Endoscopic Treatment of the Vesicoureteral Reflux by Electrocoagulation

Material and methods: Between January 1998 and December 2002, 150 patients with vesicoureteric reflux (210 refluxing ureter) underwent 291 endoscopic electrocoagulation in the hemitrigone in order to treat the reflux. Male to female ratio was 2:8. Age ranged from 2 months to 47 years, median: 7 years. Localization was bilateral 39% Rt. Side 20%, Lt Side 41%. The grade of vesicoureteric reflux ranged from 2 to 5th grade. Secondary reflux was in 18% of the cases.


Introduction
Vesicoureteric Reflux (V.U.R) indicates the retrograde flow of urine into the upper urinary tract.The overall incidence of reflux in normal children ranges from 1% to 18%.Reflux is found in up to 70% of infants who present with urinary tract infection [1].
The vast majority (85%) of reflux occurs in female [2].Males who present with urinary infection have a higher likelihood of having the anomaly.Primary reflux is congenital anomaly of the ureterovesical junction in which a deficiency of the longitudinal muscle of the intravesical ureters, results in an inadequate valvular mechanism.In one study a 5:1 ratio of tunnel length to ureteral diameter was found in normal children without reflux [3].Reflux occurs when the intravesical (intramural) ureteral length is too short.Secondary reflux is that caused by bladder obstruction and its consequent elevated pressures [4].
Familial reflux is common, being present in about one third of the siblings, in some studies, sibling reflux rate reached about 51%, [5].Vesicoureteral reflux may damage the kidney by repeated introduction of infected urine into the kidneys or by hydrostatic pressure on the renal tissue causing reflux nephropathy, which could be detected by urinary cytokines as a nephropathy marker [6].

Objectives
Objectives of this study were introduction and evaluation of electrocoagulation treatment of V.U.R.

Selection of proper patients, and determination of its efficacy.
Comparison with other historical techniques and other authors.
Determination of further complementary techniques to do in case of failure.

Materials and Methods
Between January 1998 and December 2002, 150 patients with (V.U.R) (210 refluxing ureter) underwent consequence 291 endoscopic electrocoagulation in the hemitrigone in order to treat the reflux.The patient is placed in the dorsal lithotomy position, cystoscopy is performed and the ureters are visualized, a cautery probe is advanced through the working channel, electrocoagulation is done in a limited zone of the hemitrigone, distal to the ureteral orifice of the refluxing ureter, in rhomboid shape between the ureteric orifice and the bladder neck,(about 1cm square space).The electrocoagulation done by fine probe making superficial electrocoagulation dots in the mucosa of the mentioned limited zone in the trigone [Figure 13-16].Foleys catheter is inserted at the end of the procedure to avoid bladder distention in order to enhance rapid healing of coagulated zone in the trigone; the length of procedure is less than 15 minutes.The patient is discharged from hospital the next day after removing Foleys catheter, keeping the patient on prophylactic antiseptic for 3 months, after that a Voiding Cystourethrogram (V.C.U.G) is done for follow up.Male to female ratio was 2:8.Age ranged from 2 months to 42 years, (median 7 years.).Localization was: bilateral 39%, RT side 20%, Lt Side 41%.Grading was GII: 35%, GIII: 33% GIV: 23%, GV: 9%.
Patients were followed up to five years including urine culture quarterly, and radiologic studies every two years, low dos prophylactic antiseptic were continued until the reflux resolved as expected.When present, bladder dysfuncion should be treated with anticholenergics.

Discussion
For long time surgery was the only method of treatment of V.U.R. in failure of medical treatment.Recently less invasive techniques were suggested to correct the V.U.R. endoscopically with acceptable results.This study was justified by the impact of the disease on the patients with its morbidity and to find a minimal invasive method for the treatment of V.U.R.
As the electrocoagulation is a simple, successful, durable and minimally invasive procedure, it was chosen for the treatment of the patients avoiding the use of long-term prophylactic urinary antiseptics and periodic radiographic follow-up.Moreover, the time required for conservative therapy is shortened.This treatment of electrocoagulation was performed early in Hungary by professor Gotz Frigyes et al, and had excellent results [15].
Our patients previously were treated and followed up by the pediatrician and referred to our clinic seeking further treatment.
All patients were treated initially by endoscopic electrocoagulation in a limited zone of the hemitrigone of the ipsilateral refluxing ureter followed by low dose prophylactic antiseptics until reflux resolved, some of them (25%) needed repeated electrocoagulation (2-3 times), only limited cases (12%) failed and needed surgical treatment, i.e. ureteral reimplantation because of the associated congenital abnormality at the ureterovesical junction (bladder diverticulum, duplication ureter … etc).
Hutch, Bunge and flocks suggested that the trigone (which originates in the ureter and inserts in the verumontanum) contracts during voiding, when intravesical pressure is at its maximum, thus pulling additional intravesical ureter into the bladder [16].
On this basis, it seems that after the treatment of reflux by electrocoagulation, fibrosis occurs in the hemitrigone after healing causing a pull of the ureter down more caudally, increasing the length of intravesical ureter, and antirreflux mechanism leading to reflux prevention.We recommend the wide ranging application of this technique, and this method does not influence the conditions for a potential anti -reflux plastic surgery [15].
In our study we found that the group of primary V.U.R. Grade 1-1V is ideal for this technique (93% success rate), and the group of neurogenic bladder also had good results (100% success rate) in addition to the anticholenergic treatment.
Previos urodynamic evaluation was done for patient where a secondary cause of reflux was suspected.
We revised our patients 3, 18 and 36 months after electrocoagulation (all patients were revised on the first revision at 3 months after electrocoagulation, 78 patients (112 ureteres) on the second revision at 18 month after electrocoagulation, 24 patients (34 ureteres) after 3 years of the first electrocoagulation.

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The success of the treatment by electrocoagulation increased on the second revision because of 25% of patients needed (2 or 3) episodes of electrocoagulation to completely correct the V.U.R. Follow up included ecography, urography and micturating cystogram which based on the appearance of contrast in the ureter and upper collecting system (Figure 1           We had one case of contralateral V.U.R. which was resolved at 6 months conservatively. Those cases associated with congenital abnormalities (duplication, ureterocele, diverticulum ….etc.), which did not respond to the electro coagulation, were treated surgically with good results (100% of success rate).
Open surgery has a success rate of 97% and the disadvantages are: long hospital stay, increased morbidity, high cost, and cosmotic means [7].

Conclusion
Electrocoagulation treatment of V.U.R is: -Simple, minimally invasive, durable, cost effective, less morbidity and effective.
-Has excellent results in cases of primary V.U.R. (grade I, II, III, IV).
-Is effective in the treatment of secondary V.U.R. due to bladder dysfunction and certain types of neurogenic bladder in addition of anticholenergic treatment.
-It is not effective in the treatment of V.U.R when it is associated with another anomalies ( Paraureteral Diverticulum , ureterocele , some cases of duplicated ureter).
-It could be an alternative to surgery.

Table 1
Result of treatment of V.U.R by Electrocoagulation and evolution of complications in each group.We divide the patient in 5 groups regarding the associated pathology * Revision at 3 months after treatment by electrocoagulation.** Revision at 6 or 9 months after 2 o 3 episodes of electrocoagulation.

Table 2
Comparative study between the surgical and endoscopic treatment of V.U.R by subureteral injection or electrocoagulation in several international publications