Endoscopic Injection (Deflux) for the Treatment of Vesicoureteral Reflux
Endoscopic treatment of VUR is an outpatient surgery using a bulking agent to correct Vesicoureteral Reflux. For this article we will be discussing the bulking agent Deflux, but there are others available. During surgery, the doctor uses a cystoscope to look into the bladder. A cystoscope is a thin, lighted instrument that is used to view areas of the urethra and bladder that can not easily be seen on x-ray. The cystoscope is entered through the urethra and into the bladder. During this procedure, the surgeon will use very small instruments to inject the Deflux into the lining of the bladder where the ureter enters into the bladder. By doing this, the surgeon creates a new valve that prevents the back flow of urine into the kidneys.
Deflux is a gel substance made from two types of sugar-based molecules (polysaccharides) called dextranomer and hyaluronic acid. These materials work well because they do not cause significant reactions to the body. Hyaluronic acid is actually produced naturally within the body. Because of this, the injected agent breaks down over time, leaving a permanent bulge of tissue which serves as the new valve. The urine can still pass from the ureter into the bladder, but because of the new valve, the urine cannot freely flow back into the ureters. It’s kind of like a door that only swings one way.
Deflux injection has shown the best results in children with grades I, II, III and in some cases of grade IV. The higher the grade of reflux, the less effective the injection will be. Most studies show the overall success rate of Deflux injection to be 80% or better after the first injection. Some children may require a second or third injection. With multiple injections, the success rate moves into the 90th percentile.
Children may not be good candidates for Deflux if they have kidney failure, voiding dysfunction or other bladder or kidney abnormalities. Children with grade V may not be considered as good candidates and may be encouraged to have a ureteral reimplant. In some cases, like our daughter, Deflux can be done after a reimplantation has failed. Studies show high success rates when using Deflux after an unsuccessful reimplant, depending on the reason for the previous surgeries failure. If the reflux is secondary to an underlying condition, surgery may not be effective until the underlying condition is corrected.
Deflux injection can be a good alternative to long term antibiotics and may be a good option for children with breakthrough infection. There are many advantages to having Deflux instead of open surgery. For one, it is much less invasive than reimplantation surgery. Endoscopic treatment with Deflux, does not require an incision, therefore recovery time and risk of complication are lessened. Deflux is done as an outpatient surgery, so your child can go home the same day, where reimplantation patients may have a 1-3 day hospital stay. Another plus is that having Deflux does not prevent the child from having surgery later if needed.
As with any procedure, there are also risks involved with Deflux. Deflux is less successful than the reimplantation (especially in the higher grades), and Deflux injections do not have a lot of long term studies available because it is a relatively new procedure. This procedure was approved by the FDA for use in the United States in 2001. So as of right now, there have only been 10 years worth of procedures to examine.
If you and your doctor decide that Defux is a good option for your child here is what you can expect from surgery. During the surgery, your child will undergo general anesthesia, so he/she will be completely asleep for the procedure. The doctor will perform the surgery as described earlier, and the time will depend on if the procedure is unilateral (one ureter) or bilateral (both ureters) but should generally take 15-30 minutes. When the surgery is complete, the child will go to recovery where you can be with them. As the child wakes up, they will monitor them for a short time, but your child should be able to go home that same day.
After going home, your child may have some bleeding in the urine which is normal for this procedure. General anesthesia and Deflux injection are generally low risk, but complications can occur. Complications can include blockage of the ureter (from too much injection), or infection from surgery. There can also be problems from the anesthesia.
If your child has any of the following symptoms after surgery, you should contact your doctor immediately:
Temperature over 101.4 degrees F
Excessive Vomiting
Severe pain