Comparative analysis of efficacy and safety of transurethral and vesicoscopic surgery of primary vesicoureteral reflux in children

Introduction. Research interest in vesicoureteral reflux (VUR) is determined by continued dissatisfaction with the treatment results, which do not exclude the development of renal failure and hypertension. The management tactics of such patients currently range from the dynamic follow-up to various surgical correction options, which determines the relevance of developing a personalized approach when choosing a surgical treatment technique.

Purpose of the study. The study was aimed at a comparative analysis of the efficacy and safety of transurethral administration of a polyacrylate polyalcohol copolymer (PPC) and vesicoscopic transregional ureterovesical anastomosis (VUVA) according to Cohen.

Materials and methods. The study is based on a retrospective analysis of the results of treatment of 214 patients with primary VUR, who underwent surgery from 2012 to 2018. The average age was 61.7 ± 47.9 months. Girls — 133 (62.1%), boys — 81 (37.6%). Indication for surgery in 150 (70%) children was recurrent urinary tract infection, in 64 (30%) — progressive reflux nephropathy. Bilateral process was observed in 92 (43%) patients, left-sided — in 69 (32%), right-sided — in 53 (25%). Patients were divided into two groups. Group I — 119 (55.6%) patients (179 renal units (RU)), who underwent endoscopic treatment (ET) using PPC. Group II — 95 (44.4%) children (127 RU) who underwent VUVA. Each of the groups was divided into subgroups, including RU with a low grade of (I-III) VUR and RU with a high grade of (IV-V) VUR. Complications were graded using the Clavien-Dindo classification. Statistical analysis and processing of the obtained data were performed using Microsoft Excel and STATISTICA10 software.

Results. When comparing the gender structure of the groups, differences were not detected (p >0.05). The average age in Group I was 53.5 ± 44.4 months, in Group II — 72.0 ± 50.4 months. (p <0.01). Episodes of urinary tract infection before surgery and bilateral VUR were detected more often in patients of Group I (p <0.05). Median duration of surgery (min.) and postoperative stay (days) and quartile range [Q1; Q3] in Group I were 15 [15; 15] and 2 [2; 3], respectively, and in Group II — 100 [80; 135] and 5 [4; 7], respectively (p <0.01). After the first ET, VUR was eliminated in Subgroup I (I-III deg) in 91.7%; after the second ET, the overall efficiency increased to 92.5%. In Subgroup II (I-III deg), VUR was eliminated in all children after the first surgery (p <0.05). The formation of contralateral VUR with unilateral VUR in patients of Group I (I-III) was observed in 12.8% of cases versus 0 in Group II (I-III) (p <0.05). There were no significant differences in the frequency and severity of postoperative complications between subgroups I (I-III) and II (I-III) (p >0.05). In Subgroup I (IV-V) after the first ET, reflux was eliminated in 76.3%, after the second ET the overall efficiency was 81.4%. In Subgroup II (IV-V deg), VUR was eliminated in 100% of cases (p <0.01). When comparing the frequency of contralateral reflux formation between subgroups I (IV-V) and II (IV-V), no differences were found (p >0.05). In Subgroup I (IV-V), a predominance of the III-grade complications (p <0.01) was revealed.

Conclusion. A comparative analysis of the efficacy and safety of surgical treatment of VUR using transurethral and vesicoscopic approaches revealed that ET is preferred for patients with low reflux grades (I-III). Vesicoscopic approach provides higher efficacy and safety in patients with high VUR grades (IV-V) compared with ET.

1. Riabtseva A.V., Fomin D.K., Yatsyk S.P., Sharkov S.M., Abramov K.S. Historical aspects of the vesicoureteral reflux study among children. Pediatric Pharmacology. 2008;5(6):67-74. (In Russ.). eLIBRARY ID: 12805122

2. Ardissino G, Dacco V, Testa S, Bonaudo R, Claris-Appiani A, Taioli E, Marra G, Edefonti A, Sereni F; ItalKid Project. Epidemiology of chronic renal failure in children: data from the ItalKid project. Pediatrics. 2003;111(4 Pt 1):e382-7. https://doi.org/10.1542/peds.111.4.e382

3. Jacobson SH, Hansson S, Jakobsson B. Vesico-ure-teric reflux: occurrence and long-term risks. Acta Paediatr Suppl. 1999;88(431):22-30. https://doi.org/10.1111/j.1651-2227.1999.tb01315.x

4. Sargent MA. What is the normal prevalence of vesicoureteral reflux? Pediatr Radiol. 2000;30(9):587-93. https://doi.org/10.1007/s002470000263

5. EAU Guidelines. Edn. presented at the EAU Annual Congress Amsterdam 2020. ISBN 978-94-92671-07-3.

6. Chung KLY, Sihoe J, Liu K, Chao N, Hung J, Liu C, Yam F, Leung Y, Tam P, Lee KH, Leung M. Surgical Outcome Analysis of Pneumovesicoscopic Ureteral Reimplantation and Endoscopic Dextranomer/Hyaluronic Acid Injection for Primary Vesicoureteral Reflux in Children: A Multicenter 12-Year Review. J Laparoendosc Adv Surg Tech A. 2018;28(3):348-353. https://doi.org/10.1089/lap.2017.0281

7. Kirsch AJ, Arlen AM. Evolving surgical management of pediatric vesicoureteral reflux: is open ureteral reimplantation still the 'Gold Standard'? Int Braz J Urol. 2020;46(3):314-321. https://doi.org/10.1590/S1677-5538.IBJU.2020.99.05

8. Lebowitz RL, Olbing H, Parkkulainen KV, Smellie JM, Tam-minen-Mobius TE. International system of radiographic grading of vesicoureteric reflux. International Reflux Study in Children. Pediatr Radiol. 1985;15(2):105-9. https://doi.org/10.1007/BF02388714

9. Yeung CK, Sihoe JD, Borzi PA. Endoscopic cross-trigonal ureteral reimplantation under carbon dioxide bladder insufflation: a novel technique. J Endourol. 2005;19(3):295-9. https://doi.org/10.1089/end.2005.19.295

10. Cohen SJ. Uretero cystoneostomie: eine neue antireflux technik. Aktuelle Urol. 1975;6:1-6.

11. Pirogov A.V., Sizonov V.V. Comparative analysis of efficacy of ureteral reimplantation at vesicoureteral reflux and ureterovesical junction obstruction using vesicoscopic approach in children. Herald Urology. 2017;5(4):47-57. (In Russ.). https://doi.org/10.21886/2308-6424-2017-5-4-47-57

12. Pirogov A.V., Sizonov V.V., Kogan M.I. Experience of 157 vesikoscopic operations in children. Urologiia. 2017;6:59-64 (In Russ.) eLIBRARY ID: 30754512

13. O'Donnell B, Puri P. Treatment of vesicoureteric reflux by endoscopic injection of Teflon. Br Med J (Clin Res Ed). 1984;289(6436):7-9. https://doi.org/10.1136/bmj.289.6436.7

14. Kirsch AJ, Perez-Brayfield M, Smith EA, Scherz HC. The modified sting procedure to correct vesicoureteral reflux: improved results with submucosal implantation within the intramural ureter. J Urol. 2004;171(6 Pt 1):2413-6. https://doi.org/10.1097/01.ju.0000127754.79866.7f

15. Cerwinka WH, Scherz HC, Kirsch AJ. Dynamic hydrodistention classification of the ureter and the double hit method to correct vesicoureteral reflux. Arch Esp Urol. 2008;61(8):882-7. https://doi.org/10.4321/s0004-06142008000800005

16. Politano VA, Leadbetter WF. An operative technique for the correction of vesicoureteral reflux. J Urol. 1958;79(6):932-41. https://doi.org/10.1016/s0022-5347(17)66369-9

17. Gregoir W. Le traitement chirurgical du reflux vesico-ureter-al con- genital. Acta Chir Belg. 1964;63:432.;

18. Bisignani G, Decter RM. Voiding cystourethrography after uncomplicated ureteral reimplantation in children: is it necessary? J Urol. 1997;158(3 pt 2):1229-31. https://doi.org/10.1097/00005392-199709000-00145

19. Matouschek E. Die Behandlung des vesikorenalen Refluxes durch transurethrale Einspritzung von Teflonpaste [Treatment of vesicorenal reflux by transurethral teflon-injection (author's transl)]. Urologe A. 1981;20(5):263-4. German. PMID: 7197421.

20. Elder JS, Diaz M, Caldamone AA, Cendron M, Greenfield S, Hurwitz R, Kirsch A, Koyle MA, Pope J, Shapiro E. Endoscopic therapy for vesicoureteral reflux: a meta-analysis. I. Reflux resolution and urinary tract infection. J Urol. 2006;175(2):716-22. https://doi.org/10.1016/S0022-5347(05)00210-7

21. Chertin B, Arafeh WA, Zeldin A, Ostrovsky IA, Kocherov S. Endoscopic correction of VUR using vantris as a new nonbiodegradable tissue augmenting substance: three years of prospective follow-up. Urology. 2013;82(1):201-4. https://doi.org/10.1016/j.urology.2013.01.024

22. Alizadeh F, Mazdak H, Khorrami MH, Khalighinejad P, Shoureshi p. postoperative ureteral obstruction after endoscopic treatment of vesicoureteral reflux with polyacrylate polyalcohol copolymer (Vantris®). J Pediatr Urol. 2013;9(4):488-92. https://doi.org/10.1016/jjpu-rol.2012.11.007

23. Sizonov V.V., Akramov N.R., Bondarenko S.G., Dlgov B.L., Dubrov V.I., Kagantsov I.M., Pirogov A.V., Shklyar V.N., Shchedrov D.N., Garmanova T.N. Obstructive complications of endoscopic treatment of vesicoureteral reflux in children. Detskaya khirurgiya (Russian Journal of Pediatric Surgery). 2016; 20(4):181-184. (In Russ.). https://doi.org/10.18821/1560-9510-2016-20-4-181-184

24. Sizonov VV, Kagantsov IM, Mayr JM, Akramov NR, Pirogov AV, Gasanov ZA. Risk factors for obstructive complications after endoscopic correction of vesicoureteral reflux using polyacrylate polyalcohol copolymer. Medicine. 2020;99:22(e20386). https://doi.org/10.1097/md.0000000000020386

25. Ehrlich RM, Gershman A, Fuchs G. Laparoscopic vesicoureteroplasty in children: initial case reports. Urology. 1994;43(2):255-61. https://doi.org/10.1016/0090-4295(94)90058-2

26. Bondarenko S. Laparoscopic extravesical transverse ureteral reimplantation in children with obstructive megaureter. J Pediatr Urol. 2013;9(4):437-41. https://doi.org/10.1016/j.jpurol.2013.01.001

27. Okamura K, Ono Y, Yamada Y, Kato T, Tsuji Y, Ohshima S, Miyake K. Endoscopic trigonoplasty for primary vesico-ureteric reflux. Br J Urol. 1995;75(3):390-4. https://doi.org/10.1111/j.1464-410x.1995.tb07355.x

28. Valla JS, Steyaert H, Griffin SJ, Lauron J, Fragoso AC, Arnaud p, Leculee R. Transvesicoscopic Cohen ureteric reimplantation for vesicoureteral reflux in children: a single-centre 5-year experience. J Pediatr Urol. 2009;5(6):466-71. https://doi.org/10.1016/j.jpurol.2009.03.012

29. Jayanthi VR. Vesicoscopic cross-trigonal ureteral reimplantation: High success rate for elimination of primary reflux. J Pediatr Urol. 2018;14(4):324.e1-324.e5. https://doi.org/10.1016/j.jpurol.2018.04.005

30. Tae BS, Jeon BJ, Choi H, Park JY, Bae JH. Comparison of open and pneumovesical approaches for politano-Leadbetter ureteric reimplantation: a single-center long-term follow-up study. J Pediatr Urol. 2019;15(5):513.e1-513.e7. https://doi.org/10.1016/j.jpurol.2019.05.033