Endoscopic subureteral injection treatment with calcium hidroxylapatite in primary vesicoureteral reflux

Primer vezikoüreteral reflüde kalsiyum hidroksilapatit ile endoskopik subrüreteral enjeksiyon tedavisi

BİLAL ERYILDIRIM,FATİH TARHAN,Uğur KUYUMCUOĞLU,Erkan ERBAY,Gökhan FAYDACI,Necmettin PENBEGÜL

Abstract

Introduction: During the last 20 years endoscopic treatment of vesicoureteral reflux (VUR) has gained popularity. However the choice of injection material to be used is controversial. Calcium hydroxylapatite (Coaptite(r)) biocompatible injectable material has been reported to be a promising alternative to other tissue augmenting substances. Coaptite(r) is composed of microspheres of calcium hydroxylapatite, the same material that is a major component of bone and teeth. In this study, we evaluated results of subureteric injection of calcium hydroxylapatite treatment for primary vesicoureteral reflux. Materials and Methods: Twenty three children (mean age 6.6±2.9 years) underwent subureteral injection of calcium hydroxylapatite for primary vesicoureteral reflux between April 2002 and April 2004. Reflux was unilateral in 9 cases and bilateral in 14 of affected 37 ureteral units. Preoperative urine culture, renal ultrasonography, static renal sintigraphy (DMSA) and voiding cystouretrography were performed in all cases. According to "International Reflux Classification"; grade I reflux in 5 (13.5%), grade II in 9 (24.3%), grade III in 15 (40.5%), grade IV in 7 (18.9%) and grade V in 1 üreteral unit (2.7%) was found. Wide spectrum antibiotics were given to all cases before operation. Under general anesthesia, following routine cystoscopy in dorsal lithotomy position all patients underwent endoscopic subureteral injection with calcium hydroxylapatite. Under direct vision through the 11 F cystoscope needle tip is inserted at the 6 o'clock position into the subureteric space, approximately 0.5 cm distal to the ureteral orifice. A correctly placed injection creates the appearance of a nipple and in order to avoid extravasation, from a single entrance. Following injection, after waiting for one minute needle was taken out and procedure was completed. Treatment was done on an outpatient basis. Average injected volume was 1.3 ml for per ureteral unit. Median follow-up was 11.3 months (range 8 to18 months). Antibiotic prophylaxis was prescribed for 12 weeks after the procedure. Renal sonography was performed in four weeks to determine whether hydronephrosis was present. Success of treatment was assessed by voiding cystourethrographies at 3rd and 12th month after subureteric injection. Results: The reflux was corrected in 20 (54.1%) ureteral units after a single injection and resolved after a second and third injection in 3 and 2 ureteral units, respectively. However, total success rate of reflux treatment with calcium hydroxylapatite was 67.6% in all ureteral units; the success rate was approximately 80% in patients with grade I-III VUR. Endoscopic treatment failed to correct reflux in 12 ureteral units, which were managed by ureteral reimplantation. No procedure related complications and untoward effects were observed in any patients in whom calcium hydroxylapatite was used as the injected material. In cases that showed cure by cystouretrography at 3rd month, reflux recurrence was not observed by cystouretrography on 12th month. Conclusion: Endoscopic subureteral injection of calcium hydroxylapatite in children with primary low grades vesicoureteral reflux appears to be an effective, safe and minimally invasive technique. In addition, procedure is extremely simple and no additional equipment is required.

Özet

Son 20 yıldır vezikoüreteral reflü (VUR)'nün endoskopik tedavisi popülarite kazanmıştır. Bununla birlikte kullanılacak enjeksiyon materyali seçimi tartışmalıdır. Biz bu çalışmada primer VUR olgularında subüreterik kalsiyum hidroksilapatit enjeksiyon tedavisi uygulayarak, sonuçları değerlendirdik. Nisan 2002 ile Nisan 2004 tarihleri arasında yaş ortalaması 6,6±2,9 yıl olan toplam 23 çocuğa (6 erkek ve 17 kız), primer vezikoüreteral reflü nedeniyle subüreteral kalsiyum hidroksilapatit enjeksiyonu uygulandı. Dokuz olguda tek taraflı ve 14 olguda çift taraflı olmak üzere toplam 37 üreteral ünite etkilenmişti. "İnternational Reflux Classification"a göre; 5 üreteral ünitede reflü grade I (%13.5), 9'unda grade II (%24.3), 15'inde grade III (%40.5), 7'sinde grade IV (%18.9) ve 1'inde grade V (%2.7) idi. Tedavinin başarısı subüreterik enjeksiyonu takiben 3. ve 12. aylarda yapılan sistoüretrografilerle değerlendirildi. Ortalama takip süresi 11.3 ay idi (8-18 ay). Tek enjeksiyondan sonra 37 üreteral üniteden 20 sinde (%54,1) reflü düzeldi. İkinci ve üçüncü enjeksiyonu takiben ise toplam 25 üreteral ünitede düzelme oldu. Genel başarı oranı %67,6 (25/37) olmakla birlikte, grade I-III VUR'lü olgularda bu oran % 80 civarında idi. Çocuklarda düşük dereceli primer vezikoüreteral reflülerde endoskopik subüreteral kalsiyum hidroksilapatit enjeksiyonu etkili, güvenli ve minimal invaziv bir teknik olarak görünmektedir.