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MANAGEMENT OF URETERAL OBSTRUCTION FOLLOWING ENDOSCOPIC CORRECTION OF VESICOURETERAL REFLUX (VUR)
Yehuda Warszawer, MD, Helena Volodarski, MD, Jaudat Jaber, MD, Galia Raisin, MD,
Boris Chertin, MD.
Shaare Zedek Medical Center, Jerusalem, Israel
BACKGROUND:Endoscopic injection of bulking agents has become an alternative treatment for VUR, often replacing traditional methods such as antibiotic prophylaxis and ureteral reimplantation (UR). While endoscopic correction of VUR is recognised as a safe and effective procedure, reports in the literature indicate that ureteral obstruction (UO) can occur as a complication following intervention. This obstruction may present at varying intervals, with some patients experiencing it shortly after the procedure, and others developing delayed UO months or years later.Treatment options for UO include temporary double-J stenting or UR; however, definitive management guidelines remain unclear. This study seeks to clarify strategies for managing patients who develop UO following endoscopic correction of VUR using various bulking agents.
METHODS:A retrospective review was conducted, identifying all patients treated for UO after endoscopic correction of VUR over a 33-year period. The review included patients who underwent primary surgery within the institution and externally. Demographic and operative data were collected to analyse presentation timing and treatment outcomes. Complications were classified according to the Clavien-Dindo system. Continuous variables are reported as medians with interquartile ranges, and categorical variables as frequencies and percentages.
RESULTS:Of more than 1,000 patients who underwent endoscopic correction of VUR, twenty-one patients (8 males and 13 females) developed delayed UO in 26 renal units (RUs). Obstruction occurred following injection of Teflon (1 RRU), Deflux (2 RRUs), and Vantris (23 RRUs). The mean age at initial injection was 2.7 years (SEM 1.9). Reflux grades in affected RUs were Grade II in 5 (19.2%), III in 4 (15.4%), IV in 8 (30.8%), V in 7 (26.9%), and unknown in 2 (7.7%). Median follow-up was 77.8 months (range: 11.2 months to 34 years). Diagnosis of UO occurred between 5 months and 24 years post-injection. At presentation, 54.2% had a concurrent urinary tract infection (UTI). Revision of the pretreatment VCUG showed a narrowed distal ureter in 17 of 26 RUs (65.4%).Primary UR was performed in 21 RRUs (80.8%), with 7 undergoing intra/extravesical UR and 14 laparoscopic robotic-assisted extravesical UR. No Clavien-Dindo grade 3-4 complications were observed. Balloon dilatation and double-J stent placement were attempted in 2 RRUs each (7.7%), and transurethral resection of Teflon was attempted in 1 RRU (3.8%); all failed and subsequently required UR.
CONCLUSIONS:Ureteral obstruction following endoscopic correction of VUR represents a notable and challenging complication. This condition can arise several years after the initial procedure and is frequently associated with concurrent UTIs. The underlying pathology at the ureterovesical junction (UVJ) commonly results in UO, irrespective of the bulking agent employed during the endoscopic intervention. For patients presenting with delayed UO, definitive management typically necessitates UR. An extravesical approach is recommended, which may be performed either through open surgery or using laparoscopic robotic-assisted techniques, depending on individual patient circumstances and institutional expertise.
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