatments concerned) are needed for true pharmacoeconomic comparisons.…”