Transplantation/Vascular Surgery
Endoscopic Treatment of Symptomatic Vesicoureteral Reflux after Renal Transplantation ronique Delaporte, Charlotte Maurin, Akram Akiki,* Romain Boissier, Ve Sarah Gaillet, Gilles Karsenty, Christian Coulange and Eric Lechevallier From the Department of Urology and Kidney Transplantation, La Conception University Hospital, Marseille, France
Purpose: We evaluated the success of endoscopic treatment of symptomatic vesicoureteral reflux after renal transplantation and identified factors predicting success. Materials and Methods: Endoscopy was performed for symptomatic vesicoureteral reflux after renal transplantation in 38 women and 20 men between January 2000 and December 2010. Reflux was documented by retrograde cystography and its symptomatic character was determined by at least 1 episode of acute graft pyelonephritis. The results of endoscopic treatment were evaluated clinically at 1 and 3 months, and annually, and by cystography at 3 months. Clinical success was defined as absent acute graft pyelonephritis during followup. Radiological success was defined as absent reflux on followup cystography at 3 months. Results: Endoscopic treatment was clinically successful in 32 patients (56.1%), including 26 (65%) who received dextranomer-hyaluronic acid and 5 (33.3%) who received polydimethylsiloxane. Treatment was radiologically successful in 14 patients (26.4%) at a mean SD followup of 38 33 months. On multivariate analysis male gender and dextranomer-hyaluronic acid were factors predictive of clinical success. Reflux grade did not predict success or failure. No high grade complication was reported. Conclusions: Endoscopic treatment of symptomatic vesicoureteral reflux of a transplanted kidney was effective in half of the cases regardless of the bulking agent used. However, dextranomer-hyaluronic acid appeared to be more effective than polydimethylsiloxane. Due to its minimally invasive nature and low morbidity endoscopic treatment with dextranomer-hyaluronic acid could be proposed as preoperative first line treatment for symptomatic vesicoureteral reflux of a transplanted kidney regardless of reflux grade.
Abbreviation and Acronyms AGPN ¼ acute graft pyelonephritis DX-HA ¼ dextranomer-hyaluronic acid US ¼ ultrasound VCUG ¼ voiding cystourethrogram VUR ¼ vesicoureteral reflux Accepted for publication July 23, 2014. * Correspondence: Urology and Kidney Transplantation, La Conception University Hospital, AixMarseille University, 147, Bd. Baille, Marseille, Bouches-du-Rh^one 13385, France (telephone: 0033491435173; FAX: 0033491435176).
Key Words: kidney transplantation, vesico-ureteral reflux, baysilon, dextranomer-hyaluronic acid copolymer, endoscopy
VESICOURETERAL reflux is diagnosed by VCUG in 10% to 80% of renal transplantation cases with ureterovesical anastomosis.1,2 In most cases VUR is asymptomatic and does not require surgical intervention. Asymptomatic VUR does not compromise long-term
function or survival of the transplant.3 In contrast, 3% of patients with VUR may be symptomatic. Recurrent urinary tract infections with VUR into the kidney transplant are associated with significantly decreased graft survival.4e6
0022-5347/15/1931-0225/0 THE JOURNAL OF UROLOGY® © 2015 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION AND RESEARCH, INC.
http://dx.doi.org/10.1016/j.juro.2014.07.103 Vol. 193, 225-229, January 2015 Printed in U.S.A.
www.jurology.com
j
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ENDOSCOPIC TREATMENT OF VESICOURETERAL REFLUX AFTER RENAL TRANSPLANTATION
The reference treatment for symptomatic VUR is open surgical reimplantation7,8 with an 83% to 100% success rate.9,10 However, this procedure may be difficult and it carries significant 16% to 53% morbidity, leading to the need for less invasive treatment.8e11 Endoscopic treatment is a minimally invasive procedure with low 10% morbidity and a success rate of 60% to 86%.12e16 At our center endoscopic treatment has been first line treatment for all symptomatic VUR cases after renal transplantation. We evaluated the results of endoscopic treatment of VUR after renal transplantation and identified factors predictive of success.
MATERIALS AND METHODS Study Population At our center 897 patients underwent kidney transplantation by multiple urological surgeons between January 2000 and December 2010. During transplantation a ureterovesical anastomosis was created in all cases according to the Lich-Gregoir technique. A Double-JÒ stent was routinely placed in the ureter to protect the anastomosis and it was endoscopically removed after 14 days. VUR was diagnosed by VCUG after at least 1 episode of AGPN and classified according to the international classification.17 Bacteriuria was defined as more than 100,000 pathogenic bacteria per ml in urine culture. All patients underwent preoperative US of the urinary tract, which was normal in 50. No patient had significant post-void residual urine (more than 100 ml) on preoperative imaging.
Endoscopic Procedure Urine culture was done systematically 7 days before endoscopic treatment. In cases of significant bacteriuria antibiotic therapy adapted to the antibiogram was initiated 48 hours before endoscopic treatment. The procedure was done by the same surgeons who performed transplantation with the patient under general anesthesia. Bulking agent was injected via endoscopy using a rigid cystoscope and a rigid beveled needle system. The injection was administered at the level of the ureteral neo-orifice perimeatus until obliteration of the orifice. Polydimethylsiloxane (MacroplastiqueÒ) was used as the bulking agent and DX-HA (DefluxÒ) has been used since 2003. In 1 patient the ureteral orifice was not accessible during the endoscopic procedure and surgical reimplantation was performed. In all cases a urethral catheter was placed and removed within 24 hours.
Postoperative Care US of the urinary tract was done and serum creatinine was measured systematically the day after the endoscopic procedure to detect ureteral obstruction. The followup protocol was US of the urinary tract, serum creatinine measurement and urine culture at 1 month, cystography at 3 months and an annual consultation thereafter. Clinical success was defined as absent AGPN during followup. Radiological success was defined as absent VUR
on 3-month followup cystography. If clinical failure was associated with radiological failure, new endoscopic treatment of VUR was performed. In cases of radiological failure additional treatment was only proposed if VUR became symptomatic (AGPN).
Statistical Analysis Quantitative values are shown as the mean SD and the median. For univariate analysis of predictive factors the Student t-test and Fisher exact test were used for quantitative variables, and the chi-square and Mann-Whitney tests were used for qualitative variables. All tests were considered statistically significant at p
Endoscopic Treatment of Symptomatic Vesicoureteral Reflux after Renal Transplantation ronique Delaporte, Charlotte Maurin, Akram Akiki,* Romain Boissier, Ve Sarah Gaillet, Gilles Karsenty, Christian Coulange and Eric Lechevallier From the Department of Urology and Kidney Transplantation, La Conception University Hospital, Marseille, France
Purpose: We evaluated the success of endoscopic treatment of symptomatic vesicoureteral reflux after renal transplantation and identified factors predicting success. Materials and Methods: Endoscopy was performed for symptomatic vesicoureteral reflux after renal transplantation in 38 women and 20 men between January 2000 and December 2010. Reflux was documented by retrograde cystography and its symptomatic character was determined by at least 1 episode of acute graft pyelonephritis. The results of endoscopic treatment were evaluated clinically at 1 and 3 months, and annually, and by cystography at 3 months. Clinical success was defined as absent acute graft pyelonephritis during followup. Radiological success was defined as absent reflux on followup cystography at 3 months. Results: Endoscopic treatment was clinically successful in 32 patients (56.1%), including 26 (65%) who received dextranomer-hyaluronic acid and 5 (33.3%) who received polydimethylsiloxane. Treatment was radiologically successful in 14 patients (26.4%) at a mean SD followup of 38 33 months. On multivariate analysis male gender and dextranomer-hyaluronic acid were factors predictive of clinical success. Reflux grade did not predict success or failure. No high grade complication was reported. Conclusions: Endoscopic treatment of symptomatic vesicoureteral reflux of a transplanted kidney was effective in half of the cases regardless of the bulking agent used. However, dextranomer-hyaluronic acid appeared to be more effective than polydimethylsiloxane. Due to its minimally invasive nature and low morbidity endoscopic treatment with dextranomer-hyaluronic acid could be proposed as preoperative first line treatment for symptomatic vesicoureteral reflux of a transplanted kidney regardless of reflux grade.
Abbreviation and Acronyms AGPN ¼ acute graft pyelonephritis DX-HA ¼ dextranomer-hyaluronic acid US ¼ ultrasound VCUG ¼ voiding cystourethrogram VUR ¼ vesicoureteral reflux Accepted for publication July 23, 2014. * Correspondence: Urology and Kidney Transplantation, La Conception University Hospital, AixMarseille University, 147, Bd. Baille, Marseille, Bouches-du-Rh^one 13385, France (telephone: 0033491435173; FAX: 0033491435176).
Key Words: kidney transplantation, vesico-ureteral reflux, baysilon, dextranomer-hyaluronic acid copolymer, endoscopy
VESICOURETERAL reflux is diagnosed by VCUG in 10% to 80% of renal transplantation cases with ureterovesical anastomosis.1,2 In most cases VUR is asymptomatic and does not require surgical intervention. Asymptomatic VUR does not compromise long-term
function or survival of the transplant.3 In contrast, 3% of patients with VUR may be symptomatic. Recurrent urinary tract infections with VUR into the kidney transplant are associated with significantly decreased graft survival.4e6
0022-5347/15/1931-0225/0 THE JOURNAL OF UROLOGY® © 2015 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION AND RESEARCH, INC.
http://dx.doi.org/10.1016/j.juro.2014.07.103 Vol. 193, 225-229, January 2015 Printed in U.S.A.
www.jurology.com
j
225
226
ENDOSCOPIC TREATMENT OF VESICOURETERAL REFLUX AFTER RENAL TRANSPLANTATION
The reference treatment for symptomatic VUR is open surgical reimplantation7,8 with an 83% to 100% success rate.9,10 However, this procedure may be difficult and it carries significant 16% to 53% morbidity, leading to the need for less invasive treatment.8e11 Endoscopic treatment is a minimally invasive procedure with low 10% morbidity and a success rate of 60% to 86%.12e16 At our center endoscopic treatment has been first line treatment for all symptomatic VUR cases after renal transplantation. We evaluated the results of endoscopic treatment of VUR after renal transplantation and identified factors predictive of success.
MATERIALS AND METHODS Study Population At our center 897 patients underwent kidney transplantation by multiple urological surgeons between January 2000 and December 2010. During transplantation a ureterovesical anastomosis was created in all cases according to the Lich-Gregoir technique. A Double-JÒ stent was routinely placed in the ureter to protect the anastomosis and it was endoscopically removed after 14 days. VUR was diagnosed by VCUG after at least 1 episode of AGPN and classified according to the international classification.17 Bacteriuria was defined as more than 100,000 pathogenic bacteria per ml in urine culture. All patients underwent preoperative US of the urinary tract, which was normal in 50. No patient had significant post-void residual urine (more than 100 ml) on preoperative imaging.
Endoscopic Procedure Urine culture was done systematically 7 days before endoscopic treatment. In cases of significant bacteriuria antibiotic therapy adapted to the antibiogram was initiated 48 hours before endoscopic treatment. The procedure was done by the same surgeons who performed transplantation with the patient under general anesthesia. Bulking agent was injected via endoscopy using a rigid cystoscope and a rigid beveled needle system. The injection was administered at the level of the ureteral neo-orifice perimeatus until obliteration of the orifice. Polydimethylsiloxane (MacroplastiqueÒ) was used as the bulking agent and DX-HA (DefluxÒ) has been used since 2003. In 1 patient the ureteral orifice was not accessible during the endoscopic procedure and surgical reimplantation was performed. In all cases a urethral catheter was placed and removed within 24 hours.
Postoperative Care US of the urinary tract was done and serum creatinine was measured systematically the day after the endoscopic procedure to detect ureteral obstruction. The followup protocol was US of the urinary tract, serum creatinine measurement and urine culture at 1 month, cystography at 3 months and an annual consultation thereafter. Clinical success was defined as absent AGPN during followup. Radiological success was defined as absent VUR
on 3-month followup cystography. If clinical failure was associated with radiological failure, new endoscopic treatment of VUR was performed. In cases of radiological failure additional treatment was only proposed if VUR became symptomatic (AGPN).
Statistical Analysis Quantitative values are shown as the mean SD and the median. For univariate analysis of predictive factors the Student t-test and Fisher exact test were used for quantitative variables, and the chi-square and Mann-Whitney tests were used for qualitative variables. All tests were considered statistically significant at p
