Endoscopic treatment of vesicoureteric reflux with dextranomer/hyaluronic acid copolymer (Deflux): Single-surgeon experience with 48 ureters

Abstract

Purpose:VUR is a common urologic problem in children. Cystoscopic injection of bulking agents (most commonly Deflux) has gained popularity as the first line treatment in the west. However, primarily due to cost factors, it has not gained much popularity in our country. We present our initial experience with cystoscopic Deflux injection for VUR.Materials and Methods:We reviewed our 3-yr experience with the use of Dx/HA (Deflux) for correction of VUR in children and adolescents. All children were evaluated with Ultrasound, MCUG and DMSA renal cortical scan. The indications for surgical correction of VUR included breakthrough infections while on antibiotic prophylaxis, persistent high-grade VUR beyond 3 yrs of age, and presence of significant renal damage on DMSA at diagnosis (in those children presenting with UTI). All children underwent cystoscopic Deflux injection using the standard technique of subureteral injection (0.4-1 ml per ureter). All children received antibiotic prophylaxis for 3-6 months after the injection. USG was done at 1 month and MCUG at 3-6 months after the injection.Results:33 patients (48 ureters) underwent cystoscopic Deflux injection for correction of VUR. Mean age was 4.5 yrs (1-17 yrs); there were 12 boys and 21 girls. Thirteen children had antenatally diagnosed HDN, while 20 children presented with febrile UTI. All children had primary VUR except one child with persistent VUR 4 yrs after PUV fulguration. The VUR was grade 1-2 in 8, grade 3-4 in 37, and grade 5 in 3 ureters. Every child had at least one ureter with dilating reflux (grades 3,4 or 5). When present, low grade VUR (grade 1or 2) was always on the contralateral side. Only one child received a 2nd injection after 6 months. Follow-up MCUG was done in 28 children (41 ureters). Complete reflux resolution was achieved in 27 ureters (65%), and the reflux was downgraded in 2 (5%). There were no complications of Deflux injection.Conclusions:Endoscopic correction of VUR in children is a safe and effective minimally invasive treatment for VUR. It stops or downgrades VUR in 70% of ureters. At present, we recommend it as a first-line treatment for grades 1-4 VUR requiring surgical management. Cost is the major factor limiting its use in our country.

The treatment of vesicoureteral reflux in children by endoscopic sub-mucosal intra-ureteral injection of dextranomer/hyaluronic acid: A case-series, multi-centre study

“…Since the introduction of bulking agents for endoscopic correction of VUR, the spectrum of management of such urological anomaly has been broadened and the technique has become the first-line treatment adopted by most institutions all over the world ( 14 ). Several materials have been tried and evaluated as bulking agents during the last three decades.…”

“…It is dextranomer microspheres in hyaluronic acid solution. Dx\HA is biodegradable, non-carcinogenic and non-immunogenic ( 14 ). The objective and rationale behind this study was to determine the effectiveness of endoscopic sub-ureteral dextranomer/hyaluronic acid copolymer, via the modified STING procedure for management of patients with VUR, in term of success rate.…”

Efficiency of endoscopic treatment compared to open surgical management of the vesicoureteral reflux

“…Over the last few decades, endoscopic subureteric injection with bulking agents has gained popularity in the treatment of VUR. Many authors have recommended endoscopic treatment (ET) as the first line of treatment (10)(11)(12)(13)(14)(15).…”

Long-Term Results of Dexell Endoscopic Treatment of Vesicoureteral Reflux: An Option for the Management of Recurrent Urinary Tract Infection

“…Recently, American urology association (8) guidelines stated that patients over 1 year of age who received CAP and developed febrile breakthrough UTI should be considered for open surgical ureteral reimplantation or endoscopic injection of bulking agents (8). Many authors recommended endoscopic treatment (ET) as the first line of treatment (9)(10)(11)(12)(13)(14)(15). Dexell is a new product, which is biochemically similar to Deflux but with different molecular size.…”