PEDIATRIC U R O L O G Y
ENDOSCOPIC TREATMENT OF VESICOURETERAL REFL1 IN CHILDREN WITH NEUROGENIC BLADDERS JED C. KAMINETSKY, M.D. MONEER K. HANNA, M.D. From the Department of Urology, New York University Medical Center, New York, New York
ABSTRACT--Endoscopic subureteral injection of Teflon was performed in 12 children (20 ureter~ with neurogenic bladders and vesicoureteral reflux (grades 11I-IV). Follow-up evaluation by ult~4 sonography and voiding cystourethrogram at three-month intervals up to two years reveal~ successful correction of the reflux in 70 percent of the ureters
Vesieoureteral reflux is encountered in 30 percent to 60 percent of patients with neurogenie bladder dysfunction. 1 When associated with urinary tract infections, it often leads to pye!onephritis, scarring, and progressive renal dysfunction. Most clinicians agree that children with high-grade reflux (grades IV-V), or those who break through with urinary tract infections while on prophylactic antibiotic therapy and clean intermittent catheterization, should be candidates for antireflux surgery. However, the general consensus is that low-grade reflux can be successfully treated with suppressive antibacterial therapy, antieholinergie medications, and clean intermittent catheterization. The expectation is that in the vast majority reflux will resolve spontaneously.2 There have been many operative techniques described to treat vesieoureteral reflux. 3-~ The procedures can be performed either transvesitally or extravesieally, and in 95 percent of eases are successful. The common mechanism of reflux prevention in these procedures is to lengthen the intramural ureter and to provide the ureter with a strong support by the detrusor musculature. Puri and O'Donnell6 were able to achieve a similar effect while treating experimentally-induced reflux in piglets, by endoseopieally injecting Teflon beneath the intravesieal ureter. Their results of the "sting" (subureterie Teflon injection) procedure performed in
244
children with p r i m a r y reflux were f i : ~ published in 1984.7 Herein is presented a review of our e ~ rienee with endoscopic treatment of vesie teral reflux in 12 children (20 ureters) neurogenic bladder dysfunction. Material and Methods Since January 1986, 1 boys) with neurogenie bl.' teral reflux have been tr, seopie injection of pol (Teflon). The patients rat to seventeen years. Reflux tients and unilateral in 4. III-IV reflux in at least Grading was established ternational Reflux Study tion. s All children were t m i t t e n t eatheterizatim antibacterial therapy, ant ieation for at least one ye: the "sting" procedure. The technique as des, was followed. A speeiall~ (The Stinger*) was used. jeetion gun and needle w, erine and then filled wit ylene paste. The n e e d l e *Richard Wolf Medical Instrumc
UROLOGY
/
MARCH 1991
/
VOLUME XXXVII,
ander direct vision, and ad[adder mucosa, 3-4 m m beorifice. It is crucial to the ~eedure that the injection be he 6-o'clock-position. Poly(0.2-0.6 ce) was injected 'ial was injected, a bulge ap~sult was a cone-shaped ureon a bead of paste. A eystoimmediately after injection, was still in the operating /liseharged from the hospital [lowing day. No indwelling 'as left postoperatively, and ~d intermittent eatheterizaprophylaxis for ten days was ,w-up studies included renal eeeeks. Renal sonogram and rogram were performed at and twenty-four months Results ~ters in 12 patients with neurowere treated with single endoinjection. Follow-up cystograms revealed absence of reflux in 14 Kample of a satisfactory result is are 1. In one ureter the grade of teased. In another child with unithe ureteral orifices could not be heavy trabeculation. The proceefore aborted. In the remaining 2 with bilateral reflux, failures oe)en surgery was subsequently pers 2 and 3). The postinjection eys;e 2 shows absence of reflux on the y slight reflux remaining on the kt three months, the eystogram re-
FIGURE 1. (A) Pre-injection cystogram, and (13) cystogram immediately after injection demonstrating absence of reflux, veals that reflux had recurred bilaterally (Fig. 3A). Henee, the patient underwent blateral reimplantation. At surgery, the paraureteral granulomas were seen at the site of the Teflon injeetions (Figs. 3B, 4). The surgery was not made more difficult by the previous Teflon injeetions, and the encapsulated granulomas were easily freed from the surrounding tissues. Seventeen of the twenty ureters (85 %) show absenee or marked diminution of reflux on the immediate postoperative eystogram. Of these, 2 ureters progressed to failure, requiring surgery at three months; and 14 ureters remain without reflux to the present time. There was no postinj ~ t i o n obstruction noted either clinically or by ultrasound. No patient underwent repeat injeetion of the same ureter. Comment Polytetrafluoroethylene injection has been used by urologists ~a° and otolaryngologists n-la for over twenty years--by the former group to
FICURE 2. Case 2. (,4) Bilateral reflux in preinjection eystogram; (B) cystogram after rightside in~ection; (C) cystogram after left-side injection.
MARCH1991 / VOLUMEXXXVII,NUMBER3
245
FIGURE 3. Case 2. ( ~ Follow-up cystogram,?~v~,~, three months shows;~! turn o/bilateral r N ~ ~ (B) Findings at s u r g ~ bilateral g r a n u l o ~ (arrows9 at sites oS
tion.
treat urinary incontinence, and by the latter to enlarge displaced or deformed vocal cords. The polytetrafluoroethylene paste is composed of inert sterile particles, many of which are smaller than 40 m/~. The paste has been pyrolized and suspended in glycerine. After injection, a granulomatous reaction occurs, and the particles are encapsulated by fibrous tissue. This pseudocapsule enables the paste to maintain its position and shape at the site of injection beneath the intramural ureter. This provides solid backing to the intravesieal ureter. Politano1° has treated 165 incontinent patients by injecting 10-15 ee of Teflon paste into the extremely vascular periurethral area. This is a much larger quantity than that used for the treatment of vesieoureteral reflux. Nevertheless, there were no serious complications associated with periurethral Teflon injection in his series. There remains, however, much debate regarding the potential deleterious side effects of injecting this material. Malizia et al. ~4 injected Teflon paste periurethrally in dogs and monkeys. They found a chronic inflammatory reaction at the site of injection with histioeytic and giant eells within the implant. At ten and one-half months, they found Teflon particles in pelvic lymph nodes, lung, spleen, brain, as well as other sites. In addition, a local granuloma was found at the site of the injection. The experimental demonstration of particle migration remains a cause for concern. It should be noted that Malizia et aI.~4 injected a much larger dose of the substance compared with the amount injected by Politano.~° In the treatment of vesieoureteral reflux, a relatively
246
~i~!~
fI~rU~lEu4 Case2 Pathologicspecimen after p ~ a] roethylene injection and subsequent ~ repair. Teflon injection site surrounded by p s ~ capsule (hematoxylin and eosin, original m a g ~ tion x 10).
small injection (0.4-0.6 co), aw blood vessels may mininize this The questions c o n c e r n i n g fluoroethylene paste has led to ideal injection medium. Collage: has been successful for the trea cord pathology. It also has been cosmetic surgery. Cross-linked has been tried, is It has been f( effective than Teflon because of i content. It is not thick enough t~ injeetion site and subsequently tion, diminishing its efficacy. Col patient's own tissues may prove injection medium sinee this wou
UROLOGY
/
MARCH 1991
/
VOLUME XXXVII,
~vrrect the underlying anomaly by inducing the ~rowfh of collagen fibers locally. i Despite the previously mentioned concerns ....... ion of Teflon paste, the con,pie treatment of reflux has ~ful endoscopic treatment in flux varies from 70 percent nts with neurogenic bladder ~eessfully treated in 70 perL6-18
ficant learning curve assozedure. The procedure itself yet technically exacting-lccess and the proper depth ailures occurred in Cases 2 s, 0.2 to 0.3 cc of the Teflon/ vas injected. This, in retrotent quantity because after [ycerine, reflux returned. In b.5 to 0.6 cc of the material l the problem of delayed 71.
antation remains the gold any new procedures should le the initial reports of this ,'annot match the 95 percent tble in open surgical repair, atment has many clear ad~edure is well tolerated with ne (15-20 minutes). It may mbulatory basis, and it has ttive morbidity. There has .ostoperative obstruction or series or mentioned in pre:n necessary, a second Teflon ,~rformed for persistent or reflux occurs in up to 60 perth neurogenic bladder, with i:~!6n@hritis and progressive renal disease a ~ u e n t source of morbidity. Endoscopic treati ~i:fe~t~i;,ht be ideal in these patients in order to er surgical procedure or to postlly more definitive procedure to date. Many children in this pad do not tolerate or are noneom3nie suppressive antibiotics and/ catheterization. These patients : from endoscopic t r e a t m e n t mplify their management. [1 a relatively new method for resieoureteral reflux, polytetrainjection is simple and eost-ef-
/
MARCH 1991 /
fective. Furthermore, it is associated with low morbidity. At this time, the use of Teflon for endoscopic injection is not yet approved by the Federal Drug Administration. While controversy remains regarding the ideal injection medium, the concept of endoscopic treatment of vesieoureteral reflux may represent the wave of the future in pediatric urology. It should continue to receive consideration, especially in the treatment of children with neurogenie bladders. 530 First Avenue New York, New York 10016 (DR. KAMINETSKY) References 1. Kaplan WE, and Firlit CF: Management of reflux in the mylodysplastic child, J Urol 129:1185 (1983). 2. Smellie JM, Gruneberg RN, Leakey A, and Atkin WS: Long-term low-dose co-trimoxazole in prophylaxis of childhood urinary tract infection: clinical aspects, Br Med J 2:203 (1976). 3. Politano VA, and Leadbetter WF: An operative technique for the correction of vesicoureteral reflux, J Urol 79:932 (1958). 4. Cohen J: Vesicoureteral reflux: a new surgical approach, Int Urol Pediatr 6:20 (1975). 5. Ehrlich RM: Success of the transvesiea] advancement technique for vesicoureteral reflux, J Uroi 128:554 (1982). 6. Puri P~ and O'Donnell B: Correction of experimentally induced reflux in the piglet by intravesical injection of Teflon, Br Med J 289:5 (1984). 7. O'Donnell B, and Puri P: Endoscopic correction of primary vesicoureteral reflux, Br J Urol 58:601 (1986). 8. Report of the International Reflux Study Committee: Medical versus surgical treatment of vesicoureteral reflux, Pediatrics 67:392 (1981). 9. Vorstman B, Lockhart J, Kaufman MP, and Politano V: Polytetrafluoroethylene injection for urinary incontinence in children, J Urol 133:248 (1985). 10. Politano V: Periurethral polytetrafluoroethylene injection for urinary incontinence, J Urol 127:439 (1982). 11. Lewy RB: Teflon injection of the vocal cords: complications, errors, and precautions, Ann Otol Rhinol Laryngol 72:473
(1983). 12. Arnold GE: Alleviation of aphonia or dysphonia through inehordal injection of Teflon paste, Ann Ore Rhinol Laryngol 72:
384 (1963). 13. Stone JW, and Arnold GE: Human larynx injected with Teflon paste: histiologie study on innervation and tissue reaction, Arch Otolaryngol 86:550 (1967). 14. Malizia AA Jr, et ah Migration and granulomatous reaction after periurethral injection of polytef (Teflon), JAMA 251: 3277 (1984). 15. Peters CA, and Jeffs RD: Endoscopic correction of vesicoureteral reflux with bovine collagen injected submucosally at the ureteral orifice (abstr), ] Urol 137: 122A (1987). 16. Puff P, and Guiney EJ: Endoscopic correction of vesicoureteric reflux secondary to neuropathic bladder, Br J Urol 58:504 (1986). 17. Sehulman CC, Simon J, Pamart D, and Avni FE: Endoscopic treatment of vesicoureteral reflux in children, J Urol 138: 950 (1986). 18. Kaplan WE, Dalton DP, and Firlit CF: The endoscopic correction of reflux by polytetrafluoroethylene injection, J Urol 138:953 (1986).
VOLUME XXXVII, NUMBER 3
247
ENDOSCOPIC TREATMENT OF VESICOURETERAL REFL1 IN CHILDREN WITH NEUROGENIC BLADDERS JED C. KAMINETSKY, M.D. MONEER K. HANNA, M.D. From the Department of Urology, New York University Medical Center, New York, New York
ABSTRACT--Endoscopic subureteral injection of Teflon was performed in 12 children (20 ureter~ with neurogenic bladders and vesicoureteral reflux (grades 11I-IV). Follow-up evaluation by ult~4 sonography and voiding cystourethrogram at three-month intervals up to two years reveal~ successful correction of the reflux in 70 percent of the ureters
Vesieoureteral reflux is encountered in 30 percent to 60 percent of patients with neurogenie bladder dysfunction. 1 When associated with urinary tract infections, it often leads to pye!onephritis, scarring, and progressive renal dysfunction. Most clinicians agree that children with high-grade reflux (grades IV-V), or those who break through with urinary tract infections while on prophylactic antibiotic therapy and clean intermittent catheterization, should be candidates for antireflux surgery. However, the general consensus is that low-grade reflux can be successfully treated with suppressive antibacterial therapy, antieholinergie medications, and clean intermittent catheterization. The expectation is that in the vast majority reflux will resolve spontaneously.2 There have been many operative techniques described to treat vesieoureteral reflux. 3-~ The procedures can be performed either transvesitally or extravesieally, and in 95 percent of eases are successful. The common mechanism of reflux prevention in these procedures is to lengthen the intramural ureter and to provide the ureter with a strong support by the detrusor musculature. Puri and O'Donnell6 were able to achieve a similar effect while treating experimentally-induced reflux in piglets, by endoseopieally injecting Teflon beneath the intravesieal ureter. Their results of the "sting" (subureterie Teflon injection) procedure performed in
244
children with p r i m a r y reflux were f i : ~ published in 1984.7 Herein is presented a review of our e ~ rienee with endoscopic treatment of vesie teral reflux in 12 children (20 ureters) neurogenic bladder dysfunction. Material and Methods Since January 1986, 1 boys) with neurogenie bl.' teral reflux have been tr, seopie injection of pol (Teflon). The patients rat to seventeen years. Reflux tients and unilateral in 4. III-IV reflux in at least Grading was established ternational Reflux Study tion. s All children were t m i t t e n t eatheterizatim antibacterial therapy, ant ieation for at least one ye: the "sting" procedure. The technique as des, was followed. A speeiall~ (The Stinger*) was used. jeetion gun and needle w, erine and then filled wit ylene paste. The n e e d l e *Richard Wolf Medical Instrumc
UROLOGY
/
MARCH 1991
/
VOLUME XXXVII,
ander direct vision, and ad[adder mucosa, 3-4 m m beorifice. It is crucial to the ~eedure that the injection be he 6-o'clock-position. Poly(0.2-0.6 ce) was injected 'ial was injected, a bulge ap~sult was a cone-shaped ureon a bead of paste. A eystoimmediately after injection, was still in the operating /liseharged from the hospital [lowing day. No indwelling 'as left postoperatively, and ~d intermittent eatheterizaprophylaxis for ten days was ,w-up studies included renal eeeeks. Renal sonogram and rogram were performed at and twenty-four months Results ~ters in 12 patients with neurowere treated with single endoinjection. Follow-up cystograms revealed absence of reflux in 14 Kample of a satisfactory result is are 1. In one ureter the grade of teased. In another child with unithe ureteral orifices could not be heavy trabeculation. The proceefore aborted. In the remaining 2 with bilateral reflux, failures oe)en surgery was subsequently pers 2 and 3). The postinjection eys;e 2 shows absence of reflux on the y slight reflux remaining on the kt three months, the eystogram re-
FIGURE 1. (A) Pre-injection cystogram, and (13) cystogram immediately after injection demonstrating absence of reflux, veals that reflux had recurred bilaterally (Fig. 3A). Henee, the patient underwent blateral reimplantation. At surgery, the paraureteral granulomas were seen at the site of the Teflon injeetions (Figs. 3B, 4). The surgery was not made more difficult by the previous Teflon injeetions, and the encapsulated granulomas were easily freed from the surrounding tissues. Seventeen of the twenty ureters (85 %) show absenee or marked diminution of reflux on the immediate postoperative eystogram. Of these, 2 ureters progressed to failure, requiring surgery at three months; and 14 ureters remain without reflux to the present time. There was no postinj ~ t i o n obstruction noted either clinically or by ultrasound. No patient underwent repeat injeetion of the same ureter. Comment Polytetrafluoroethylene injection has been used by urologists ~a° and otolaryngologists n-la for over twenty years--by the former group to
FICURE 2. Case 2. (,4) Bilateral reflux in preinjection eystogram; (B) cystogram after rightside in~ection; (C) cystogram after left-side injection.
MARCH1991 / VOLUMEXXXVII,NUMBER3
245
FIGURE 3. Case 2. ( ~ Follow-up cystogram,?~v~,~, three months shows;~! turn o/bilateral r N ~ ~ (B) Findings at s u r g ~ bilateral g r a n u l o ~ (arrows9 at sites oS
tion.
treat urinary incontinence, and by the latter to enlarge displaced or deformed vocal cords. The polytetrafluoroethylene paste is composed of inert sterile particles, many of which are smaller than 40 m/~. The paste has been pyrolized and suspended in glycerine. After injection, a granulomatous reaction occurs, and the particles are encapsulated by fibrous tissue. This pseudocapsule enables the paste to maintain its position and shape at the site of injection beneath the intramural ureter. This provides solid backing to the intravesieal ureter. Politano1° has treated 165 incontinent patients by injecting 10-15 ee of Teflon paste into the extremely vascular periurethral area. This is a much larger quantity than that used for the treatment of vesieoureteral reflux. Nevertheless, there were no serious complications associated with periurethral Teflon injection in his series. There remains, however, much debate regarding the potential deleterious side effects of injecting this material. Malizia et al. ~4 injected Teflon paste periurethrally in dogs and monkeys. They found a chronic inflammatory reaction at the site of injection with histioeytic and giant eells within the implant. At ten and one-half months, they found Teflon particles in pelvic lymph nodes, lung, spleen, brain, as well as other sites. In addition, a local granuloma was found at the site of the injection. The experimental demonstration of particle migration remains a cause for concern. It should be noted that Malizia et aI.~4 injected a much larger dose of the substance compared with the amount injected by Politano.~° In the treatment of vesieoureteral reflux, a relatively
246
~i~!~
fI~rU~lEu4 Case2 Pathologicspecimen after p ~ a] roethylene injection and subsequent ~ repair. Teflon injection site surrounded by p s ~ capsule (hematoxylin and eosin, original m a g ~ tion x 10).
small injection (0.4-0.6 co), aw blood vessels may mininize this The questions c o n c e r n i n g fluoroethylene paste has led to ideal injection medium. Collage: has been successful for the trea cord pathology. It also has been cosmetic surgery. Cross-linked has been tried, is It has been f( effective than Teflon because of i content. It is not thick enough t~ injeetion site and subsequently tion, diminishing its efficacy. Col patient's own tissues may prove injection medium sinee this wou
UROLOGY
/
MARCH 1991
/
VOLUME XXXVII,
~vrrect the underlying anomaly by inducing the ~rowfh of collagen fibers locally. i Despite the previously mentioned concerns ....... ion of Teflon paste, the con,pie treatment of reflux has ~ful endoscopic treatment in flux varies from 70 percent nts with neurogenic bladder ~eessfully treated in 70 perL6-18
ficant learning curve assozedure. The procedure itself yet technically exacting-lccess and the proper depth ailures occurred in Cases 2 s, 0.2 to 0.3 cc of the Teflon/ vas injected. This, in retrotent quantity because after [ycerine, reflux returned. In b.5 to 0.6 cc of the material l the problem of delayed 71.
antation remains the gold any new procedures should le the initial reports of this ,'annot match the 95 percent tble in open surgical repair, atment has many clear ad~edure is well tolerated with ne (15-20 minutes). It may mbulatory basis, and it has ttive morbidity. There has .ostoperative obstruction or series or mentioned in pre:n necessary, a second Teflon ,~rformed for persistent or reflux occurs in up to 60 perth neurogenic bladder, with i:~!6n@hritis and progressive renal disease a ~ u e n t source of morbidity. Endoscopic treati ~i:fe~t~i;,ht be ideal in these patients in order to er surgical procedure or to postlly more definitive procedure to date. Many children in this pad do not tolerate or are noneom3nie suppressive antibiotics and/ catheterization. These patients : from endoscopic t r e a t m e n t mplify their management. [1 a relatively new method for resieoureteral reflux, polytetrainjection is simple and eost-ef-
/
MARCH 1991 /
fective. Furthermore, it is associated with low morbidity. At this time, the use of Teflon for endoscopic injection is not yet approved by the Federal Drug Administration. While controversy remains regarding the ideal injection medium, the concept of endoscopic treatment of vesieoureteral reflux may represent the wave of the future in pediatric urology. It should continue to receive consideration, especially in the treatment of children with neurogenie bladders. 530 First Avenue New York, New York 10016 (DR. KAMINETSKY) References 1. Kaplan WE, and Firlit CF: Management of reflux in the mylodysplastic child, J Urol 129:1185 (1983). 2. Smellie JM, Gruneberg RN, Leakey A, and Atkin WS: Long-term low-dose co-trimoxazole in prophylaxis of childhood urinary tract infection: clinical aspects, Br Med J 2:203 (1976). 3. Politano VA, and Leadbetter WF: An operative technique for the correction of vesicoureteral reflux, J Urol 79:932 (1958). 4. Cohen J: Vesicoureteral reflux: a new surgical approach, Int Urol Pediatr 6:20 (1975). 5. Ehrlich RM: Success of the transvesiea] advancement technique for vesicoureteral reflux, J Uroi 128:554 (1982). 6. Puri P~ and O'Donnell B: Correction of experimentally induced reflux in the piglet by intravesical injection of Teflon, Br Med J 289:5 (1984). 7. O'Donnell B, and Puri P: Endoscopic correction of primary vesicoureteral reflux, Br J Urol 58:601 (1986). 8. Report of the International Reflux Study Committee: Medical versus surgical treatment of vesicoureteral reflux, Pediatrics 67:392 (1981). 9. Vorstman B, Lockhart J, Kaufman MP, and Politano V: Polytetrafluoroethylene injection for urinary incontinence in children, J Urol 133:248 (1985). 10. Politano V: Periurethral polytetrafluoroethylene injection for urinary incontinence, J Urol 127:439 (1982). 11. Lewy RB: Teflon injection of the vocal cords: complications, errors, and precautions, Ann Otol Rhinol Laryngol 72:473
(1983). 12. Arnold GE: Alleviation of aphonia or dysphonia through inehordal injection of Teflon paste, Ann Ore Rhinol Laryngol 72:
384 (1963). 13. Stone JW, and Arnold GE: Human larynx injected with Teflon paste: histiologie study on innervation and tissue reaction, Arch Otolaryngol 86:550 (1967). 14. Malizia AA Jr, et ah Migration and granulomatous reaction after periurethral injection of polytef (Teflon), JAMA 251: 3277 (1984). 15. Peters CA, and Jeffs RD: Endoscopic correction of vesicoureteral reflux with bovine collagen injected submucosally at the ureteral orifice (abstr), ] Urol 137: 122A (1987). 16. Puff P, and Guiney EJ: Endoscopic correction of vesicoureteric reflux secondary to neuropathic bladder, Br J Urol 58:504 (1986). 17. Sehulman CC, Simon J, Pamart D, and Avni FE: Endoscopic treatment of vesicoureteral reflux in children, J Urol 138: 950 (1986). 18. Kaplan WE, Dalton DP, and Firlit CF: The endoscopic correction of reflux by polytetrafluoroethylene injection, J Urol 138:953 (1986).
VOLUME XXXVII, NUMBER 3
247
