Endoscopic treatment with dextranomer/hyaluronic acid for complex cases of vesicoureteral reflux

Purpose: The surgical correction of primary vesicoureteral reflux (VUR) is highly successful. This success decreases in more complex cases and often involves reoperation and increased morbidity. We present our experience with the use of subureteral injection of dextranomer/hyaluronic acid (Dx/HA) in complex cases of vesicoureteral reflux in which open surgery would have been indicated. Materials and Methods: Between October 2001 and July 2003, 72 patients 9 months to 31 years old (mean age 5.6 years) underwent subureteral injection of Dx/HA for complex VUR at our institutions. Dx/HA was injected submucosally within the intramural ureter (modified STING) in most cases. A guidewire was used to manipulate the ureteral orifice and a retrograde ureterogram was used to delineate the anatomy in selected cases. The average volume of injected material was measured for each ureter. Renal sonography was performed to determine if hydronephrosis was present. At 3 months fluoroscopic voiding cystourethrograms were used to evaluate for the presence of VUR. Results: A total of 93 ureters were treated in 55 girls and 17 boys. All cases were considered to be complex as 17 had persistent reflux after open surgery (7 megaureters repairs, 2 extravesical repairs, 7 intravesical reimplants and 1 blind ureter), 11 had persistent reflux and neurogenic bladder, 7 had ectopic ureters to bladder neck, 6 had bilateral Hutch diverticulum, 6 had persistent stump reflux, 5 had ureterocele after puncture or incision, 15 had duplications, 1 had the prune belly syndrome, 2 had posterior urethral valve following resection, 1 had epispadias and 1 had urogenital sinus. The average maximum reflux grade was IV. An average of 1.1 cc (range 0.4 to 2) was injected per ureter. Of the patients 69 had 3-month followup results. The overall success rate was 68% after 1 implantation (47 of 69). Conclusions: Submucosal intraureteral implantation with Dx/HA corrected complex vesicoureteral reflux in 68% of patients. In all of these patients open surgery would have potentially been difficult. The use of fluoroscopy and/or guidewires is a useful adjunct in these cases. We believe that this minimally invasive approach is warranted as an initial step in the management of complex cases of VUR before resorting to more difficult open surgical procedures.