ENDOSCOPIC TREATMENT OF VESICOURETERAL REFLUX AND URINARY-INCONTINENCE - TECHNICAL PROBLEMS IN THE PEDIATRIC-PATIENT

Objective Bovine collagen has been successfully used for the endoscopi c treatment of urinary incontinence (UI) and vesico-ureteric reflux (V UR) in children for more than 8 years, although its long-term efficacy has sometimes: been questioned. Its failure is generally ascribed eit her to technical difficulties or to instability of collagen at the sit e 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-epispadi as complex who were still incontinent after bladder neck reconstructio n) had periurethral or pericervical glutaraldehyde cross-linked botine collagen injection for UI. Five more children with exstrophy-epispadi as complex (aged 1-3 years) underwent periurethral collagen injection to stimulate bladder enhancement and allow subsequent bladder neck rec onstruction. Results In children treated for VUR, a single injection p roved successful in 72.2% of cases (127 ureters); a second collagen in jection raised the success rate to 81%. Continence improved in all nin e neuropathic bladders and in 10 of 16 children with exstrophy-epispad ias 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%. Conc lusions Endoscopic treatment of VUR seems to be a valid alternative to open surgery, even though concerns remain about the long-term efficac y of collagen implantation. An important distinction should be made be tween early and late failure of the procedure. Early failure, which we define as persistence of reflux, is usually due to incorrect techniqu e or technical difficulties. Late failure, or recurrence of reflux, wh ich has previously been attributed to the biodegradability of collagen , seems to be due to the displacement of the injected collagen. Mictur ition itself or high bladder pressure (such as detrusor instability) c ould be responsible for the displacement of the injected collagen medi ally and distally, where it can no longer support the submucosal urete ric tunnel. In the treatment of urinary incontinence, both the implant technique and the choice of the site of injection seem to have a cons iderable 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 tec hnical adjustments and refinements are essential to obtain the best re sults.