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12-09-2011 | Surgery | Article

Endoscopic injection therapy is viable for pediatric VUR


Free abstract

MedWire News: An endoscopic injection of dextranomer/hyaluronic acid (Dx/HA) in children with vesicoureteral reflux (VUR) is a viable treatment option even in the presence of overactive bladder (OAB), report US researchers.

Postoperative resolution was comparable among those with and without OAB, while nearly half of children with well-controlled OAB no longer needed therapy for it.

"Injection therapy... avoids the disadvantages associated with long-term antibiotic prophylaxis, such as compliance and resistance, as well as the need for more invasive procedures, such as open ureteral re-implantation," say Andrew Kirsch (Emory University School of Medicine, Atlanta, Georgia) and co-investigators.

The team assessed outcomes for 41 patients aged a mean 6.7 years old who underwent Dx/HA endoscopic injection for VUR during 2002 through 2007. A voiding cystourethrogram (VCUG) was performed 6-12 weeks after surgery to determine VUR status, and the cohort was followed up for a mean 2 years (range 1-5) post-treatment.

At the time of surgery, 13 patients had well-controlled OAB, defined as resolution of OAB symptoms (urgency, daytime wetting, the need for ongoing outpatient behavior/anticholinergic therapy), and received a mean 1.19 ml Dx/HA per ureter, while 28 patients had poorly controlled OAB, defined as persistent symptoms and ongoing outpatient therapy, and received 1.01 ml.

In all, 83% (n=34) of patients were negative for VUR after a single injection, and those with persistent VUR had a mean grade of 1.89 after therapy versus a mean grade of 2.42 beforehand.

After successful treatment, four of the 10 patients with well-controlled OAB (40.0%, 9.8% overall) had an unanticipated return to normal voiding patterns and continence and were able to cease OAB therapy, report the researchers in Urology.

"This finding suggests that VUR might be an underlying cause of urgency in patients diagnosed with OAB," write the researchers.

In addition, four (16.7%, 9.8% overall) of the 24 patients with poorly controlled OAB had a resolution of OAB symptoms and a return to normal voiding patterns.

Kirsch and colleagues note that the overall clinical success rate, defined as no evidence of a urinary tract infection (UTI) after negative VUR findings, reached 78% for the cohort during the study. This translated to a rate "consistent with the incidence of UTI in children with normal voiding patterns."

In a related editorial, Joseph Ortenberg (Louisiana University Health Science Center, New Orleans, USA) remarked that the overall success rate achieved in the study was "commendable".

He added that: "This retrospective series emphasizes the need for the recognition and treatment of OAB symptoms before endoscopic injection and suggests that a greater volume of Dx/HA injection might be warranted if the OAB symptoms cannot be fully controlled properly."

By Sarah Guy

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