Low Risk Of Secondary Treatment After Endoscopic Injection Of VUR Using The Double HIT Method: Analysis Of 3059 Procedures Over 19 Years
Ricardo A. Arceo-Olaiz, MD, Shuvro De, MD, Andrew Kirsch, MD.
Emory University School of Medicine, Atlanta, GA, USA.
BACKGROUND: Individuals with VUR have increased risk of recurrent febrile urinary tract infections, increasing the risk of renal scarring, and end stage renal disease. Endoscopic injection was first proposed in the 1980s as a means of curing VUR as a minimally invasive alternative to open ureteral reimplantation. Despite high success rates with reimplantation, it generally involves an open approach with associated risks and potentially painful recovery. Review of the contemporary Double HIT method reaches success rates of 93%; however, the need for secondary procedures has not been evaluated. The objective of our study is to report our experience for additional Deflux injections after first injection failure.
Methods: We retrospectively reviewed our database of children who underwent Deflux (Dx/HA) from April 2003 to December 2021. We divided our population in 2 groups: STING/HIT Dx/HA injection from 2003 till 2012 represents historical method of endoscopic injection, and Double HIT Method Dx/HA injection from 2013 till 2021 representing the double HIT method. We compared both groups to assess the need of additional endoscopic injections (AEI).
Results: A total of 3059 Dx/HA injections were performed by 8 surgeons. We excluded patients > 18 years of age, leaving 3005 injections in this timeframe (2515 girls; 490 boys). In the STING/HIT Group 2167 injections (72%) were done and in the Double HIT Method Group, 838 patients (28%) were injected. A total of 305 AEI were performed during the whole period, representing only 10% of all procedures; most of them (83% vs 27%) done in the STING/HIT group. 282 (92.6%) of the AEI were second injections and 23 (7.4%) represented a third injection. In the STING/HIT group, 253 AEI were done (mean 11.2/year) compared to 52 in the Double HIT Method group (mean 6.5/year). A statistically significant 79% of decrease in AEI was seen in the Double HIT Method, as well as a 42% decrease in mean injections per year. CONCLUSIONS: Endoscopic injection of a bulking agent to correct VUR has a high success rate, comparable to ureteral reimplantation. In our experience, primary injection with the double HIT method has a low chance of additional endoscopic injections and supports its use as a first line option for children with primary VUR.
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