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December 1993, Volume 43, Issue 12

Original Article

Endoscopic Correction of Vesicoureteric Reflux in Children

Khalid Rasheed  ( Department of Surgery, The Aga Khan University Hospital, Karachi. )

Abstract

Vesicoureteric reflux (VUR) Is a common cause of recurrent urinary tract infections in children. Mild reflux (grade I-II) Is usually managed conservatively with antiblotici but severe degree of reflux (grades ill, IV, V) requires surgical intervention. We present our initial experience with endoscopic correction of vesicoureteric reflux by sub-ureteric teflon injection (STING) In ten patients. Results are available for 15 ureters with a success rate of 86.6%. There was no change in the grade of VUR in two ureters. There were no complications. Endoscopic correction of vesico-ureteric reflux by sub-ureteric teflon injection is effective and simple with no pain to the child. It averts the need for open operations (JPMA 43:255, 1993).

Introduction

Urinary tract infection (TJTI) is a common proffiem in children and one third to half the cases are due to vesicoureteric reflux. Vesicoureteric reflux in an undi­lated system is likely to disappear over the years and is managed by continuous low dose chemoprophylaxis until disappearance is documented. Severe vesicoureteric reflux is unlikely to disappear and general­ly require surgical intervention. Several open anti-reflux reimplantation operations are performed with good results. Now in the era of minimal invasiveness, endo­scopic correction of vesicoureteric reflux with sub­uretéric teflon injection (STING) is replacing open surgical procedures in many centres. This study reports our initial experience with this technique.

Patients and Methods

STING (sub-ureteric teflon injection) was per­formed under general anaesthesia at cystoscopy after identifying the refluxing ureteric orifice in 10 children. Pun’s catheter (Storz), 4F or 5F with 21G needle at the end, introduced through a 11F cystoscope, was placed in the submucosa below the affected ureteric orifice. Teflon paste, taken in 1 ml syringe with a metal sheath and piston (Stroz) was injected. It fornis a nipple on top ofwhich the ureteric orifice appears as a crescent. During voiding the ureteric orifice maintains its compliance and stops refluxing2. Vesicoureteric reflux was graded according to the international classification pf reflux (Figure 1):

grade I ureter only; grade II ureter, pelvis and calices, no dilatation, normal caliceal fornices; grade III mild or moderate dilatation or tortuosity of ureter and mild or moderate dilatations of renal pelvis but slight or no blunting of fornices; grade IV moderate dilatation or tortuosity of ureter and moderate dilatation of renal pelvis and calices, complete obliteration of sharp angle of fornices but maintenance of papillary impressions in most calices; grade V gross dilatation and tortuosity of ureter, gross dilatation of renal pelvis and calices and papillary impressions no longer visible in most calices5. All patients were admitted on the day of the procedure, some were discharged on the same day and a few stayed over night in the hospital. All patients were kept on prophylactic dose of antibiotic. Follow-up included monthly urine cultures, ultrasound examina­tions and a voiding cystourethrogram 3 months after the STING procedure. Post-sting ultrasound examinations were performed to rule out any increasing bydronephrosis due to obstruction at the ureteric orifice.

Results

During the last one year 10 patients had STING for vesicoureteric reflux. There were 4 males and6 females. Mean age was 4.1 years (range 3 to 10 years).

Table I shows the arading ofvesicoureteric reflux. Seven patients (6 females, 1 male) had primary reflux while three had secondary vcotcoureteric reflux (2 secondary to posterior urethral valves, 1 secondary to re- implanta­tion). Eight patients had bilateral VUR and two had unilateral reflux so there were a total of 18 refluxing ureters. Two patients with bilateral and another with unilateral vesicoureteric refiux are awaiting their post-STING voiding cystourethrogram, so results are available on fifteen ureters (Table II).

Reflux of urine stopped in 6 ureters after STING (Figure 2 a, b),

confirmed by YCUG. There was improvement of reflux to grade I in five and grade II in two ureters. These 7 ureters with improved grades of VUR are unlikely to require any further surgery. There has been a success rate of 86.6%. There were no immediate post-operative complications. In the short follow up of 6 to 9 months there has been no incidence of obstruction. Patients with no change in reflux will require another STING.

Discussion

Lower grades of VUR are managed with conserva­tive antibiotics treatment but higher grade usually re­quire surgery. Open operations with reimplantation of ureters using different techniques are available. These require prolonged hospital stays and a lot of post-opera­tive pain to the patients. Endoscopic correction of vesicoureteric reflux with STING is an alternative way to manage the problem with less pain and scars to the child. Indications for STING remains the same as those for open operations for reimplantation of ureters. Teflon paste is a suspension of biologically inert polytetrafluorethylene particles in glycerin. Glycerin is absorbed after the injection and teflon implant achieves firm consistency and retains its shape, encapsulated by thin fibrous tissue2. Teflon is being used in the medical field for a long time for augmentation of the vocal cords, hip implants and periurethral tissue. There is no evidence to date to suggest that use of teflon is associated with any morbidity in humans and no clinical complications suggestive of distant migration have been reported6,7. The main mechanism of incompetent vesico­ureteric orifice is believed to be presence of short intramural tunnel and absence of adequate support for the intravesical ureter8. In a normal ureter, intramural portion has longitudinal muscle fibres only. These fibres continue downwards beyond the ureteric orifice into the trigone, fanning out and giving a firm attachmene9. Congenital deficiency or absence of the longitudinal muscle of the intramural ureter, as found in primary reflux, results in upward or lateral displacement of the orifice, thereby reducing the length and obliquity of the intramural ureter. Subureteric teflon implant produce a solid support behind the intravesical ureter and provides a firm anchorage, thus preventingit from sliding upwards or laterally during voiding and stops the reflux. STING stops the reflux or improves the grade of reflux and can be performed more than once to com­pletely cure the reflux. In two ureters of our series there was no change in the grade of reflux. In these patients procedure can be repeated7. The presence of teflon implant does not affect the reimplantation surgery if required10. Very few recurrences of reflux after STING procedure have been reported in the long term fol­lowup7,10. We intend to follow our patients with ultrasound examinations and DTPA/DMSA renal isotope scans. We have presented our unitial results with short follow-up. The technique requires precision. Endoscopic correction of vesicoureteric reflux by STING is simple and effective. It is well tolerated, prevents open operation, can be performed as day surgery and can be offered to all children with vesicoureteric reflux.

References

1. Hodaon, C.J. and Cotran, R.S. tteflux nepbropathy. Hosp. Pract., 1982;17:133-56.
2. Purl, P. and O\\\'Donnell, B. Correction of experimentally produced vealcoureteric reflux in the piglet byintravesical injection of teflon. Br.Med.J., 1984;289:5-7.
3. O’Donnell, B. and Purl, P. Treatmentofveaicouretericreflux byendoacopicinjeccion of teflon. Br.Med.J., 1984;289:7-9.
4. Reportof the International RefluxStudyCommittee. Mediralverausaurgical treatment ofprimaryveaicoureteral reflux. Paediatrics, 1961;67:392-400.
5. Dewan, P. Ia injected polytetrafluoroetheylene (polytef) carcinogenic? Br.J.Urol., 1992;69:29-33.
6. Puri, P. Endoacopic correction of primacy vesicoureteric reflux by aubureteric teflon injection (S’TING): followup atudyin 123 patients. Paediatr. Sur& Int., 1991;6:269-72.
7. Stephens, F.D. and Lenaghan, D. The anatomical basis and dynamics ofveaicoureteral reflux. J.Urol., 196287:669-80.
8. Lyon, R.P., Marshall, & and Tanagho, RH. The ureteral orifice: its configuration and competency. J.UroL, 1969;102:504-9.
10. Frey, P. and Whitalcar, RH. Prevention ofveaicouretericrefluxbyendoacopicinjection. Br.J.Urol., 1992;69:1-6.

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