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Objective: To evaluate a single referral center's experience with vesicoureteral reflux (VUR) and its role in management before bladder neck reconstruction (BNR) in exstrophy patients after modern staged repair of exstrophy (MSRE). VUR after primary closure of bladder exstrophy can usually be managed conservatively until ureteral reimplantation (UR) at the time of BNR. However, VUR in these patients is occasionally associated with febrile urinary tract infection and worsening renal function necessitating UR before BNR., Materials and Methods: A total of 199 patients who underwent MSRE were identified from an institutional review board-approved database. Patient demographics, closure history, postprimary closure VUR, history of urinary tract infection, cystography outcomes, renal function, history of UR before BNR, and UR outcomes were recorded. Univariate and multivariate analyses were performed to determine factors predicting high-grade VUR and the need for pre-BNR UR., Results: After primary closure, VUR was observed in 150 patients (75.4%) of whom 31 (15.58%) had high-grade VUR. Closure without osteotomy and postclosure outlet obstruction were independently associated with postprimary closure high-grade VUR (P <.05). Twenty-two patients (11.06%) required pre-BNR UR. Female gender and those with high-grade VUR were more likely to require UR before BNR (P <.05). Early UR did not affect the continence rate., Conclusion: VUR after exstrophy closure can generally be managed with conservative treatment and periodic monitoring of the upper urinary tracts. About 11% of patients undergoing MSRE will require UR before BNR. Closure without osteotomy and patients who develop outlet obstruction after closure are at increased risk for developing high-grade VUR., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: To represent our experience in the management of posterior urethral valves and concomitant vesicoureteral reflux (VUR)., Methods: A total of 326 children with posterior urethral valve who had underwent valve ablation/bladder neck incision were studied, and those who had persistent VUR and were categorized under 3 main groups were followed up. Group 1 (n = 71) received prophylactic antibiotic, group 2 (n = 50) underwent Deflux injection (2a) (n = 28): Deflux injection alone, group 2b (n = 22) Deflux with concomitant autologous blood injection (HABIT), and group 3 (n = 19) underwent ureteroneocystostomy before referral and was followed up conservatively. VUR resolution, incidence of urinary tract infections (UTI), and bladder function were assessed., Results: Mean duration of follow-up was 3.8 years; VUR resolution occurred in 66.1%, 86.0%, and 94.0% of groups 1-3, respectively (P = .013). Resolution rate in group 2b was significantly higher than group 2a (90.9% vs 78.5%). Patients in group 2 experienced a longer UTI-free period compared with others (P <.05). Urodynamic studies demonstrated significant decrease in maximum voiding detrusor pressure and detrusor overactivity in all groups (P <.001). Children in group 3 ended up with lower compliance compared with others (P <.001). After toilet training, only 2.8%, 21.4%, 13.6%, and 27% children were diagnosed with lower urinary tract dysfunction in groups 1-3, respectively (P = .027). Myogenic failure developed only in 3 boys in group 3., Conclusion: Ablation/bladder neck incision leads to significant improvement in VUR status in part because of improvement in bladder function. After successful valve removal, conservative therapy can be regarded as the mainstay of reflux treatment, whereas HABIT is recommended for high grade VUR associated with febrile UTI or deterioration in renal function., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objective: To report the results of a single-center experience with the endoscopic injection of Deflux as the initial minimally invasive approach in patients with vesicoureteral reflux (VUR) and coexisting obstruction at the ureteropelvic junction (UPJO) level who presented with VUR., Methods: Between May 2004 and July 2011, 2810 children with a diagnosis of VUR were referred to our center; 143 (5%) had concomitant UPJO. On the basis of the study inclusion criteria, 76 were included. All patients received antibiotic therapy. VUR and UPJO resolved in 50 children without the need for further intervention, and 26 underwent endoscopic Deflux injection by applying the hydrodistention autologous blood injection technique (HABIT). All patients received antibiotic prophylaxis until resolution of VUR was confirmed on voiding cystourethrogram (VCUG). Patients underwent follow-up visits at 1, 6, and 12 months postoperatively., Results: At a mean follow up of 20.0 ± 1.6 months, 20 of those with concomitancy showed resolution of VUR and the coexisting UPJO after the first injection (success rate, 76.9%), and 2 resolved after the second injection, leading to an overall success rate of 84.6%. Finally, 3 patients required further ureteral reimplantation, and 3 underwent pyeloplasty for correction of UPJO by applying miniature pyeloplasty technique. Differential renal function was preserved in all patients., Conclusion: Performing an initial endoscopic injection of Deflux in the management of concomitant VUR and UPJO provides promising results in terms of spontaneous resolution of obstruction at the UPJ level and complete resolution or decrease in hydronephrosis., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Purpose: To identify independent factors that may predict vesicoureteral reflux (VUR) resolution after endoscopic treatment using dextranomer/hyaluronic acid copolymer (Deflux) in children free of anatomical anomalies., Materials and Methods: A retrospective study was conducted in our pediatric referral center from 1998 to 2011 on children with primary VUR who underwent endoscopic injection of Deflux with or without concomitant autologous blood injection (called HABIT or HIT, respectively). Children with secondary VUR or incomplete records were excluded from the study. Potential factors were divided into three categories including preoperative, intraoperative and postoperative. Success was defined as no sign of VUR on postoperative voiding cystourethrogram. Univariate and multivariate logistic regression models were constructed to identify independent factors that may predict success. Odds ratio (OR) and 95 % confidence interval (95 % CI) for prediction of success were estimated for each factor., Results: From 485 children received Deflux injection, a total of 372 with a mean age of 3.10 years (ranged from 6 months to 12 years) were included in the study and endoscopic management was successful in 322 (86.6 %) of them. Of the patients, 185 (49.7 %) underwent HIT and 187 (50.3 %) underwent HABIT technique. On univariate analysis, VUR grade from preoperative category (OR = 4.79, 95 % CI = 2.22-10.30, p = 0.000), operation technique (OR = 0.33, 95 % CI = 0.17-0.64, p = 0.001) and presence of mound on postoperative sonography (OR = 0.06, 95 % CI = 0.02-0.16, p = 0.000) were associated with success. On multivariate analysis, preoperative VUR grade (OR = 4.85, 95 % CI = 2.49-8.96, p = 0.000) and identification of mound on postoperative sonography (OR = 0.07, 95 % CI = 0.01-0.18, p = 0.000) remained as independent success predictors., Conclusion: Based on this study, successful VUR correction after the endoscopic injection of Deflux can be predicted with respect to preoperative VUR grade and presence of mound after operation.

Objective: To find the association between mound appearance on ultrasound imaging and successful correction of vesicoureteral reflux (VUR)., Methods: We retrospectively reviewed the ultrasound and voiding cystourethrogram (VCUG) results of patients who underwent dextranomer/hyaluronic acid injection via the hydrodistention injection technique (HIT) or HIT with concomitant autologous blood injection (HABIT) for 5 years postoperatively. VUR resolution at postoperative VCUG was considered as a success. Retained volumes of implants were measured and compared between HABIT and HIT and successful and failed treatments. Presence of mound on ultrasound imaging was also evaluated as a predictor of VUR resolution on VCUG., Results: Measured mound volume was significantly higher in treatments that were successful than in those that were failures (P <.05). During 5-year follow-up, measured mound volumes in the HABIT group were significantly higher than in the HIT group (P <.05). Sensitivity, specificity, positive predictive value, and negative predictive value of mound visualization on the first-month sonography to predict success were 97.7%, 21.5%, 89.6%, and 60%, respectively. These results were dramatically changed for the 50 patients with further VCUG after 1 year of follow-up, with 95.7% sensitivity, 37.0% specificity, 54.0% positive predictive value, and 90.9% negative predictive value., Conclusion: Reduction or absence of the mound after implantation is more frequent among failed treatments in which visualization of the mound on postoperative sonography can predict VUR resolution. Autologous blood injection concomitant with dextranomer/hyaluronic acid implantation results in better immediate and long-term mound preservation, which could possibly be the reason for the higher success rate in HABIT group., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Purpose: We present the long-term results of a new modification of endoscopic treatment of vesicoureteral reflux involving concomitant injection of autologous blood following the standard hydrodistention injection technique to prevent bulking agent leakage immediately after the procedure., Materials and Methods: A total of 341 children underwent endoscopic implantation of dextranomer/hyaluronic acid for vesicoureteral reflux. A subset of 171 patients underwent hydrodistention autologous blood injection, while 170 underwent classic hydrodistention injection. Frequency of symptomatic urinary tract infection after endoscopic treatment was recorded. Success was defined as absence of vesicoureteral reflux on postoperative voiding cystourethrography., Results: A total of 523 ureters in 214 girls and 127 boys were treated. In patients undergoing hydrodistention autologous blood injection mean age was 39.48 months, mean maximal reflux grade was 3.02 and success rate was 93.6% after the first injection (98.0% in patients with grade II, 92.1% with grade III, 93.3% with grade IV and 85.7% with grade V reflux). In patients who underwent classic hydrodistention injection mean age was 36.12 months, mean maximal reflux grade 3.05 and success rate was 81.8% after the first injection (91.5% in patients with grade II, 89.4% with grade III, 74.4% with grade IV and 44.4% with grade V reflux). The success rate was significantly higher (p = 0.001) in patients undergoing hydrodistention autologous blood injection vs classic hydrodistention injection. Of the patients 1.7% in the hydrodistention autologous blood injection group and 2.9% in the classic hydrodistention injection group reported symptomatic urinary tract infection during followup., Conclusions: Immediate injection of autologous blood following dextranomer/hyaluronic acid injection to create a blood clot and barricade against bulking agent leakage is more effective than pure dextranomer/hyaluronic acid implantation. This novel modification stabilizes the subureteral implant mount and may affect the antireflux outcome., (Copyright © 2012 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: To present the results of our experience with combined endoureterotomy and endoscopic injection of dextranomer/hyaluronic acid (Deflux) for the treatment of primary obstructive refluxing megaureter (PORM)., Patients and Methods: Eighteen children (12 female, 6 male; mean age-14 months) with 20 PORM units underwent concomitant endoureterotomy and endoscopic subureteral Deflux injection. All patients underwent endoureterotomy at the 6-o'clock position with insertion of a 3F Double-J ureteral stent into the obstructed segment of ureter and subureteral injection of Deflux at the 5-o'clock and 7-o'clock positions. The Double-J stent was left in place with its distal tip fixed with a single knot to the external genitalia for easy removal after 1 week. Patients with refluxing nonobstructive ureter on the contralateral side of the PORM unit (seven children) underwent simultaneous endoscopic subureteral injection of Deflux. Voiding cystourethrography (VCUG) was performed at 6 months, and ultrasonography was performed at 1 week 3, 6, and 12 months postoperatively., Results: With a mean follow-up of 30 months, the procedure was uneventful in all patients. Follow-up VCUG showed no evidence of reflux in 15 ureterorenal (75%), significant decrease in reflux grade in 2 (10%), and no change in 3 (15%) in the endoscopic treated PORM units. No evidence of reflux was observed in the treated contralateral refluxing nonobstructive ureters. Ultrasonography revealed no ureterovesical junction obstruction. In 19 ureterorenal (95%) units, there was a complete resolution or decrease in hydroureteronephrosis., Conclusions: The results of this study demonstrate that combined endoureterotomy and subureteral injection of Deflux is safe and effective in the treatment of PORM in selected patients.

Purpose: Primary bladder neck dysfunction has been under diagnosed as a treatable cause of vesicoureteral reflux. We evaluated the effect of prazosin administration on vesicoureteral reflux resolution and urodynamic parameters in children with idiopathic primary reflux and primary bladder neck dysfunction., Materials and Methods: A total of 62 children (mean ± SD age 7.9 ± 2.4 years) with documented vesicoureteral reflux and urodynamics proved primary bladder neck dysfunction were randomized to receive either 0.025 mg/kg α-blocker (prazosin, 40 patients) or placebo (22) nightly for 1 week with a subsequent increase to 2 divided doses. Patients were followed for 12 months with clinical evaluation and uroflowmetry performed every 2 months, and each patient underwent complete urodynamic study at 6-month intervals., Results: In the placebo group no uroflowmetry or urodynamic parameter changed significantly at 1-year followup. A 60% decrease in reflux grade was observed in the treatment group compared to 17% in the placebo group. Mean maximal detrusor pressure, post-void residual and opening time were significantly decreased in both followup sessions in the prazosin group (p <0.05). Average flow rate improved from 4.30 to 12.80 ml per second at 6 months and to 13.10 ml per second at 12 months (both p <0.05)., Conclusions: Special attention should be given to secondary causes of vesicoureteral reflux (such as primary bladder neck dysfunction, an underdiagnosed entity in children), since conventional treatment will most likely fail if these conditions are not addressed promptly. In this study prazosin was effective therapy for children with vesicoureteral reflux and primary bladder neck dysfunction., (Copyright © 2010 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate the state of autophagy and its interactions with apoptosis and cell proliferation in patients who underwent successful early closure or delayed closure of exstrophy. They compared those outcomes with cell culture samples from patients with vesicoureteral reflux as control.Patients and Methods: Primary cultures of bladder smooth muscle cells (SMCs) were established from patients with successful neonatal bladder closure (group 1, N = 5), delayed closure because of small bladder template (group 2, N = 5), and vesicoureteral reflux as control (group 3, N = 5). The myogenicity of the cultures was determined using anti-Desmin antibody. Immunostainings for LC3 to assess autophagy and Ki67 to assess cell proliferation were applied. Apoptosis was assessed by the terminal deoxynucleotidyl transferase-mediated dUTP digoxigenin nick-end labeling assay.Results: Autophagy marker (LC3) expression was significantly higher in the delayed closure group than in the other groups, whereas no significant difference was noted between the neonatal closure and the control groups. Apoptotic indices of the SMCs were remarkably higher in SMC cultures from the delayed closures than in the neonatal closure and the control groups. A significantly lower expression of proliferation marker (Ki67) in the delayed closure group compared with the control and the neonatal closure group was also of note.Conclusion: Patients with small bladder template and delayed closure showed upregulated autophagic process and increased apoptotic indices while experiencing a dramatic decrease in the proliferation of their bladder SMCs. Finally, the concept of manipulating autophagy may lead to promising outcomes for patients with bladder exstrophy in the future. [ABSTRACT FROM AUTHOR]