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Endoscopic treatment of vesico-ureteric reflux and urinary incontinence: technical problems in the paediatric patient
N Capozza1, P Caione, M De Gennaro
1Department of Paediatric Surgery, Bambino Gesù Children's Hospital, Rome, Italy.
Insights
Endoscopic bovine collagen injections effectively treat pediatric urinary incontinence and vesico-ureteric reflux. Success rates for VUR reached 81% after a second injection, and continence improved in UI patients, highlighting the procedure
Area of Science:
- Pediatric Urology
- Minimally Invasive Surgery
- Biomaterials in Medicine
Background:
- Bovine collagen has been used for over 8 years to treat pediatric urinary incontinence (UI) and vesico-ureteric reflux (VUR).
- Concerns regarding long-term efficacy persist, often attributed to technical challenges or collagen implant instability.
- This study evaluates the efficacy of endoscopic collagen treatment in children treated between 1990 and 1993.
Purpose of the Study:
- To assess the efficacy of endoscopic glutaraldehyde cross-linked bovine collagen injections for treating VUR in children.
- To evaluate the effectiveness of periureteral collagen injections for UI in pediatric patients.
- To determine the impact of collagen injection on bladder enhancement in specific pediatric cases.
Main Methods:
- 156 children with VUR underwent endoscopic collagen treatment.
- 25 children with UI (neuropathic bladder or exstrophy-epispadias complex) received periureteral/pericervical collagen injections.
- 5 children with exstrophy-epispadias complex underwent periureteral collagen injection for bladder enhancement.
Main Results:
- A single collagen injection successfully treated VUR in 72.2% of ureters; a second injection increased success to 81%.
- Continence improved in all nine neuropathic bladders and 10 of 16 UI patients with exstrophy-epispadias complex.
- Bladder capacity increased by 25% in four of five exstrophy-epispadias complex patients undergoing bladder enhancement.
Conclusions:
- Endoscopic collagen injection is a viable alternative to open surgery for pediatric VUR.
- Early VUR failure is linked to technique, while late failure may result from collagen displacement.
- Effective UI treatment depends on implant technique and injection site; patient selection and technical refinement are crucial.
Objective:
Bovine collagen has been successfully used for the endoscopic treatment of urinary incontinence (UI) and vesico-ureteric reflux (VUR) in children for more than 8 years, although its long-term efficacy has sometimes been questioned. Its failure is generally ascribed either to technical difficulties or to instability of collagen at the site of the implant. To assess the efficacy of the procedure we evaluated the children treated at this hospital between 1990 and 1993.
Patients And Methods:
A total of 156 children, aged 5 months to 13 years, were treated for VUR. Over the same period, 25 patients aged between 2 and 14 years (nine with neuropathic bladder and 16 with exstrophy-epispadias complex who were still incontinent after bladder neck reconstruction) had periurethral or pericervical glutaraldehyde cross-linked bovine collagen injection for UI. Five more children with exstrophy-epispadias complex (aged 1-3 years) underwent periurethral collagen injection to stimulate bladder enhancement and allow subsequent bladder neck reconstruction.
Results:
In children treated for VUR, a single injection proved successful in 72.2% of cases (127 ureters); a second collagen injection raised the success rate to 81%. Continence improved in all nine neuropathic bladders and in 10 of 16 children with exstrophy-epispadias complex treated for UI after bladder neck reconstruction. In four of the five exstrophy-epispadias complex patients who were treated to stimulate bladder enhancement, bladder capacity increased by 25%.
Conclusions:
Endoscopic treatment of VUR seems to be a valid alternative to open surgery, even though concerns remain about the long-term efficacy of collagen implantation. An important distinction should be made between early and late failure of the procedure. Early failure, which we define as persistence of reflux, is usually due to incorrect technique or technical difficulties. Late failure, or recurrence of reflux, which has previously been attributed to the biodegradability of collagen, seems to be due to the displacement of the injected collagen. Micturition itself or high bladder pressure (such as detrusor instability) could be responsible for the displacement of the injected collagen medially and distally, where it can no longer support the submucosal ureteric tunnel. In the treatment of urinary incontinence, both the implant technique and the choice of the site of injection seem to have a considerable effect on the results. In our experience, endoscopic collagen injection is effective in the treatment of both urinary incontinence and VUR in paediatric patients. Accurate selection of patients and technical adjustments and refinements are essential to obtain the best results.