Howard M. Snyder, III, MD, is professor of surgery in urology, Children's Hospital of Philadelphia.
The treatment paradigm for vesicoureteral reflux has undergone a significant shift in recent years. Endoscopic surgery has provided an effective, minimally invasive option that is gradually eliminating the need for prolonged antibiotic use, monitoring with voiding cystourethrograms (VCUGs), and open surgery in children with most grades and forms of VUR.
While endoscopic treatment of intermediate grades of VUR is not new, its use has been limited by the lack of an effective bulking agent. That changed with the FDA approval of dextranomer/hyaluronic acid (Dx/HA [Deflux]) in 2001. This agent provides a stable implant to support the intramural ureter. It is relatively easy to inject and, unlike other bulking substances, is not associated with scarring or allergic reactions. Success rates with intermediate grades of VUR are 80% to 90% in experienced hands.
Since the advent of Dx/HA, pediatric urologists have learned a great deal about the endoscopic treatment of VUR.
Endoscopic treatment of grade V VUR also appears to be highly successful, as discussed in this issue of Urology Times (see, "First-line endoscopic Tx effective in severe VUR,"). After one injection, complete resolution of VUR was seen in 53% of treated ureters with the most severe form of VUR, and after two to three injections, VUR resolved in an additional 22% and 6%, respectively, giving a total resolution rate of 81%.
Second, endoscopic injection of Dx/HA is a technically demanding procedure with a learning curve that is longer than many pediatric urologists presumed. Thankfully, the maker of the substance has developed a well-designed needle that facilitates precise submucosal placement of injections.
A modified injection technique known as the hydrodistention-implantation technique has also contributed to our knowledge of proper needle placement and has led to a significant improvement in cure rates (J Urol 2004; 171:2413-6). In the hydrodistention technique, pioneered by Andrew Kirsch, MD, pressurized irrigation is directed into the ureter during hydrodistention, causing the ureteral orifice to open pre-treatment and allowing for a clear view of the course of the ureter and, thus, where the implant should be placed.
Third, there is a rationale for more than one treatment with Dx/HA, as 20% to 25% of the substance is absorbed as it becomes encapsulated. The initial implant may not coalesce in exactly the position that the surgeon intended. Also, an initial injection may open up the dissection plane, allowing for a substantial further improvement after the first injection. The fact that a second procedure is needed should not be construed as an indication that the first one was poorly performed.
In summary, the launch of an effective bulking substance and improved injection techniques have raised the bar for endoscopic management of VUR. The morbidity associated with VUR management has also been lowered appreciably, providing more evidence that the minimally invasive revolution in medicine has made its mark on pediatric urology.