[Failures of endoscopic treatment of vesico-ureteric reflux in children using Macroplastique]

Macroplastique has been used since 1993 for the endoscopic treatment of vesico-ureteric reflux in children with a failure rate per injected ureteric unit of 21%. The objective of this study was to analyse these failures on the basis of endoscopic findings on injection, ultrasound data at 2 months post-endoscopy and operative findings during the secondary reimplantation.

The authors retrospectively reviewed cases of failure of Macroplastique treatment from September 1993 to December 2002. Only children undergoing subsequent surgical reimplantation were included in the study: 60 cases (57 girls, 3 boys). Another 68 patients also presented recurrence of reflux, but are currently asymptomatic and have not been reoperated. Twenty five patients (42%) initially presented unilateral vesico-ureteric reflux: bilateral injection was performed in 17 of these cases because of the anatomical findings on endoscopy. In 92% of cases, the refluxing ureteric orifice appeared to be abnormal (in terms of position, appearance and the submucosal course of the ureter).

Eleven children (18%) presented symptomatic or asymptomatic urinary tract infection before the first clinical and radiological review at 2 months. On the first ultrasound examination, the implant was visualized in the bladder wall in 71% of cases. At reimplantation, the bladder mucosa was inflammatory in 56 patients (94%). The ureteric orifice remained gaping in 38% of cases and the implant appeared to be modified (migration, decreased volume) in 35% of cases.

Failures of endoscopic treatment by Macroplastique can be due to persistence of pre-existing ureteric anatomical lesions (poor indication, technical error or difficulty) or modification of the injected product. Bladder inflammation and therefore previous or post-endoscopy urinary tract infections may also play a role.