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Abstract
Purpose
We reviewed the operative outcome and the cause of failure for performing subureteral injection of polydimethylsiloxane (PDS, Macroplastique®, Uroplasty Inc. Geleen, The Netherlands), when it is used as a bulking agent for the endoscopic treatment of vesicoureteral reflux (VUR) patients.
Materials and Methods
A total of 29 patients (a total of 37 ureters), with primary grades I to V VUR were treated with a single subureteral injection from 2001 to 2004; these patients were followed for an average of 21.5 months. Each patient underwent preoperative voiding cystourethrography, renal ultrasound, a dimercapto-succinic acid (DMSA) scan and urine culture. With the patient under general anesthesia, the PDS implant was injected transurethrally at the 6 o'clock position of the ureteral opening in the affected renal unit by a modified subureteral transurethral injection (STING) procedure. Renal ultrasound was done at 1 week and voiding cystourethrography was done at 3 months to rule out obstruction at the injection site and/or persistent reflux, respectively. Cure was defined as an absence of VUR on voiding cystourethrography at 3 months after injection. Statistical analyses were performed using the chi-square test.
Results
The grade of reflux was I, II, III, IV and V in 6, 4, 12, 9 and 6 ureteral units respectively. After a single injection, the VUR was cured in 30 ureteral units (81.1%). There were 7 (18.9%) patients who received a second injection after a failed single injection. In these patients, the injected PDS volume was not changed on ultrasound. On the other hand, cystoscopy showed mound displacement in 4 patients, no volcano appearance but rather a broad elevation in 2 patient, and distal ureteral fistula and mound extrusion in 1 patient.
Figures and Tables
Fig. 1
Urinary bladder sonography. (A) Preoperative bladder sonography shows no specific echogenic shadow at the right ureteral orifice. (B) Postoperative bladder sonography shows an echogenic nodule (arrow) of injected polydimethylsiloxane (PDS).
Fig. 2
Cystoscopic findings. (A) Preoperative cystoscopy shows a "golf hole" appearance of the right ureteral orifice in a Gr III vesicoureteral reflux (VUR) patient. (B) Postoperative cystoscopy. (a) Competent ureteral orifice on the top of a "volcano" after the cystoscopic submucosal injection of polydimethylsiloxane (PDS). (b) Competent ureteral orifice on the top of a "volcano" after injection of PDS for Gr II VUR. (c) Incompetent ureteral orifice; a main mound (arrow) is seen above the ureteral orifice. (d) Incompetent ureteral orifice; a mound is still poorly seen around ureteral orifice at 5-7 o'clock. (e) Left ureteral orifice is barely seen at the top of mound due to overcorrection (cystoscopy at 1st operation). (f) Extrusion of PDS is seen due to mucosal necrosis after overcorrection. (g) Ureteral fistula near the Rt. ureteral orifice is seen. It might be the result of complete extrusion of PDS after overcorrection.
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