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Pediatrics
Diagnosis
Genitourinary
Bladder Abnormalities
Post-Deflux Procedure Appearance
Post-Deflux Procedure Appearance
Sara M. O'Hara, MD, FAAP
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KEY FACTS

  • Terminology

    • Imaging

      • Top Differential Diagnoses

        • Clinical Issues

          TERMINOLOGY

          • Definitions

            • Bulking agent injected near ureterovesical junction (UVJ) to alter UVJ orientation & prevent vesicoureteral reflux (VUR)
              • Deflux (Q-Med; Uppsala, Sweden): Dextranomer-hyaluronic acid copolymer (DHA, DxHA); most commonly used in USA
                • In use clinically since 1995, FDA approved 2001
                • Relatively large particle size inhibits migration
                • Biodegradable, stable in vivo
              • Dexell (Istem Medical; Ankara, Turkey); most commonly used in Europe
                • Manufactured since 2007
                • Polycationic derivative of Dextran & cross-linked hyaluronic acid
                • Similar size & biologic profile to Deflux
              • Macroplastique (Congentix; Geleen, Netherlands)
                • FDA approved in 2006
                • Polydimethylsiloxane (solid silicone elastomer)
                • Suspended in bioexcretable polyvinylpyrrolidone gel
              • Vantris (Promedon; Cordoba, Argentina)
                • Manufactured since 2005
                • Polyacrylate-polyalcohol copolymer not biodegraded
                • Induces fibrotic response → difficult revision

          IMAGING

          • General Features

            • Radiographic Findings

              • Ultrasonographic Findings

                • Imaging Recommendations

                  DIFFERENTIAL DIAGNOSIS

                    CLINICAL ISSUES

                    • Presentation

                      • Natural History & Prognosis

                        Selected References

                        1. Kirsch AJ et al: Non-animal stabilized hyaluronic acid/dextranomer gel (NASHA/Dx, Deflux) for endoscopic treatment of vesicoureteral reflux: what have we learned over the last 20 years? Urology. ePub, 2021
                        2. Steinborn M et al: The color Doppler twinkling artifact of implants after endoscopic treatment of vesicoureteral reflux in children: a common finding with high potential for misdiagnosis. J Pediatr Urol. ePub, 2021
                        3. Alizadeh F et al: A comparison between dextranomer/hyaluronic acid and polyacrylate polyalcohol copolymer as bulking agents for treating primary vesicoureteral reflux. Urol J. 16(2):174-9, 2019
                        4. Friedmacher F et al: Ureteral obstruction after endoscopic treatment of vesicoureteral reflux: does the type of injected bulking agent matter? Curr Urol Rep. 20(9):49, 2019
                        5. Han DS et al: Reflux timing is a predictor of successful endoscopic treatment of vesicoureteral reflux. Urology. 124:237-40, 2019
                        6. Wang HH et al: Endoscopic treatment for post-transplant vesicoureteral reflux. Transplant Proc. 51(5):1420-3, 2019
                        7. García-Aparicio L et al: Randomized clinical trial between polyacrylate-polyalcohol copolymer (PPC) and dextranomer-hyaluronic acid copolymer (Dx/HA) as bulking agents for endoscopic treatment of primary vesicoureteral reflux (VUR). World J Urol. 36(10):1651-6, 2018
                        8. Leung L et al: Endoscopic injection for primary vesicoureteric reflux: predictors of resolution and long term efficacy. J Pediatr Surg. 52(12):2066-9, 2017
                        9. Romain J et al: Delayed-onset ureteral obstruction and calcification masquerading as renal colic following Deflux° injection. Urology. 94:218-20, 2016
                        10. Kirsch AJ et al: Evaluation of new Deflux administration techniques: intraureteric HIT and double HIT for the endoscopic correction of vesicoureteral reflux. Expert Rev Med Devices. 11(5):439-46, 2014
                        11. Verma A et al: Role of endoscopic treatment of vesico-ureteric reflux in downgrading renin angiotensin system activation. J Pediatr Urol. 10(2):386-90, 2014
                        12. Cambareri GM et al: Practice patterns among pediatric urologists in the use of Deflux® for vesicoureteral reflux: a survey. J Pediatr Urol. 9(6 Pt A):955-61, 2013
                        13. Hidas G et al: Is the appearance of the dextranomer/hyaluronic acid mound predictive of reflux resolution? J Urol. 189(5):1882-5, 2013
                        14. Rubenwolf PC et al: Delayed-onset ureteral obstruction after endoscopic dextranomer/hyaluronic acid copolymer (Deflux) injection for treatment of vesicoureteral reflux in children: a case series. Urology. 81(3):659-62, 2013
                        15. Yankovic F et al: Incidence of Deflux® calcification masquerading as distal ureteric calculi on ultrasound. J Pediatr Urol. 9(6 Pt A):820-4, 2013
                        16. Kaye JD et al: Clinical and radiographic results of endoscopic injection for vesicoureteral reflux: Defining measures of success. J Pediatr Urol. 8(3):297-303, 2011
                        17. Kraft KH et al: Is Endoscopic injection therapy a reasonable treatment option for low-grade vesicoureteral reflux in association with overactive bladder? Urology. 78(3):675-8, 2011
                        18. Palagiri AV et al: Distal ureteral calcification secondary to deflux injection: a reality or myth? Urology. 77(5):1217-9, 2011
                        19. Cerwinka WH et al: Radiologic features of implants after endoscopic treatment of vesicoureteral reflux in children. AJR Am J Roentgenol. 195(1):234-40, 2010
                        20. Chertin B et al: Long-term results of endoscopic treatment of vesicoureteric reflux with different tissue-augmenting substances. J Pediatr Urol. 6(3):251-6, 2010
                        21. Peters CA et al: Summary of the AUA guideline on management of primary vesicoureteral reflux in children. J Urol. 184(3):1134-44, 2010
                        22. Romero NP et al: Deflux injections for vesicoureteral reflux in transplanted kidneys. Transplant Proc. 42(8):2892-5, 2010
                        23. Sorensen MD et al: Injection volumes of dextranomer/hyaluronic acid are increasing in the endoscopic management of vesicoureteral reflux. Pediatr Surg Int. 26(5):509-13, 2010
                        24. Williams MA et al: Endoscopic Deflux injection for pediatric transplant reflux: a feasible alternative to open ureteral reimplant. J Pediatr Urol. 4(5):341-4, 2008
                        Related Anatomy
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                        Related Differential Diagnoses
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                        References
                        Tables

                        Tables

                        KEY FACTS

                        • Terminology

                          • Imaging

                            • Top Differential Diagnoses

                              • Clinical Issues

                                TERMINOLOGY

                                • Definitions

                                  • Bulking agent injected near ureterovesical junction (UVJ) to alter UVJ orientation & prevent vesicoureteral reflux (VUR)
                                    • Deflux (Q-Med; Uppsala, Sweden): Dextranomer-hyaluronic acid copolymer (DHA, DxHA); most commonly used in USA
                                      • In use clinically since 1995, FDA approved 2001
                                      • Relatively large particle size inhibits migration
                                      • Biodegradable, stable in vivo
                                    • Dexell (Istem Medical; Ankara, Turkey); most commonly used in Europe
                                      • Manufactured since 2007
                                      • Polycationic derivative of Dextran & cross-linked hyaluronic acid
                                      • Similar size & biologic profile to Deflux
                                    • Macroplastique (Congentix; Geleen, Netherlands)
                                      • FDA approved in 2006
                                      • Polydimethylsiloxane (solid silicone elastomer)
                                      • Suspended in bioexcretable polyvinylpyrrolidone gel
                                    • Vantris (Promedon; Cordoba, Argentina)
                                      • Manufactured since 2005
                                      • Polyacrylate-polyalcohol copolymer not biodegraded
                                      • Induces fibrotic response → difficult revision

                                IMAGING

                                • General Features

                                  • Radiographic Findings

                                    • Ultrasonographic Findings

                                      • Imaging Recommendations

                                        DIFFERENTIAL DIAGNOSIS

                                          CLINICAL ISSUES

                                          • Presentation

                                            • Natural History & Prognosis

                                              Selected References

                                              1. Kirsch AJ et al: Non-animal stabilized hyaluronic acid/dextranomer gel (NASHA/Dx, Deflux) for endoscopic treatment of vesicoureteral reflux: what have we learned over the last 20 years? Urology. ePub, 2021
                                              2. Steinborn M et al: The color Doppler twinkling artifact of implants after endoscopic treatment of vesicoureteral reflux in children: a common finding with high potential for misdiagnosis. J Pediatr Urol. ePub, 2021
                                              3. Alizadeh F et al: A comparison between dextranomer/hyaluronic acid and polyacrylate polyalcohol copolymer as bulking agents for treating primary vesicoureteral reflux. Urol J. 16(2):174-9, 2019
                                              4. Friedmacher F et al: Ureteral obstruction after endoscopic treatment of vesicoureteral reflux: does the type of injected bulking agent matter? Curr Urol Rep. 20(9):49, 2019
                                              5. Han DS et al: Reflux timing is a predictor of successful endoscopic treatment of vesicoureteral reflux. Urology. 124:237-40, 2019
                                              6. Wang HH et al: Endoscopic treatment for post-transplant vesicoureteral reflux. Transplant Proc. 51(5):1420-3, 2019
                                              7. García-Aparicio L et al: Randomized clinical trial between polyacrylate-polyalcohol copolymer (PPC) and dextranomer-hyaluronic acid copolymer (Dx/HA) as bulking agents for endoscopic treatment of primary vesicoureteral reflux (VUR). World J Urol. 36(10):1651-6, 2018
                                              8. Leung L et al: Endoscopic injection for primary vesicoureteric reflux: predictors of resolution and long term efficacy. J Pediatr Surg. 52(12):2066-9, 2017
                                              9. Romain J et al: Delayed-onset ureteral obstruction and calcification masquerading as renal colic following Deflux° injection. Urology. 94:218-20, 2016
                                              10. Kirsch AJ et al: Evaluation of new Deflux administration techniques: intraureteric HIT and double HIT for the endoscopic correction of vesicoureteral reflux. Expert Rev Med Devices. 11(5):439-46, 2014
                                              11. Verma A et al: Role of endoscopic treatment of vesico-ureteric reflux in downgrading renin angiotensin system activation. J Pediatr Urol. 10(2):386-90, 2014
                                              12. Cambareri GM et al: Practice patterns among pediatric urologists in the use of Deflux® for vesicoureteral reflux: a survey. J Pediatr Urol. 9(6 Pt A):955-61, 2013
                                              13. Hidas G et al: Is the appearance of the dextranomer/hyaluronic acid mound predictive of reflux resolution? J Urol. 189(5):1882-5, 2013
                                              14. Rubenwolf PC et al: Delayed-onset ureteral obstruction after endoscopic dextranomer/hyaluronic acid copolymer (Deflux) injection for treatment of vesicoureteral reflux in children: a case series. Urology. 81(3):659-62, 2013
                                              15. Yankovic F et al: Incidence of Deflux® calcification masquerading as distal ureteric calculi on ultrasound. J Pediatr Urol. 9(6 Pt A):820-4, 2013
                                              16. Kaye JD et al: Clinical and radiographic results of endoscopic injection for vesicoureteral reflux: Defining measures of success. J Pediatr Urol. 8(3):297-303, 2011
                                              17. Kraft KH et al: Is Endoscopic injection therapy a reasonable treatment option for low-grade vesicoureteral reflux in association with overactive bladder? Urology. 78(3):675-8, 2011
                                              18. Palagiri AV et al: Distal ureteral calcification secondary to deflux injection: a reality or myth? Urology. 77(5):1217-9, 2011
                                              19. Cerwinka WH et al: Radiologic features of implants after endoscopic treatment of vesicoureteral reflux in children. AJR Am J Roentgenol. 195(1):234-40, 2010
                                              20. Chertin B et al: Long-term results of endoscopic treatment of vesicoureteric reflux with different tissue-augmenting substances. J Pediatr Urol. 6(3):251-6, 2010
                                              21. Peters CA et al: Summary of the AUA guideline on management of primary vesicoureteral reflux in children. J Urol. 184(3):1134-44, 2010
                                              22. Romero NP et al: Deflux injections for vesicoureteral reflux in transplanted kidneys. Transplant Proc. 42(8):2892-5, 2010
                                              23. Sorensen MD et al: Injection volumes of dextranomer/hyaluronic acid are increasing in the endoscopic management of vesicoureteral reflux. Pediatr Surg Int. 26(5):509-13, 2010
                                              24. Williams MA et al: Endoscopic Deflux injection for pediatric transplant reflux: a feasible alternative to open ureteral reimplant. J Pediatr Urol. 4(5):341-4, 2008