© 1991 S. Karger AG, Basel 0302-2838/91/0194-0291 $2.75/0
Eur Urol 1991;19:291-294
Endoscopic Treatment of Vesicoureteral Reflux following Transurethral Resection of a Vesical Carcinoma by Teflon Injection M. Gonzâlez Martin, A. Sousa Escandón, L. Busto Castanon, F. Gomez Veiga, V. Chantada Abal, J. Serrano Barrientos Division of Urology, Department of Surgery, Juan Canalejo Hospital, La Coruna, Spain 1616892
Key Words. Vesicoureteral reflux • Bladder cancer • Teflon injection • Upper urinary tract tumors Abstract. We have treated 33 patients who presented with reflux in 40 ureters following transurethral resection (TUR) for bladder cancer. One or two injections of Teflon were made under the submucosal intramural ureter. Among the 32 ureters that could be correctly evaluated, we observed that vesicoureteral reflux disappeared in 18 (56.3%), and decreased the grade of reflux in 5 (15.6%). There were no modifications in the 9 remaining ureteral units (28.1 %). Control urogram and/or sonogram scan were performed in all cases and demonstrating the absence of obstructive uropathy.
In 1981 Matouscheck [1] described a simple and ele gant technique for vesicoureteral reflux (VUR) treat ment, consisting of the endoscopic injection of polytetrafluoroethylene paste (Teflon) under the ureteral meatus, in order to produce an elongation of the submucosal intramural ureter, trying to reproduce the lost valvular mechanism. Since then, some authors have treated different types of VUR, primary or secondary to neurogenic bladder, with a high success rate ranging between 76 and 97% [2-6]. VUR following transurethral resection (TUR) for bladder cancer is a frequent complication. Prophylactic endovesical chemotherapy has also been implicated as an inductive factor of reflux. Since 1985 we have treated VUR secondary to TUR and/or endovesical chemother apy in patients with bladder cancer by the endoscopic
injection of Teflon paste. To the best of our knowledge no other group has reported the use of Teflon injection for the treatment of this type of reflux. Material and Methods During the period from 1985 to 1988, we treated 40 ureters with reflux in 33 patients. In all cases, VUR was secondary to TURs carried out in our department during the last 10 years. Eight ureters in 6 patients were excluded from evaluation due to incomplete follow-up protocol in 4 patients (loss to follow-up in 3, exitus in 1), and infiltrating tumor in the perimeatic area in 2 cases. Among the 27 patients included, 24 were males and 3 females. Their ages varied between 41 and 71 years, with a mean age of 58 years. Twenty-two patients had unilateral reflux while the other 5 cases showed bilateral disease. Finally, our study material com prised a total of 32 units. The reflux grade was evaluated using the Rolleston classification into three grades: 9 ureters with grade I (slight); 13 ureters with grade II (moderate), and the other 10 with grade III (severe). Downloaded by: University of Exeter 144.173.6.94 - 1/25/2020 11:00:42 AM
Introduction
Gonzâlez Martin/Sousa Escandón/Busto Castanon/Gomez Veiga/Chantada Abal/Serrano Barrientos
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Fig. 1. Grade-II bilateral VUR after TUR.
Fig. 2. Disappearance of the reflux after endoscopic Teflon injection (control at 6 months).
All patients were previously treated for superficial bladder can cer using TUR (1-5 procedures), followed by endovesical instilla tions of oncothiotepa and/or adriamycin. VUR was demonstrated in all cases on cystograms and mictional cystourethrograms (fig. 1). These explorations were also carried out 1 and 6 months after Teflon injection in order to evaluate the evo lution of the reflux (fig. 2). Urographs and/or sonogram scans were made after Teflon injection to demonstrate the absence of obstruc tive uropathy. The follow-up ranged between 6 months and 3 years without complications related to the Teflon paste.
changed into a star-shaped or fish-mouth orifice. This injection is often difficult because of the resistance of the fibrous tissue. We prefer to evaluate the absence of reflux with in situ fluoros copy. A urethral catheter remains in place for 24 h while the patient is hospitalized. Oral antiseptic treatment for 1 week is recom mended.
Technique After the absence of urinary infection had been ascertained, a wide spectrum antibiotic was administered to the patient 1 h before the surgical procedure. Under regional anesthesia or analgesia, an endoscopic explora tion with a 23-Charrière caliber cystoscope and a 30° optic was performed. Teflon paste was injected through a needle inserted into a ureteral catheter. The bladder mucosa is punctured 1 cm under the ureteral meatus and the needle introduced obliquely, following the ureteral submucosal pathway. We injected 2-4 ml Teflon paste until the deformation of the ureteral meatus can be verified by the eleva tion of the posterior wall. The usual golf hole conformation is
Cystographic control in the 1st month has demon strated the absence of reflux in 17 of 32 ureters (53.1 %) and diminution of reflux grade in 3 others (9.3%). Reflux persisted with the same grade in the 12 (37.5%) remaining ureteral units (table 1). In the second cystographic control, performed 6 months later, reflux reappeared in 3 of the 17 initially resolved ureters. The number of refluxing ureteral units successfully treated with the first injection is then only 14 (43.8%).
Results
Downloaded by: University of Exeter 144.173.6.94 - 1/25/2020 11:00:42 AM
Eur Urol 1991;19:291-294
Endoscopic Treatment of Vesicoureteral Reflux following Transurethral Resection of a Vesical Carcinoma by Teflon Injection M. Gonzâlez Martin, A. Sousa Escandón, L. Busto Castanon, F. Gomez Veiga, V. Chantada Abal, J. Serrano Barrientos Division of Urology, Department of Surgery, Juan Canalejo Hospital, La Coruna, Spain 1616892
Key Words. Vesicoureteral reflux • Bladder cancer • Teflon injection • Upper urinary tract tumors Abstract. We have treated 33 patients who presented with reflux in 40 ureters following transurethral resection (TUR) for bladder cancer. One or two injections of Teflon were made under the submucosal intramural ureter. Among the 32 ureters that could be correctly evaluated, we observed that vesicoureteral reflux disappeared in 18 (56.3%), and decreased the grade of reflux in 5 (15.6%). There were no modifications in the 9 remaining ureteral units (28.1 %). Control urogram and/or sonogram scan were performed in all cases and demonstrating the absence of obstructive uropathy.
In 1981 Matouscheck [1] described a simple and ele gant technique for vesicoureteral reflux (VUR) treat ment, consisting of the endoscopic injection of polytetrafluoroethylene paste (Teflon) under the ureteral meatus, in order to produce an elongation of the submucosal intramural ureter, trying to reproduce the lost valvular mechanism. Since then, some authors have treated different types of VUR, primary or secondary to neurogenic bladder, with a high success rate ranging between 76 and 97% [2-6]. VUR following transurethral resection (TUR) for bladder cancer is a frequent complication. Prophylactic endovesical chemotherapy has also been implicated as an inductive factor of reflux. Since 1985 we have treated VUR secondary to TUR and/or endovesical chemother apy in patients with bladder cancer by the endoscopic
injection of Teflon paste. To the best of our knowledge no other group has reported the use of Teflon injection for the treatment of this type of reflux. Material and Methods During the period from 1985 to 1988, we treated 40 ureters with reflux in 33 patients. In all cases, VUR was secondary to TURs carried out in our department during the last 10 years. Eight ureters in 6 patients were excluded from evaluation due to incomplete follow-up protocol in 4 patients (loss to follow-up in 3, exitus in 1), and infiltrating tumor in the perimeatic area in 2 cases. Among the 27 patients included, 24 were males and 3 females. Their ages varied between 41 and 71 years, with a mean age of 58 years. Twenty-two patients had unilateral reflux while the other 5 cases showed bilateral disease. Finally, our study material com prised a total of 32 units. The reflux grade was evaluated using the Rolleston classification into three grades: 9 ureters with grade I (slight); 13 ureters with grade II (moderate), and the other 10 with grade III (severe). Downloaded by: University of Exeter 144.173.6.94 - 1/25/2020 11:00:42 AM
Introduction
Gonzâlez Martin/Sousa Escandón/Busto Castanon/Gomez Veiga/Chantada Abal/Serrano Barrientos
292
£
,
ì
.# ls
t
1
•
*
* at
*
m
* ut
V ì **' »
rt:.
- s*fe ,-v
r*i
Fig. 1. Grade-II bilateral VUR after TUR.
Fig. 2. Disappearance of the reflux after endoscopic Teflon injection (control at 6 months).
All patients were previously treated for superficial bladder can cer using TUR (1-5 procedures), followed by endovesical instilla tions of oncothiotepa and/or adriamycin. VUR was demonstrated in all cases on cystograms and mictional cystourethrograms (fig. 1). These explorations were also carried out 1 and 6 months after Teflon injection in order to evaluate the evo lution of the reflux (fig. 2). Urographs and/or sonogram scans were made after Teflon injection to demonstrate the absence of obstruc tive uropathy. The follow-up ranged between 6 months and 3 years without complications related to the Teflon paste.
changed into a star-shaped or fish-mouth orifice. This injection is often difficult because of the resistance of the fibrous tissue. We prefer to evaluate the absence of reflux with in situ fluoros copy. A urethral catheter remains in place for 24 h while the patient is hospitalized. Oral antiseptic treatment for 1 week is recom mended.
Technique After the absence of urinary infection had been ascertained, a wide spectrum antibiotic was administered to the patient 1 h before the surgical procedure. Under regional anesthesia or analgesia, an endoscopic explora tion with a 23-Charrière caliber cystoscope and a 30° optic was performed. Teflon paste was injected through a needle inserted into a ureteral catheter. The bladder mucosa is punctured 1 cm under the ureteral meatus and the needle introduced obliquely, following the ureteral submucosal pathway. We injected 2-4 ml Teflon paste until the deformation of the ureteral meatus can be verified by the eleva tion of the posterior wall. The usual golf hole conformation is
Cystographic control in the 1st month has demon strated the absence of reflux in 17 of 32 ureters (53.1 %) and diminution of reflux grade in 3 others (9.3%). Reflux persisted with the same grade in the 12 (37.5%) remaining ureteral units (table 1). In the second cystographic control, performed 6 months later, reflux reappeared in 3 of the 17 initially resolved ureters. The number of refluxing ureteral units successfully treated with the first injection is then only 14 (43.8%).
Results
Downloaded by: University of Exeter 144.173.6.94 - 1/25/2020 11:00:42 AM
