Mid-Term Safety and Efficacy of the Modified Double Hydrodistention Implantation Technique (HIT), Termed Systematic Multi-Site HIT (SMHIT), for Patients with Primary Vesicoureteral Reflux

Figures & data

Figure 1 Dextranomer/hyaluronic acid (Dx/HA) injection therapies for primary vesicoureteral reflux. *Extravesical portion of ureter (adjacent to ureteral hiatus). ×: position of needle insertion. (A) Double hydrodistention implantation technique (double HIT). (B) Systematic-multisite hydrodistention implantation technique (SMHIT) These figures show the coronal section of the ureterovesical junction. Multiple Dx/HA injections are sequentially and systematically administered from the proximal to the distal intramural ureter in SMHIT. The coaptation area of the intramural ureter created by Dx/HA bulges can be extended out further by SMHIT than by double HIT.

Figure 2 The first half of SMHIT (systematic-multisite hydrodistention implantation technique) for left VUR grade Ⅳ. ＊Extravesical portion of ureter (adjacent to ureteral hiatus). (A) Left ureteral orifice before SMHIT. (B) Mild opening of the ureteral orifice during hydrodistention. (C) intramural ureter. (D) First insertion of a needle and injection of Dx/HA. (E) Bulge after first injection of Dx/HA and second insertion of a needle. (F) Second injection of Dx/HA. (G) Bulge after second injection of Dx/HA. (H) Bulge after second injection of Dx/HA and third insertion of a needle.

Figure 3 The latter half of SMHIT (systematic-multisite hydrodistention implantation technique) for left VUR grade Ⅳ (A and B) Third injection of Dx/HA. (C) Fourth insertion of a needle. (D and E) Fourth injection of Dx/HA (STING (subureteral transurethral injection) technique). (F) Fifth insertion of a needle. (G) Fifth injection of Dx/HA. (H) Left ureteral orifice after SMHIT.

Table 1 Preoperative Patient Characteristics

Patient	Sex	Age at SMHIT	Affected Side of VUR		Grade of Preoperative VUR*	Split Renal Function (%)	Timing of VUR	Preoperative BBD
								Voiding Symptoms	Defecation Symptoms	Duration of BBD Treatment (Months)
1	Female	5y9m	Bilateral	Right	III	50	Filling	+	+	13
				Left	III	50
2	Female	8y8m	Unilateral	Left	III	47	Voiding	+	–	21
3	Male	10y3m	Unilateral	Right	III	46	Filling	–	–	–
4	Female	9y4m	Bilateral	Right	III	45	Filling	+	–	18
				Left	III	55
5	Male	1y8m	Bilateral	Right	IV	47	Filling	–	–	–
				Left	IV	53
6	Female	12y4m	Unilateral	Right	III	47	Filling	+	–	23
7	Female	7y6m	Bilateral	Right	III	48	Filling	–	–	–
				Left	III	52
8	Female	12y9m	Unilateral	Left	II	51	Filling	–	+	7
9	Female	9y7m	Unilateral	Left	II	42	Filling	+	+	27
10	Female	11y11m	Unilateral	Left	III	41	Voiding	+	–	52
11	Female	1y6m	Bilateral	Right	IV	49	Filling	–	–	–
				Left	III	51
12	Male	5y6m	Unilateral	Left	III	21	Filling	–	–	–
Average		8y0m								23

Notes: *The grade of VUR was determined according to the International Classification System (International Reflux Study Committee).

Abbreviations: BBD, bladder-bowel dysfunction; SMHIT, systematic multi-site hydrodistention implantation technique; VUR, vesicoureteral reflux.

Table 2 Intraoperative and Postoperative Results

Patient	Sex	Age at SMHIT	Indication for SMHIT	Affected Side of VUR		Grade of Preoperative VUR*	Number of Needle Insertion	Dose of Dx/HA Injection (mL)	Grade of Postoperative VUR*			Postoperative Complications	Postoperative FUTIs	Postoperative Follow-Up Period
									3–4 Months	1 Year	3 Years
1	Female	5y9m	Persistent VUR	Bilateral	Right	III	4	0.5	0	I	I	–	–	9y2m
					Left	III	5	0.5	0	0	0
2	Female	8y8m	Persistent VUR	Unilateral	Left	III	3	0.6	0	0	0	–	–	9y0m
3	Male	10y3m	Persistent VUR	Unilateral	Right	III	3	0.8	0	0	0	–	–	9y0m
4	Female	9y4m	Persistent VUR	Bilateral	Right	III	4	0.9	0	I	0	–	–	8n2m
					Left	III	3	0.5	0	0	0
5	Male	1y8m	Breakthrough FUTI	Bilateral	Right	IV	4	0.6	III	0	I	–	–	7y11m
					Left	IV	3	0.5	0	0	0
6	Female	12y4m	Persistent VUR	Unilateral	Right	III	6	1.8	0	0	0	–	–	7y1m
7	Female	7y6m	Persistent VUR	Bilateral	Right	III	7	1.5	0	0	0	–	–	6y8m
					Left	III	3	0.5	0	0	0
8	Female	12y9m	Persistent VUR	Unilateral	Left	II	6	1.4	0	0	0	–	–	5y8m
9	Female	9y7m	Persistent VUR	Unilateral	Left	II	5	1.2	0	0	0	Left lumbar pain	–	5y1m
10	Female	11y11m	Breakthrough FUTI	Unilateral	Left	III	5	1.1	0	0	0	–	–	5y0m
11	Female	1y6m	Breakthrough FUTI	Bilateral	Right	IV	4	1.3	0	0	0	–	–	4y7m
					Left	III	4	1	0	0	0
12	Male	5y6m	Persistent VUR	Unilateral	Left	III	4	0.5	0	0	0	–	–	4y3m
Average		8y0m					4.3	0.89						6y9m

Notes: *The grade of VUR was determined according to the International Classification System (International Reflux Study Committee).

Abbreviations: Dx/HA, dextranomer/hyaluronic acid; FUTI, febrile urinary tract infection; SMHIT, systematic multi-site hydrodistention implantation technique; VUR, vesicoureteral reflux.