Info

□ Table 5.1. Pediatric cystourethroscopes

Shaft (Fr)

Angle of view

Length

Irrigating/working channels

Tip/Proximal

(degrees)

(cm)

(Fr)

Olympus

S-1234/1

6.4/7.8

13.0

4.2, straight

S-1234/2a

8.6/9.8

14.0

6.6, straight

Storz

27030Ka

7.5/8.5

11.0

2.4, 3.5, straight

27030Ka

10.0/10.5

11.0

5.5, straight

Wolf

4615.401

4.5/6.0

11.0

2.4

8616.411a

6.0/7.5

1 4.0

4.0

8626.431a

9.5

11.6

5.0, straight

a Autoclavable for sterilization.

a Autoclavable for sterilization.

reimplantation. Endoscopic treatment was started with the subureteric injection of Teflon. Outstanding results have been reported, with an overall cure rate of 90%, although a number of children will require two or even three treatments (Puri 1995). Injection of Teflon paste has not been accepted in the United States where some studies have demonstrated migration of Teflon particles to other parts of the body. Consequently, a search has been on for other injectable agents. The viability of endoscopic injection has proven to be highly dependent on the selected injectable agent. Numerous materials have been tried. Teflon, silicone and cross-linked bovine collagen have been studied thoroughly. However, concerns regarding the safety and efficacy of these agents have precluded their widespread use.

The only agent that is currently approved by the American Food and Drug Administration for this purpose is Deflux. Dextranomer/ hyaluronic acid copolymer is biodegradable and devoid of allergenic, immunogenic or mutage-nic potential. Success rates with Deflux average about 70% per injection, even in expert hands. Morbidity is minimal, with the procedure being performed on an outpatient basis in most cases, and there is no need for a catheter, as dysuria is minimal and the child return to normal activity within 1 day.

One fascinating new concept and new treatment algorithm is that of immediate endoscopic treatment of reflux of any grade at any age. The philosophy behind this still experimental approach is that compared with antibiotic prophylaxis, immediately successful endoscopic repair with minimal morbidity provides a better cure rate; no risk of poor compliance or bacterial resistance; avoids annual VCUGs or radionuclide tests; and avoids the use of prophylactic antibiotics and therefore much anxiety and stress on the family, thus conforming to parental preference. Randomized clinical trials of immediate endoscopic treatment vs traditional management are under investigation. Preliminary results demonstrate a 77% cure rate; the 23% who still have reflux are treated with prophylaxis and urotherapy, which should result in a 20% further reflux resolution rate. In the remaining 2%-5% of patients, open surgical correction is preferred.

Indications

™ Primary reflux grade II, III and IV as an alternative to antibiotic prophylaxis.

™ Grade I in bilateral reflux.

™ Reflux persistence or recurrence after surgical treatment.

™ First-line treatment of any reflux in the future?

Limited (no) Indications

™ Primary grade V reflux.

™ Lateralized golf-ball-sized orifice.

™ Reflux and ureterocele.

™ Ureteral duplication.

™ Chronic cystitis and dysfunctional voiding.

™ Neurogenic bladder.

Endoscopic Injection Technique

(Step by Step)

™ Prepare the 8-Fr urethrocystoscope with straight working channel and 30° lens.

™ Fill the bladder to half of age-related capacity.

™ Insert the needle (3 or 5-Fr) in the 6 o'clock position under the mucosa of the orifice 2-3 mm proximal to the orifice and elevate the needle.

™ Inject the bulking agent until a volcano-shaped and slit like orifice is obtained.

™ Keep the needle in place 30 s. after the end of injection.

™ No catheter drainage.

Tips and Tricks

™ Do not fill the bladder too much before the procedure.

™ Use a metal needle (3.7 Fr Cook) with two reference marks to guide proper placement during the procedure.

™ Twist the needle during injection to the left and to the right.

™ Instill a local anaesthetic lubricant into the urethra after the procedure to avoid painful micturition.

Sources of Failure

™ Displacement of the material. ™ Loss of the material volume. ™ Dysfunctional voiding.

Smellie at al. had demonstrated that children with reflux but no renal scarring who where maintained infection-free did not suffer serious consequences as adults.

Consequently, there is a need for early recognition and treatment of children with reflux and UTI to limit scar development. Vesicoure-teral reflux (VUR) is not a single pathological entity but a the result of a dynamic interaction between normal anatomy and function. Voiding dysfunction is now recognized to play an important role in the etiology of primary reflux. Antibiotics, endoscopic treatment and surgery are choices to manage reflux. It is important to explain and discuss the risks, benefits and follow-up of each treatment. Management should be individualized, is based on specific indications and parental preference. Many families still start with antibiotic prophylaxis to await the spontaneous resolution of reflux and to avoid anesthesia and surgery. Surgery may be favoured if VUR is severe, if there are other related medical conditions or if the highest success rate is the most important factor in family's personal view. In several pediatric urology centers, endoscopic treatment is being considered as the first option to treat reflux. The durability and the incidence of UTI and scarring after endoscopic treatment remain unanswered.

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