Pediatric endourology and ureterovesical junction

Introduction: Since the first case of dextranomer/hyaluronic acid (Dx/HA) implant calcification in 2008, concern about the long-term sequelae of Dx/HA injection has been growing. According to previous reports, the incidence of Dx/HA calcification 4 years after injection would be around 2%. Aim: The primary aim was to estimate the incidence of Dx/HA implant calcification after endoscopic treatment of vesicoureteral reflux in pediatric patients. Secondary objectives were to establish risk factors and to perform a survival analysis after Dx/HA injection. Study design: Patients undergoing Dx/HA endoscopic injection from 2007 to 2014 were prospectively registered. The database included clinical, surgical and radiological outcomes. Patients that showed Dx/HA implant calcification during follow-up were compared to those who did not. Univariable and survival statistical analyses were performed. Results: 30 implants calcified over 355 ureters endoscopically treated. Age at first treatment was lower in patients with implant calcification (2.4 ± 1.3 years vs 3.6 ± 2.5 years; p<0.005). The risk of implant calcification was 8.45% (95% CI: 5.96-11.85%). Median follow-up was 7.6 years (IQR: 5.2-9.5). The incidence rate was 12.06 cases per 1000 ureters-year. The period of highest hazard of implant calcification was between 3 and 5 years after injection. The only risk factor related to implant calcification was the age at first injection: relative risk of implant calcification was 4.4 (95% CI: 1.6 to 12.4; p=0.002) for patients first treated before the age of 3.5 years. Discussion: The risk and the incidence rate of Dx/HA implant calcification were higher than previous data. The period of highest hazard and detection of implant calcification were consistent with previous reports. Patients first treated before the age of 3.5 had shorter survival time without implant calcification. These are the first data about risk factors and survival function of Dx/HA implant calcification. However, our conclusions about the clinical significance of Dx/HA implant calcification were limited because the patients with implant calcification were Journal Pre-proof 2 asymptomatic. Further studies with larger sample and longer follow-up should confirm the clinical significance and life-long tendency of Dx/HA implant calcification. Conclusions: The risk and the incidence rate of Dx/HA implant calcification were higher than expected. The hazard of calcification was higher between 3 and 5 years after injection. The risk was especially higher in patients treated before the age of 3.5. Caution should be taken not to confuse implant calcifications with ureteric stones. A 5-year follow-up would set a better understanding of the actual incidence and clinical significance of implant calcification.

Objective To compare the radiological and clinical outcomes of endoscopic treatment of primary VUR using polyacrylatepolyalcohol copolymer (PPC-Vantris®) or dextranomer-hyaluronic acid copolymer (Dx/HA-Defux®). Materials and methods From October 2014 to April 2017, patients with primary VUR grade III to V that needed endoscopic treatment (ET) were eligible for this randomized clinical trial. We excluded toilet-trained patients with lower urinary tract symptoms. Patients were randomized and allocated into two groups: PPC group and Dx/HA group. After endoscopic treatment a voiding cystourethrography (VCUG) was performed at 6 months; if VUR was still present a second ET was performed. Radiological success was considered if postoperative VUR grade was 0 and clinical success rate was considered if no more fUTI appeared during follow-up. Results Forty-six patients were eligible but 2 did not accept the trial. Forty-four patients with 73 refuxing ureters were included. PPC: 34 refuxing ureters; and Dx/HA: 39 refuxing ureters. Both groups were statistically homogeneous and comparable. Mean follow-up was 27.6 months. Radiological success rate (82.2%) and clinical success rate (92.3%) were similar in both groups (p>0.05). The volume of bulking agent used in those successfully treated was greater in Dx/HA group (p<0.05). Distal ureter was excise in all cases of ureteral reimplantation after PPC treatment; however, distal ureter was preserved in all ureters reimplanted after Dx/HA injection. Conclusion PPC and Dx/HA had similar outcomes, but we must warn that ureteral reimplantation after endoscopic treatment with PPC is difcult because of the periureteral fbrosis.

Malakoplakia is a rare chronic inflammatory disease that was originally described in the urinary bladder but can involve many other organs and soft tissues. It is believed to be caused by an alteration in the bacterial phagocytic system. Clinically, it is described as single or multiple tumors that can appear in any part of the body. Histologically, the presence of Michaelis-Gutmann bodies is pathognomonic. Malakoplakia in children is rare. Few pediatric cases in the urinary tract, kidney, or gastrointestinal tract have been published. We present a case of urinary and gastrointestinal malakoplakia in a 12-year-old girl.

Lower urinary tract tumours are uncommon in paediatrics. Transitional cell carcinoma of the bladder (TCCB) is rarely found in the first two decades of life and is exceptional under 10 years of age. The present series aimed to expand the number of reported cases in the literature. In 1984-2007, six patients (four male, two female), aged 6, 9, 12, 13, 14 and 17 years, were treated at our centre. Clinical presentation was macroscopic haematuria in five and pyelonephritis in one. Physical examination, laboratory analysis, ultrasound and cystoscopy were performed before surgical treatment in all patients. Follow up was by clinical and ultrasound assessment. Neither physical examination nor laboratory analysis revealed any significant abnormalities, but ultrasound showed exophytic intravesical lesions. Surgical resection was performed endoscopically. Histological studies showed grade I TCCB in all cases. The immediate postoperative period was uneventful and long-term follow up did not reveal recurrence. Despite its low incidence in children, TCCB must be suspected in the event of macroscopic haematuria. Ultrasound followed by cystoscopy are the ideal diagnostic tools for visualization of these tumours. Endoscopic resection proved effective in all the present cases. Follow up must be clinical with periodic ultrasound evaluation. Urine cytologic examination is ineffective. Periodic cystoscopy is indicated only in cases of clinical or ultrasonographic suspicion of recurrence.

Objective: To present our cases of ureteral obstruction after endoscopic treatment of vesicoureteral reflux (VUR) with dextranomer/hyaluronic acid (Dx/HA). Patients and methods: We collected data from patients who had suffered ureteral obstruction after endoscopic treatment of VUR with Dx/HA in our institution. Results: From April 2002 to April 2011 we treated endoscopically 475 ureters with VUR, and detected 5 ureteral obstructions. Median age at reflux treatment was 39 months. Reflux grade before treatment was III in one patient and IV in four. Three ureterovesical junctions (UVJ) were blocked after a second endoscopic treatment. The median of Dx/HA injected was 1 ml (0.6-1.1). In two patients ureteral obstruction presented acutely and was treated with a ureteral stent. In the other three, the ureteral obstruction appeared gradually and was detected by ultrasound scans and MAG3 diuretic renogram; one underwent nephrectomy because of poor renal function, and the other two were treated with endoscopic dilatation of the UVJ. In all these patients both reflux and obstructions have resolved. Conclusions: On preoperative cystography, three of the patients had a narrowed distal ureter, and probably had a refluxing and obstructive megaureter. Other causes are not clear, except for those patients with acute presentation in whom edema of the UVJ was found. Ureteral obstruction after endoscopic treatment of VUR is rare. Endoscopic intervention such as ureteral stent placement or high-pressure balloon dilatation of the UVJ has good results as a treatment of acute and delayed obstruction.

Purpose: To compare efficacy of Cohen's ureteral reimplantation and endoscopic treatment with Dx/HA in patients with primary VUR grades II, III and IV. Methods: From April 2002 to June 2004, patients over 1 year old with VUR grade I, II, III or IV were included. Patients were randomized into two groups: endoscopic treatment (ET) or ureteral reimplantation (UR). In the ET group, an ultrasonography study was performed 24 h and 1 month after surgery, and two voiding cystourethrographies at 3 and 6 months post treatment. In the UR group, an ultrasonography study was done 7 days and 1 month after surgery and a micturial cystography 6 months post surgery. A postoperative nuclear direct cystogram was performed 5 years later in both groups. Results: A total of 41 patients were included in this study: in ET 22 patients with 35 refluxing ureters and in UR 19 patients with 32 refluxing ureters. The VUR grades in ET were: 16 grade II, 16 grade III and 3 grade IV; and in UR: 15 grade II, 12 grade III and 5 grade IV. VUR was resolved in 91% (32/35) of ET (28% of ureters needed a second injection), and in 100% of UR group. Five years after the procedure, VUR was still resolved in 30/32 of ET and 32/32 of UR. Conclusion: Short- and long-term follow up shows that multiple endoscopic treatment of VUR grades II, III and IV with Dx/HA is as effective as ureteral reimplantation.

Objective: To compare the outcomes between high-pressure balloon dilatation (HPBD) of the ureterovesical junction and the ureteral reimplantation with ureteral tapering to treat primary obstructive megaureter. Patients and methods: Retrospective review of clinical data from patients who underwent surgical treatment of POM from 2005 to 2010. Patients were divided in two groups: endoscopic treatment (ET) and ureteral reimplantation (UR). ET treatment was performed with UVJ dilatation, and Cohen's or Leadbetter-Politano neoureterocystostomy and Hendren´s tapering was performed in UR group. Preoperative studies included: ultrasound scan, voiding cystourethrography, and diuretic isotopic renogram in both groups. Outcomes were achieved with ultrasound scan (US), differential renal function (DRF), presence of postoperative vesicoureteral reflux, need for secondary reimplantation and complications. Qualitative data were analyzed with Chi-square test or Fischer´s test, and quantitative date we analyzed with U-Mann-Whitney test for impaired data and Wilcoxon test for paired data. Results: Group ET: 13 patients with a median age of 7 (4-24) months and group UR: 12 patients with a median age of 14 (7-84) months, with no statistical differences in age and gender. Preoperative ultrasound parameters were similar in both groups with no statistical differences. ET group: mean diameter of renal pelvis, calices and ureter were: 23.5 mm, 13.46 mm and 15.77 mm respectively. UR group: mean diameter of renal pelvis, calices and ureter were 22.25 mm, 11.75 mm, and 19.08 mm, respectively. Preoperative DRF were 45.62% and 39.33% for ET and UR groups, respectively (p>0.05). Significant improvement of the hydroureteronephrosis was observed in 11/13 patients and 11/12 patients in ET and UR groups. (p>0.05) Postoperative vesicoureteral reflux was observed in 2 patients in ET group and one in UR group (p>0.05). A secondary ureteral reimplantation was used in 3 patients of ET group and 2 patients in UR group (p>0.05) Conclusion: Endoscopic treatment of POM is as effective as ureteral reimplantation, but long-term follow-up is needed.