Efficacy of Three Different Injection Techniques for the Endoscopic Treatment of Vesicoureteral Reflux (VUR) in Children: A Review of 10 Years of Experience

Abstract

Aim

To review our 10 years of experience with the endoscopic treatment of vesicoureteral reflux (VUR) in children, emphasizing the long-term efficacy of the “combined STING-HIT” technique.

Materials and Methods

A retrospective study was performed including all children with symptomatic VUR undergoing the cystoscopic injection of bulking agents from January 2013 to December 2022 in our pediatric tertiary referral center. Three different endoscopic techniques were adopted: the “combined STING-HIT” technique, the STING technique, and the HIT technique. Treatment success was defined as symptom remission and VUR resolution on the voiding cystourethrogram (VCUG) performed at the 3-month follow-up.

Results

In the study period, 140 (F:M = 64:76) patients and 228 ureters were treated at a median patient age of 3 (2.0–6.0) years. After a single endoscopic treatment, VUR resolved in 203 (88%) ureters. The VUR resolution rate after a single endoscopic treatment was 95% (n=70/74) in case of I–II VUR, 88% (n=87/99) in case of III VUR; 83% (n=38/46) in case of IV VUR; 89% (n=8/9) in case of V VUR (p-value: 0.174). Overall, one or two endoscopic treatments succeeded in 219 (96%) ureters. The overall VUR resolution rate following one or two endoscopic treatments was 100% (74/74) in case of I–II VUR, 93% (n=92/99) in case of III VUR; 96% (n=44/46) in case of IV VUR; 100% (n=9/9) in case of V VUR (p-value: 0.083). Despite not being statistically significant, the VUR resolution rate was higher for the “combined STING-HIT” technique, both after one (92%: n=110/119; versus 85%; n=62/73 versus 86%; n=31/36; p-value: 0.225) or two (98%: n=116/119; versus 95%; n=69/73 versus 94%; n=34/36; p-value: 0.469) endoscopic treatments.

Conclusion

The endoscopic approaches were highly successful for the treatment of VUR in children. The “combined STING-HIT” technique was a safe and effective procedure, being associated with the higher resolution rate.

Keywords:

• vesicoureteral reflux
• injection technique
• endoscopic technique
• pediatrics

Ethical Approval

All procedures performed in the study involving human participants were under the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. According to our Institution’s regulations (ie, Department of Pediatric Surgery, Buzzi Children’s Hospital, 20154 Milan, Italy), the need for ethics approval for this non-interventional study’s retrospectively obtained and anonymized data were waived. The reservedness of the collected information was ensured according to Regulation (EU)/2016/679 GDPR (Regulation (EU) 2016/679), Legislative Decree n.101/18. Full informed consent was obtained from the study participants’ guardians.

Acknowledgments

We want to thank the Foundation Romeo and Enrica Invernizzi for supporting this project. Moreover, we would like to acknowledge the support of the APC central fund of the University of Milano.

Disclosure

The authors report no conflicts of interest in this work.