Editing Pediatrics: Vesicoureteral Reflux (section)

=== Endoscopic ===
* '''A reasonable alternative for children being considered for surgical correction'''
* '''Success rates vary across centers and that outcomes may not be durable.'''
** Higher success rates associated with:
**# Volume of Dx/HA used
**# Surgeon experience
**# Volcano-shaped mound with no hydrodistention
**# Utilization of the double hydrodistention-implantation technique
**# Accurate needle entry point during endoscopic injection, as well as the needle placement
*** Negative intraoperative cystogram is not associated with endoscopic success rates
* '''Untreated BBD is associated with decreased resolution rates of VUR at initial follow-up in children treated with endoscopic surgery'''
* The learning curve for endoscopic injection is believed to be different from that of open surgical reimplantation, but studies have compared these two approaches
* Indications for treatment are the same as that of open surgical reimplantation
* '''Materials used for endoscopic correction of reflux'''
** Characteristics of an ideal injectable biomaterial (4):
**# Non-toxic and stable without migration to vital organs
**# Cause minimal local inflammation, while at the same time be well encapsulated by normal fibrous tissue and fibrocytes
**# Easy to inject through a long needle that passes easily through most standard endoscopic instruments
**# Viscous enough to prevent leakage from the puncture site and maintain its injected volume and the mound shape after the normal process of exchange and excretion of any carrier molecules.
** '''Classified as particulate vs. degradable and autologous vs. non-autologous'''
*** '''Disadvantage of particulate agents is risk of migration'''
*** '''Disadvantage of degradable agents is less durability'''
**** '''Deflux is biodegradable, the carrier gel is reabsorbed''', and the dextranomer microspheres become capsulated by fibroblast migration and collagen ingrowth
**** '''DX/HA loses ≈23% of its volume beyond 3 months of follow-up'''
*** '''Autologous Materials'''
**** '''Fat, collagen, muscle, and chondrocytes have been evaluated as bulking agents'''
* '''Follow-Up after Endoscopic Treatment'''
** '''The child is maintained on antibiotics for 3 months.'''
** '''US and VCUG are obtained at 3 months.'''
*** '''If reflux is persistent, a repeat injection can be considered 6 months after the initial injection'''
*** '''If there is still no resolution, open surgery is recommended.'''
**** '''Most reports to date have not indicated any additional difficulty with open surgery after endoscopic correction using Deflux'''