deflux in reflux - pedsurgerydelhi.com€¦ · the reflux rate is 54% among girls ages 1 to 3 years...

Deflux In Reflux

Dr Prashant jain

Vesicoureteric Reflux

• Refers to a condition in which

urine flows from the bladder

BACKWARDS up the ureter

and back into the kidneys

• Primary:

Due to defect in the uretero-

vesical valves

• Secondary:

Neurogenic/Obstruction

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Epidemiology of VUR

the most common urologic finding in children, occurring in approximately

1% of newborns

With UTI:

About 30-45% of children have VUR following first confirmed UTI1

The reflux rate is 54% among girls ages 1 to 3 years with a history of

febrile UTI2

The risk of febrile UTI recurrence is approximately 30% in children with

grade III or IV reflux3-5

Recurrence rate may be lower in reflux grade I and II

5-10% of Pediatric ESRD is due to Reflux Nephropathy

1. Conway PH, et al. JAMA. 2007;298(2):179-186. 2. Jodal U. Infect Dis Clin North Am. 1987;1:713-729.

3. Pennesi M, et al. Pediatrics. 2008;121:e1489-1494. 4. Montini G, et al. Pediatrics. 2008;122:1064-1071.

5. Brandstrom P, et al. J Urol. 2010;184:286-291.

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Symptoms

Antenatal hydronephrosis

Febrile UTI is a defining symptom

Unexplained fever

Urine dribbling between urinating

Dysuria (pain on urination)

Strong-smelling, cloudy, or bloody urine (hematuria)

Abdominal, back, or side pain

VUR grades

• The severity of VUR is based upon a grading system, reflecting the extent of reflux

and ureter abnormality1

• More severe VUR is associated with more severe renal scarring and increased

complications2,3

1AUA Guidelines 1997; 2Gonzalez 2005; 3Caione 2004

Kidney

Ureter

Bladder

Kidney

Ureter

Bladder

Kidney

Ureter

Bladder

Kidney

Ureter

Bladder

Kidney

Ureter

Bladder

Grade I Grade II Grade III Grade IV Grade V

Renal Scarring

• VUR + Pyelonephritis:

The odds of renal scarring in

children with VUR and

pyelonephritis are 2.8 times

greater than the odds of

scarring for children with

pyelonephritis without VUR.

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Renal Scarring Increases with Severity of VUR

Patients (N=161) included boys (n=41; mean age 1.2 years) and girls (n=120; mean age 2.9

years) with VUR grades 0 to V; no children had grade V reflux.

Gonzalez E, et al. J Urol. 2005;173:571-574

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Frequency (%) of Renal Scarring in Children Following

Febrile UTI With Acute Lesions

47%

60%

78%

Definition of success in VUR treatment

Aim of treatment

• Protect against febrile UTIs

• Prevent renal scarring

Definition of success

• The successful prevention of febrile UTIs that could lead to renal scarring

VUR Treatment Options

Prophylactic Antibiotics Open Surgery

Curative 83% Success Rate**

Duration of Treatment 1 – 5 years*

Endoscopic Injection

Curative 95% Success Rate

Duration of Treatment up to 3 days (inpatient)1

Not Curative 5 – 13% Annual Resolution

* Optimal duration of antibiotic prophylaxis is undetermined but clinical studies have used 1-5 years

** Majority of patients are cured after a single treatment

Duration of Treatment 1 day (outpatient)1

1Kobelt 2003

What is Deflux?

• Viscous substance

• Combination of Hyaluronic acid and Dextronomer

• Bulking agent and coapts the ureteric orifice during

bladder filling and emptying

• Safe and well tolerated

• Reproducible

• No major adverse reactions

• Does not alter the open surgery success

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STING technique

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Submucosal plane of the INTRAVESICAL URETER

STING technique (Subureteric transurethral injection)

The tip of the DEFLUX needle is inserted under the bladder mucosa 2 to 3 mm below the ureteral orifice at 6 o’clock position

The needle tip is positioned in submucosal plane of the INTRAVESICAL URETER

DEFLUX is injected until a prominent bulge appears and the orifice has a crescent-like shape

.

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