Vezikoüreteral Reflü Tedavisinde Subüreteral Enjeksiyon Uygulamasinin Etkinliginin Prospektif Arastirilmasi

Vezikoüreteral reflünün (VÜR) cerrahi tedavisinde son yillarda özellikle medikal tedaviye alternatif olara k gündeme gelmesi nedeniyle endoskopik subüreteral enjeksiyon giderek önem kazanmaktadir. Bu çalismada dextranomer enjeksiyonu ile endoskopik tedavi uygulanan VÜR hastalarinda tedavi basarisinin prospektif olarak degerlendirilmesi amaçlandi. Miksiyonsistoüretragrafi (MSÜG) sonucunda VÜR tanisi konmus olan ve endoskopik tedavi uygun görülen toplam 22 hasta (27 renal ünite) çalismaya alindi. Sekonder VÜR vakalari çalismaya dahil edilmedi. Çalismaya alinan hastalarda MÜSG degerlendirmesinde 5 ünitede grade II (2 hastada bilateral VÜR), 19 ünitede grade III (3 hastada bilateral VÜR), 3 ünitede de grade IV reflü izlendi. Tüm vakalarda enjeksiyon maddesi olarak dextranomer (deflux) kullanildi. Islem sirasinda üreter orifisinden saat 6 hizasinda enjeksiyon ignesi 0,8cm kadar ilerletilerek volkan görünümünün elde edilmesi amaçlandi. Tedavi etkinligi postoperatif 3. aydaki MSÜG tetkikinde reflü olmamasi olarak kabul edildi. Postoperatif 3. ayda yapilan kontrol MSÜG’de 27 renal ünitede %81 (22/27), hasta bazinda da %77 (17/22) basari saptandi. Reflü derecesine göre basarilar grade II reflüde %80 (4/5 renal ünite), grade III reflülerde %84 (16/19 renal ünite), grade IV reflüde %66 (2/ 3 renal ünite) olarak saptandi. Sonuç olarak endoskopik subüreteral dextranomer tedavisi iyi seçilmis VÜR vakalarinda yüksek basari oranlarina sahiptir

Anahtar Kelimeler:

Vezikoüreteral reflü (VUR), dextranomer

Prospective Evaluation of the Efficacy of Subureteral Injection in the Management of Vesicoureteral Reflux

Endoscopic subureteral injection constitutes a valuable treatment option in the surgical management of vesicoureteral reflux (VUR). Recently, it regains popularity as it has been proposed an alternative to conservative management of VUR. The objective of the current study was to prospectively evaluate the efficiency of subueretal dextranomer in jection in VUR. Twenty-two patients (27 renal units) with vesicoureteral reflux scheduled for endoscopic treatment were included in the study. Secondary reflux cases were excluded. Of the patients included in the study, grade II reflux in 5 units (bilateral reflux in two cases), grade III reflux in 19 renal units (bilateral reflux in 3), grade IV reflux in 3 units were noted. Dextranomer (deflux) was used in all the cases as bulking agent. Injection needle was introduced at six o’clock position at the ureteral orifice and further moved for 0.8 cm before injection. Injection was continued until volcanic appearance of the orifice was obtained. Success was defined as no reflux in the voiding cystourethrography obtained 3 months after the operation. Postoperative control cystourethrography showed no reflux in 22 renal units of 27 (81%), the success was 77% (17/22) when the number of the patients taken into consideration. Grade II, grade III, and grade IV refluxes resolved in 80% (4/5 renal units), 84% (16/19 renal units), 66% (2/3 renal units) respectively. We concluded that endoscopic suburethral dextranomer treatment has high success rates in the treatment of VUR for properly selected cases

Keywords:

Vesicoureteral reflux (VUR), dextranomer,

PDF

___

Lebowitz RL. The detection and characterization of vesicoureteral reflux in the child. J Urol . 134:855-859, 1985.
Dwoskin JY, Perlmutter AD. Vesicoureteral reflux in children: a computerized review. J Urol .109(5):888- 890, 1973.
Belman AB. Vesicoureteral reflux. Pediatr Clin North Am. 44(5):1171-1190, 1997.
Hodson CJ, Edwards D. Chronic pyelonephritis and vesicoureteral reflux. Clin. Radiol.11:219-231, 1960.
Puri P. Endoscopic treatment of vesicourethral reflux. In Gearhhart JP, Rink RC, Mouriquand PDE (eds). Pediatric Urology. Phhiladelphia, WB Saunders Co., pp 411-420, 2001.
Capozza N, Lais A, Matarazzo E, Nappo S, Patricolo M, Caione P. Treatment of vesico-ureteric reflux: a new algorithm based on parental preference. BJU Int. 92(3):285-288, 2003.
Elder JS, Peters CA, Arant BS Jr, Ewalt DH, Hawtrey CE, Hurwitz RS, Parrott TS, Snyder HM 3rd, Weiss RA, Woolf SH, Hasselblad V. Pediatric Vesicoureteral Reflux Guidelines Panel summary report on the management of primary vesicoureteral reflux in children. J Urol 157(5):1846-51, 1997.
Matouschek E. New concept for the treatment of vesico-ureteral Endoscopic application of teflon. Arch Esp Urol. 34: 385-388, 1981. reflux.
O’Donnell B and Puri P. Treatment of vesicoureteric reflux by injection of Teflon. Br Med J (Clin Res Ed). 289:7-9, 1984. endoscopic
Canning DA. Deflux for vesicoureteral reflux: pro—the case for endoscopic correction. Urology. 68 (2):239-41, 2006.
Arant BS Jr. Medical management of mild and moderate vesicoureteral reflux: followup studies of infants and young children. A preliminary report of the Southwest Pediatric Nephrology Study Group. J Urol. 148:1683-1687, 1992.
Ogan K, Pohl HG, Carlson D, Belman AB, Rushton HG. Parental preferences in the management of vesicoureteral reflux. J Urol. 166(1):240-243, 2001.
Stenberg AM, Sundin A, Larsson BS, Lackgren G, Stenberg A. Lack of distant migration after injection of a 125iodine labeled dextranomer based implant into the rabbit bladder. J Urol. 158:1937– 1941, 1997.
Malizia AA Jr, Reiman HM, Myers RP, Sande JR, Barham SS, Benson RC Jr, Dewanjee MK, Utz WJ. Migration and granulomatous reaction after periurethral injection of polytef (Teflon). JAMA. 251:3277–3281, 1984.
Lavelle MT, Michael JC, Conlin MJ, Skoog SJ. Subureteral injection of deflux for correction of reflux: analysis of factors predicting success. Urology. 65:564-567, 2005.
Lackgren G, Wahlin N, Skoldenberg E, Stenberg A: Long-term followup of children treated with dextranomer/hyaluronic acid copolymer for vesicoureteral reflux. J Urol. 166:1887–1892, 2001.
Kirsch AJ, Perez-Brayfield MR, and Scherz C. Minimally invasive treatment of vesicoureteral reflux with endoscopic injection of dextranomer/hyaluronic acid copolymer: The Children’s Hospitals of Atlanta experience. J Urol. 170: 211–215, 2003.
Puri P, Chertin B, Velayudham M, Dass L, Colh oun E. Treatment of vesicoureteral reflux by endoscopic injection of dextranomer/hyaluronic acid copolymer: preliminary results. J Urol. 170:1541– 1544, 2003.
Oswald J, Riccabona M, Lusuardi L, et al: Prospective comparison and 1 year follow up of a single endoscopic subureteral polydimethylsiloxane versus dextranomer/hyaluronic acid copolymer injection for treatment of vesicoureteral reflux in children. Urology. 60: 894–897, 2002.
Elder JS, Diaz M, Caldamone AA, Cendron M, Greenfield S, Hurwitz R, Kirsch A, Kolye MA, Pope J, Shapiro E. Endoscopic Therapy for vesicoureteral reflux: A meta-analysis. I. Reflux resolution and urinary tract infection. J Urol. 175, 716-722, 2006.
Capozza N, Lais A, Matarazzo E, Nappo S, Patricolo M, Caione P. Influence of voiding dysfunction on the outcome of endoscopic treatment for vesicoureteral reflux. J Urol. 168: 1695–1698, 2002.