Pediatric Urology Late Ureteral Obstruction After Endoscopic Treatment of Vesicoureteral Reflux With Polyacrylate Polyalcohol Copolymer € ur Ozkan, €lya Yıldırım, Keramettin Ug Arzu S¸encan, Hu Bas¸ak Uc¸an, Aytac¸ Karkıner, and €r €nevver Hos¸go Mu OBJECTIVE
PATIENTS AND METHODS
RESULTS
CONCLUSION
To investigate the incidence and presentation of ureteral obstruction after endoscopic injection of polyacrylate polyalcohol copolymer (PPC) for the treatment of vesicoureteral reflux, and to analyze its possible causes, together with histopathologic assessment. The data of 189 patients who underwent endoscopic injection of PPC between May 2011 and December 2013 were retrospectively reviewed. After the injection, patients were followed up by urinalysis and ultrasonography monthly for 3 months. Control voiding cystouretrography was performed in the third postoperative month. Patients were then followed up by ultrasound every 3 months. If a new-onset hydroureteronephrosis (HUN) was observed, control ultrasound was performed monthly to follow the change in the degree of HUN. If a moderate or severe HUN was observed, technetium-99m mercaptoacetyltriglycine or dimercaptosuccinic acid scintigraphy was performed. For patients who needed open surgery, Cohen ureteroneocystostomy was performed. The distal 1 cm of the ureters was resected and examined histopathologically. One hundred eighty-nine patients with 268 refluxing ureters underwent endoscopic injection of PPC. Ureteral obstruction was observed in 3 ureters (1.1%), in 3 female patients of whom the degrees of reflux were grade 4, 5, and 5, respectively. Obstruction showed late onset in all 3 patients. Manifestations of obstruction included pain in 2 patients and recurrent febrile urinary tract infection with loss of function in scintigraphy in 1. All 3 patients underwent open ureteroneocystostomy. PPC may cause ureteral obstruction several months or even years after injection. Patients who undergo endoscopic treatment of PPC need long-term follow-up, despite reflux showing complete resolution. UROLOGY 84: 1188e1193, 2014. 2014 Elsevier Inc.
E
ndoscopic injection has proved to be a highly successful minimally invasive treatment for the correction of vesicoureteral reflux (VUR). With the development of new substances, subureteral injection of bulking agents has become a very popular alternative to ureteral reimplantation. Polyacrylate polyalcohol copolymer (PPC) (Vantris, Promedon, Cordoba, Argentina) is the newest injection material used in the endoscopic treatment. It is a nonbiodegradable substance of synthetic origin belonging to the acrylic family. It leads to the formation of a fibrotic capsule that can result in better
Financial Disclosure: The authors declare that they have no relevant financial interests. _ From the Department of Pediatric Surgery, Dr. Behc¸et Uz Children’s Hospital, Izmir, _ Turkey; and the Department of Pathology, Dr. Behc¸et Uz Children’s Hospital, Izmir, Turkey Address correspondence to: Arzu S¸encan, M.D., Department of Pediatric Surgery, _ Dr. Behc¸et Uz Children’s Hospital, Ismet Kaptan Mah. Sezer Dog an Sok. No: 11, _ 35210, Alsancak, Konak, Izmir 35350, Turkey. E-mail: [email protected] Submitted: May 21, 2014, accepted (with revisions): July 15, 2014
1188
ª 2014 Elsevier Inc. All Rights Reserved
stability and long-term durability in treating VUR. PPC particles have an average diameter of 300 mm. Therefore, the expected risk of migration is low.1 Very few studies about ureteral obstruction after endoscopic treatment of VUR with PPC have been reported in the literature before.2,3 Therefore, in this study, we aimed to report our cases of ureteral obstruction after injection of PPC, together with presenting patterns and histopathologic assessments.
PATIENTS AND METHODS The data of 189 patients who underwent endoscopic injection of PPC at our institution between May 2011 and December 2013 were retrospectively reviewed. All the patients who were included in this study had VUR determined by voiding cystouretrography (VCUG) and renal scarring in radionuclide scintigraphy. The reflux grade in VCUG was based according to the International Classification System (International Reflux Study Committee). Renal scarring in dimercaptosuccinic acid http://dx.doi.org/10.1016/j.urology.2014.07.030 0090-4295/14
Table 1. Characteristics of patients with ureteral obstruction after injection of polyacrylate polyalcohol copolymer Characteristic Age, y Sex Side and grade of VUR Side of obstruction Renal scarring Injected volume, mL Injection technique Number of injections Ureteral orifice configuration Associated condition Presentation Time of obstruction after injection, mo Treatment Follow-up period, mo
Patient 1
Patient 2
Patient 3
5 F Left, 4 Left Moderate 0.5 STING 1 Golf hole None Abdominal pain 6 Ureteral stent placement þ UNC 18
5 F Right, 5 Right Moderate 0.6 STING 1 Golf hole None Abdominal pain 24 UNC 32
3 F Left, 5 Left Mild 0.4 STING 2 Golf hole None Recurrent febrile UTI 6 UNC 8
F, female; STING, subureteric transurethral injection; UNC, ureteroneocystostomy; UTI, urinary tract infection; VUR, vesicoureteral reflux.
(DMSA) scintigraphy was classified in 3 groups: mild (focal defects with uptake between 40% and 45%), moderate (uptake of renal radionuclide between 20% and 40%), and severe (shrunken kidney with relative uptake
PATIENTS AND METHODS
RESULTS
CONCLUSION
To investigate the incidence and presentation of ureteral obstruction after endoscopic injection of polyacrylate polyalcohol copolymer (PPC) for the treatment of vesicoureteral reflux, and to analyze its possible causes, together with histopathologic assessment. The data of 189 patients who underwent endoscopic injection of PPC between May 2011 and December 2013 were retrospectively reviewed. After the injection, patients were followed up by urinalysis and ultrasonography monthly for 3 months. Control voiding cystouretrography was performed in the third postoperative month. Patients were then followed up by ultrasound every 3 months. If a new-onset hydroureteronephrosis (HUN) was observed, control ultrasound was performed monthly to follow the change in the degree of HUN. If a moderate or severe HUN was observed, technetium-99m mercaptoacetyltriglycine or dimercaptosuccinic acid scintigraphy was performed. For patients who needed open surgery, Cohen ureteroneocystostomy was performed. The distal 1 cm of the ureters was resected and examined histopathologically. One hundred eighty-nine patients with 268 refluxing ureters underwent endoscopic injection of PPC. Ureteral obstruction was observed in 3 ureters (1.1%), in 3 female patients of whom the degrees of reflux were grade 4, 5, and 5, respectively. Obstruction showed late onset in all 3 patients. Manifestations of obstruction included pain in 2 patients and recurrent febrile urinary tract infection with loss of function in scintigraphy in 1. All 3 patients underwent open ureteroneocystostomy. PPC may cause ureteral obstruction several months or even years after injection. Patients who undergo endoscopic treatment of PPC need long-term follow-up, despite reflux showing complete resolution. UROLOGY 84: 1188e1193, 2014. 2014 Elsevier Inc.
E
ndoscopic injection has proved to be a highly successful minimally invasive treatment for the correction of vesicoureteral reflux (VUR). With the development of new substances, subureteral injection of bulking agents has become a very popular alternative to ureteral reimplantation. Polyacrylate polyalcohol copolymer (PPC) (Vantris, Promedon, Cordoba, Argentina) is the newest injection material used in the endoscopic treatment. It is a nonbiodegradable substance of synthetic origin belonging to the acrylic family. It leads to the formation of a fibrotic capsule that can result in better
Financial Disclosure: The authors declare that they have no relevant financial interests. _ From the Department of Pediatric Surgery, Dr. Behc¸et Uz Children’s Hospital, Izmir, _ Turkey; and the Department of Pathology, Dr. Behc¸et Uz Children’s Hospital, Izmir, Turkey Address correspondence to: Arzu S¸encan, M.D., Department of Pediatric Surgery, _ Dr. Behc¸et Uz Children’s Hospital, Ismet Kaptan Mah. Sezer Dog an Sok. No: 11, _ 35210, Alsancak, Konak, Izmir 35350, Turkey. E-mail: [email protected] Submitted: May 21, 2014, accepted (with revisions): July 15, 2014
1188
ª 2014 Elsevier Inc. All Rights Reserved
stability and long-term durability in treating VUR. PPC particles have an average diameter of 300 mm. Therefore, the expected risk of migration is low.1 Very few studies about ureteral obstruction after endoscopic treatment of VUR with PPC have been reported in the literature before.2,3 Therefore, in this study, we aimed to report our cases of ureteral obstruction after injection of PPC, together with presenting patterns and histopathologic assessments.
PATIENTS AND METHODS The data of 189 patients who underwent endoscopic injection of PPC at our institution between May 2011 and December 2013 were retrospectively reviewed. All the patients who were included in this study had VUR determined by voiding cystouretrography (VCUG) and renal scarring in radionuclide scintigraphy. The reflux grade in VCUG was based according to the International Classification System (International Reflux Study Committee). Renal scarring in dimercaptosuccinic acid http://dx.doi.org/10.1016/j.urology.2014.07.030 0090-4295/14
Table 1. Characteristics of patients with ureteral obstruction after injection of polyacrylate polyalcohol copolymer Characteristic Age, y Sex Side and grade of VUR Side of obstruction Renal scarring Injected volume, mL Injection technique Number of injections Ureteral orifice configuration Associated condition Presentation Time of obstruction after injection, mo Treatment Follow-up period, mo
Patient 1
Patient 2
Patient 3
5 F Left, 4 Left Moderate 0.5 STING 1 Golf hole None Abdominal pain 6 Ureteral stent placement þ UNC 18
5 F Right, 5 Right Moderate 0.6 STING 1 Golf hole None Abdominal pain 24 UNC 32
3 F Left, 5 Left Mild 0.4 STING 2 Golf hole None Recurrent febrile UTI 6 UNC 8
F, female; STING, subureteric transurethral injection; UNC, ureteroneocystostomy; UTI, urinary tract infection; VUR, vesicoureteral reflux.
(DMSA) scintigraphy was classified in 3 groups: mild (focal defects with uptake between 40% and 45%), moderate (uptake of renal radionuclide between 20% and 40%), and severe (shrunken kidney with relative uptake
