Factors Influencing Success in Endoscopic Treatment of Grade 4-5 Primary Vesicoureteric Reflux (VUR) in Infancy and Childhood
There is equipoise among pediatric urologists regarding endoscopic versus surgical intervention for symptomatic Grade 4-5 Vesicoureteric Reflux (VUR), particularly in infancy. Our aim was to assess outcomes of first-line endoscopic treatment in all cases of symptomatic Grade 4-5 VUR and we hypothesi...
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description | There is equipoise among pediatric urologists regarding endoscopic versus surgical intervention for symptomatic Grade 4-5 Vesicoureteric Reflux (VUR), particularly in infancy. Our aim was to assess outcomes of first-line endoscopic treatment in all cases of symptomatic Grade 4-5 VUR and we hypothesised that using endoscopic Dx/HA as first line management for primary VUR would obviate the need for ureteric reimplantation in the majority of cases.
Retrospective single-surgeon analysis of consecutive patients with primary Grade 4-5 VUR over 15 years. Indication for intervention was breakthrough UTI on prophylaxis. Endoscopic dextranomer/hyaluronic acid co-polymer (Dx/HA; Deflux®) injection was first-line procedure. Primary outcomes were both post-procedure febrile culture positive urinary tract infection (UTI) and VUR recurrence on post-operative VCUG requiring further surgical intervention. We postulated that risk factors influencing outcome are: age under 1 year, female gender, postnatal versus antenatal presentation, duplex anatomy, circumcision status and presence of congenital uptake defects on DMSA. Data analysed using Fisher's Exact Test/Multivariate Analysis.
77 patients with Grade 4-5 VUR were identified, of whom 49 (11 bilateral) underwent a Dx/HA injection at median 12 (3-84) months. Median follow-up post-injection was 32 (2–145) months. There were no reported complications or ureteral obstruction. Sixteen (33 %) patients suffered a febrile UTI at follow-up; on further investigation, half (8/16) of these were found to have recurrent VUR. Therefore 67 % were symptom free and 84 % did not require further intervention after one injection (41/49), and 98 % after further injections (48/49). Duplex systems had a similar outcome of 80 % not requiring further intervention. On multivariate analysis, males were found to have a significantly better outcome than females (p |
doi_str_mv | 10.1016/j.jpedsurg.2025.162157 |
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Retrospective single-surgeon analysis of consecutive patients with primary Grade 4-5 VUR over 15 years. Indication for intervention was breakthrough UTI on prophylaxis. Endoscopic dextranomer/hyaluronic acid co-polymer (Dx/HA; Deflux®) injection was first-line procedure. Primary outcomes were both post-procedure febrile culture positive urinary tract infection (UTI) and VUR recurrence on post-operative VCUG requiring further surgical intervention. We postulated that risk factors influencing outcome are: age under 1 year, female gender, postnatal versus antenatal presentation, duplex anatomy, circumcision status and presence of congenital uptake defects on DMSA. Data analysed using Fisher's Exact Test/Multivariate Analysis.
77 patients with Grade 4-5 VUR were identified, of whom 49 (11 bilateral) underwent a Dx/HA injection at median 12 (3-84) months. Median follow-up post-injection was 32 (2–145) months. There were no reported complications or ureteral obstruction. Sixteen (33 %) patients suffered a febrile UTI at follow-up; on further investigation, half (8/16) of these were found to have recurrent VUR. Therefore 67 % were symptom free and 84 % did not require further intervention after one injection (41/49), and 98 % after further injections (48/49). Duplex systems had a similar outcome of 80 % not requiring further intervention. On multivariate analysis, males were found to have a significantly better outcome than females (p < 0.015) irrespective of circumcision status. Forty-one percent of the children in our cohort had uptake defects on DMSA prior to intervention, but this did not have any difference on outcome.
Endoscopic Dx/HA injection is a safe first-line, day-case treatment for Grade 4-5 VUR in children of any age, with a low complication rate. Two-thirds of patients are asymptomatic after one injection; 84 % do not require further procedures after one injection, and 98 % after 2 injections.</description><identifier>ISSN: 0022-3468</identifier><identifier>ISSN: 1531-5037</identifier><identifier>EISSN: 1531-5037</identifier><identifier>DOI: 10.1016/j.jpedsurg.2025.162157</identifier><identifier>PMID: 39823695</identifier><language>eng</language><publisher>United States: Elsevier Inc</publisher><subject>Deflux injection ; Dextranomer hyaluronic acid ; Endoscopic injection ; Endoscopic treatment ; Hydrodistension ; Renal scarring ; Subureteric injection ; Urinary tract infection ; Vesicoureteral reflux ; Vesicoureteric reflux ; VUR children</subject><ispartof>Journal of pediatric surgery, 2025-03, Vol.60 (3), p.162157, Article 162157</ispartof><rights>2025 Elsevier Inc.</rights><rights>Copyright © 2025 Elsevier Inc. All rights reserved.</rights><lds50>peer_reviewed</lds50><woscitedreferencessubscribed>false</woscitedreferencessubscribed><cites>FETCH-LOGICAL-c1605-605ed5338686d58c4e133c3c4e15bd38b8ef57fa0358a94b11c0e091d788d3b73</cites><orcidid>0000-0003-1900-8611 ; 0000-0002-7046-9731 ; 0000-0002-1302-0735</orcidid></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktohtml>$$Uhttps://www.sciencedirect.com/science/article/pii/S0022346825000028$$EHTML$$P50$$Gelsevier$$H</linktohtml><link.rule.ids>314,776,780,3537,27901,27902,65306</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/39823695$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Tiboni, Sonia G.</creatorcontrib><creatorcontrib>Bethell, George S.</creatorcontrib><creatorcontrib>Davidson, Joseph R.</creatorcontrib><creatorcontrib>Farrugia, Marie-Klaire</creatorcontrib><title>Factors Influencing Success in Endoscopic Treatment of Grade 4-5 Primary Vesicoureteric Reflux (VUR) in Infancy and Childhood</title><title>Journal of pediatric surgery</title><addtitle>J Pediatr Surg</addtitle><description>There is equipoise among pediatric urologists regarding endoscopic versus surgical intervention for symptomatic Grade 4-5 Vesicoureteric Reflux (VUR), particularly in infancy. Our aim was to assess outcomes of first-line endoscopic treatment in all cases of symptomatic Grade 4-5 VUR and we hypothesised that using endoscopic Dx/HA as first line management for primary VUR would obviate the need for ureteric reimplantation in the majority of cases.
Retrospective single-surgeon analysis of consecutive patients with primary Grade 4-5 VUR over 15 years. Indication for intervention was breakthrough UTI on prophylaxis. Endoscopic dextranomer/hyaluronic acid co-polymer (Dx/HA; Deflux®) injection was first-line procedure. Primary outcomes were both post-procedure febrile culture positive urinary tract infection (UTI) and VUR recurrence on post-operative VCUG requiring further surgical intervention. We postulated that risk factors influencing outcome are: age under 1 year, female gender, postnatal versus antenatal presentation, duplex anatomy, circumcision status and presence of congenital uptake defects on DMSA. Data analysed using Fisher's Exact Test/Multivariate Analysis.
77 patients with Grade 4-5 VUR were identified, of whom 49 (11 bilateral) underwent a Dx/HA injection at median 12 (3-84) months. Median follow-up post-injection was 32 (2–145) months. There were no reported complications or ureteral obstruction. Sixteen (33 %) patients suffered a febrile UTI at follow-up; on further investigation, half (8/16) of these were found to have recurrent VUR. Therefore 67 % were symptom free and 84 % did not require further intervention after one injection (41/49), and 98 % after further injections (48/49). Duplex systems had a similar outcome of 80 % not requiring further intervention. On multivariate analysis, males were found to have a significantly better outcome than females (p < 0.015) irrespective of circumcision status. Forty-one percent of the children in our cohort had uptake defects on DMSA prior to intervention, but this did not have any difference on outcome.
Endoscopic Dx/HA injection is a safe first-line, day-case treatment for Grade 4-5 VUR in children of any age, with a low complication rate. Two-thirds of patients are asymptomatic after one injection; 84 % do not require further procedures after one injection, and 98 % after 2 injections.</description><subject>Deflux injection</subject><subject>Dextranomer hyaluronic acid</subject><subject>Endoscopic injection</subject><subject>Endoscopic treatment</subject><subject>Hydrodistension</subject><subject>Renal scarring</subject><subject>Subureteric injection</subject><subject>Urinary tract infection</subject><subject>Vesicoureteral reflux</subject><subject>Vesicoureteric reflux</subject><subject>VUR children</subject><issn>0022-3468</issn><issn>1531-5037</issn><issn>1531-5037</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2025</creationdate><recordtype>article</recordtype><recordid>eNqFkE9L7DAUxYMoOm_0K0iWuui8pJmk6U4ZRp8gKP7bhjS51QydZExa0YXf3QxVt29xuXA59xzOD6FjSmaUUPF3NVttwKYhPs9KUvIZFSXl1Q6aUM5owQmrdtGEkLIs2FzIA_QnpRUh-UzoPjpgtSyZqPkEfV5o04eY8JVvuwG8cf4Z3w_GQErYebz0NiQTNs7ghwi6X4PvcWjxZdQW8Lzg-Da6tY4f-AmSM2GI0EPM6jvIfu_45Onx7nRrlP21Nx9Ye4sXL66zLyHYQ7TX6i7B0feeoseL5cPiX3F9c3m1OL8uDBWEF3nAcsakkMJyaeZAGTNsu3ljmWwktLxqNWFc6nreUGoIkJraSkrLmopN0cnou4nhdYDUq7VLBrpOewhDUoxyUYta5owpEqPUxJBShFZtxoKKErVFr1bqB73aolcj-vx4_J0xNGuwv28_rLPgbBRAbvrmIKpkXCYO1kUwvbLB_S_jC8XXmCY</recordid><startdate>202503</startdate><enddate>202503</enddate><creator>Tiboni, Sonia G.</creator><creator>Bethell, George S.</creator><creator>Davidson, Joseph R.</creator><creator>Farrugia, Marie-Klaire</creator><general>Elsevier Inc</general><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>7X8</scope><orcidid>https://orcid.org/0000-0003-1900-8611</orcidid><orcidid>https://orcid.org/0000-0002-7046-9731</orcidid><orcidid>https://orcid.org/0000-0002-1302-0735</orcidid></search><sort><creationdate>202503</creationdate><title>Factors Influencing Success in Endoscopic Treatment of Grade 4-5 Primary Vesicoureteric Reflux (VUR) in Infancy and Childhood</title><author>Tiboni, Sonia G. ; Bethell, George S. ; Davidson, Joseph R. ; Farrugia, Marie-Klaire</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c1605-605ed5338686d58c4e133c3c4e15bd38b8ef57fa0358a94b11c0e091d788d3b73</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2025</creationdate><topic>Deflux injection</topic><topic>Dextranomer hyaluronic acid</topic><topic>Endoscopic injection</topic><topic>Endoscopic treatment</topic><topic>Hydrodistension</topic><topic>Renal scarring</topic><topic>Subureteric injection</topic><topic>Urinary tract infection</topic><topic>Vesicoureteral reflux</topic><topic>Vesicoureteric reflux</topic><topic>VUR children</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Tiboni, Sonia G.</creatorcontrib><creatorcontrib>Bethell, George S.</creatorcontrib><creatorcontrib>Davidson, Joseph R.</creatorcontrib><creatorcontrib>Farrugia, Marie-Klaire</creatorcontrib><collection>PubMed</collection><collection>CrossRef</collection><collection>MEDLINE - Academic</collection><jtitle>Journal of pediatric surgery</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Tiboni, Sonia G.</au><au>Bethell, George S.</au><au>Davidson, Joseph R.</au><au>Farrugia, Marie-Klaire</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Factors Influencing Success in Endoscopic Treatment of Grade 4-5 Primary Vesicoureteric Reflux (VUR) in Infancy and Childhood</atitle><jtitle>Journal of pediatric surgery</jtitle><addtitle>J Pediatr Surg</addtitle><date>2025-03</date><risdate>2025</risdate><volume>60</volume><issue>3</issue><spage>162157</spage><pages>162157-</pages><artnum>162157</artnum><issn>0022-3468</issn><issn>1531-5037</issn><eissn>1531-5037</eissn><abstract>There is equipoise among pediatric urologists regarding endoscopic versus surgical intervention for symptomatic Grade 4-5 Vesicoureteric Reflux (VUR), particularly in infancy. Our aim was to assess outcomes of first-line endoscopic treatment in all cases of symptomatic Grade 4-5 VUR and we hypothesised that using endoscopic Dx/HA as first line management for primary VUR would obviate the need for ureteric reimplantation in the majority of cases.
Retrospective single-surgeon analysis of consecutive patients with primary Grade 4-5 VUR over 15 years. Indication for intervention was breakthrough UTI on prophylaxis. Endoscopic dextranomer/hyaluronic acid co-polymer (Dx/HA; Deflux®) injection was first-line procedure. Primary outcomes were both post-procedure febrile culture positive urinary tract infection (UTI) and VUR recurrence on post-operative VCUG requiring further surgical intervention. We postulated that risk factors influencing outcome are: age under 1 year, female gender, postnatal versus antenatal presentation, duplex anatomy, circumcision status and presence of congenital uptake defects on DMSA. Data analysed using Fisher's Exact Test/Multivariate Analysis.
77 patients with Grade 4-5 VUR were identified, of whom 49 (11 bilateral) underwent a Dx/HA injection at median 12 (3-84) months. Median follow-up post-injection was 32 (2–145) months. There were no reported complications or ureteral obstruction. Sixteen (33 %) patients suffered a febrile UTI at follow-up; on further investigation, half (8/16) of these were found to have recurrent VUR. Therefore 67 % were symptom free and 84 % did not require further intervention after one injection (41/49), and 98 % after further injections (48/49). Duplex systems had a similar outcome of 80 % not requiring further intervention. On multivariate analysis, males were found to have a significantly better outcome than females (p < 0.015) irrespective of circumcision status. Forty-one percent of the children in our cohort had uptake defects on DMSA prior to intervention, but this did not have any difference on outcome.
Endoscopic Dx/HA injection is a safe first-line, day-case treatment for Grade 4-5 VUR in children of any age, with a low complication rate. Two-thirds of patients are asymptomatic after one injection; 84 % do not require further procedures after one injection, and 98 % after 2 injections.</abstract><cop>United States</cop><pub>Elsevier Inc</pub><pmid>39823695</pmid><doi>10.1016/j.jpedsurg.2025.162157</doi><orcidid>https://orcid.org/0000-0003-1900-8611</orcidid><orcidid>https://orcid.org/0000-0002-7046-9731</orcidid><orcidid>https://orcid.org/0000-0002-1302-0735</orcidid></addata></record> |
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subjects | Deflux injection Dextranomer hyaluronic acid Endoscopic injection Endoscopic treatment Hydrodistension Renal scarring Subureteric injection Urinary tract infection Vesicoureteral reflux Vesicoureteric reflux VUR children |
title | Factors Influencing Success in Endoscopic Treatment of Grade 4-5 Primary Vesicoureteric Reflux (VUR) in Infancy and Childhood |
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