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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Veröffentlicht in:Journal of pediatric surgery 2025-03, Vol.60 (3), p.162157, Article 162157
Hauptverfasser: Tiboni, Sonia G., Bethell, George S., Davidson, Joseph R., Farrugia, Marie-Klaire
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creator Tiboni, Sonia G.
Bethell, George S.
Davidson, Joseph R.
Farrugia, Marie-Klaire
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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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 &lt; 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. 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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 &lt; 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 &lt; 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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