Radiologic Features of Implants

After Endoscopic Treatment of

Vesicoureteral Reflux in
Children

Oleh :
Rivanny Frivandiny 1210070100041

Preceptor :
dr.Dessy Wimelda Sp.Rad
Endoscopic treatment of vesi-coureteral reflux
(VUR) was in-troduced as an investigational
method in 1981 and was first used to treat
patients in 1984.

As the injec-tion techniques evolved, the cure

rates of en-doscopic treatment of VUR have
significant-ly improved to rival those of open
ureteral reimplantation.

Many of these patients will undergo imaging

studies unrelated to VUR. Visualization of the
injected bulking agent at the ureterovesical
junction (UVJ) could po-tentially lead to
misdiagnosis and unwarrant-ed intervention.
Injectable Agents

A
dextranomer–
hyaluronic acid
polytef copolymer
(Deflux, Oceana
Therapeutics)

glutaradehide
Injection Technique
The double hydrodis-tention implantation
technique entails the passage of an injection
needle under cysto-scopic guidance into the
ureteral orifice

Suf-ficient bulking agent is injected

submucosal-ly to produce a bulge, which
initially coapts the detrusor tunnel

A second implant within the most distal

intramural tunnel then leads to coaptation of
the ureteral orifice. An average of 1–1.5 mL of
bulking material is in-jected per ureter
Radiologic Findings
The copolymer of dextranomer
and hy-aluronic acid has a
Radiography radiographic density
comparable with that of soft
tissue, 24 HU, and is not
visualized on radiography

• B, Dextranomer–hyaluronic acid copolymer shows low

density on radiograph.
•Voiding Cystourethrography

Fig. 3—8-year-old boy who underwent imaging 6 weeks after endoscopic

treatment with dextranomer–hyaluronic acid copolymer (1.5 mL injected at
each ureter) for right grade IV and left grade III vesicoureteral reflux.
Implants were not seen on radiography (not shown).
Sonography
(Fig. 4). Dextranomer–hyaluronic acid copolymer blebs with tissue density on CT appeared
isoechoic on ultrasound, whereas calcified blebs were hyperechoic with postenhancement
shadowing on sonography and could be mistaken for distal ureteral calculi.

• Fig. 4—Sonography of 7-year-old girl who underwent imaging 3 months

after endoscopic treatment of bilateral grade II vesicoureteral reflux (right
ureter, 1.0 mL injected; left ureter, 1.0 mL injected).
CT Scan
In a series of 17 patients who
underwent dextranomer–hyaluronic acid
copolymer in-jection for VUR, all 33 implants
were seen on CT; 36% had calcifications with a
medi-an attenuation value of 193 HU (range,
126–367 HU).
CT of dextranomer–hyaluronic acid copolymer implants.
A–C, 4-year- old boy 3 years after endoscopic treatment with dextranomer–hyaluronic acid copolymer for bilateral
grade III vesicoureteral reflux (right ureter, 1.2 mL injected; left ureter, 1.6 mL injected) . CT was performed for
neuroblastoma surveillance. CT scans show bilateral high-density implants (arrows) at ureterovesical junction (UVJ)
with mean attenuation of 398 HU.

D–F, 6 -year-old girl 1 year after endoscopic treatment with dextranomer–hyaluronic acid copolymer for right grade II
and left grade I vesicoureteral reflux (right ureter, 1.8 mL injected; left ureter, 1.0 mL injected). CT was performed
to evaluate right flank pain. CT scans show bilateral low-density implants (arrows) at UVJ with mean attenuation of
20 HU.
 Two patients with bilateral calcified blebs had multiple CT scans. The
median attenu-ation of these implants increased from 193 HU (range, 179–
211 HU) to 387 HU (range, 326–420 HU) over an average of 17 months
(Fig. 6).

2-year-old girl who underwent bilateral dextranomer–hyaluronic acid copolymer injection for bilateral grade II
vesicoureteral reflux (right ureter, 1.5 mL injected; left ureter, 0.4 mL injected). Multiple CT scans were obtained
because of recurrent histiocytosis.

A–C, CT scans show implants (arrows) at ureterovesical junction with increasing density 26 months (202 HU) (A), 35
months (263 HU) (B), and 43 months (348 HU) (C) after endoscopic treatment.
 Patients after endoscopic VUR treatment may develop urolithiasis and
pres-ent with renal colic (Fig. 7).

7—6 -year-old girl 3 years after left endoscopic injection of 1 mL dextranomer–hyaluronic acid copolymer for grade II
vesicoureteral reflux. Study was performed to evaluate abdominal pain during emergency department visit.

A–C, CT scans show calculus (left arrow, A; arrow, B) at right ureterovesical junction (UVJ) and calcified implant
(right arrow, A; arrow, C) at left UVJ.
 In these cases, a history of VUR
treatment, the side of the in-jection and flank
pain, the presence of hydro-nephrosis, and the
exact location of calcifica-tion in relation to the
UVJ help to distinguish urinary calculi from
calcified implants.
 Glutaraldehyde cross-linked collagen was
used in pediatric urology for antireflux pro-
cedures and has shown the potential to cal-cify.
A case report described a symptomat-ic
calcification (hematuria and back pain) that had
eroded at the UVJ after injection for VUR
treatment 10 years earlier.
 • MRI
In a series of 16 patients who had under-gone dextranomer–
hyaluronic acid copo-lymer injection for VUR, all 27 dextrano-mer–
hyaluronic acid copolymer implants were identified on MRI as bright UVJ
struc-tures on T2-weighted sequences only includ-ing T2-weighted
maximum intensity pro-jections.

8—3.5-year-old girl who had undergone bilateral dextranomer–hyaluronic acid copolymer injection for right grade II
and left grade IV vesicoureteral reflux (right ureter, 1.3 mL injected; left ureter, 1.5 mL injected) 7 months earlier.
MR urography was performed to evaluate bilateral hydronephrosis for obstruction.

A, Coronal T2-weighted image shows bilateral bright implants at ureterovesical junction (arrows); bladder is drained
by indwelling Foley catheter.
 • Although not seen on unenhanced T1-weighted sequences, excre-tory MR
urography depicted the implants as filling defects; dextranomer–hyaluronic
acid copolymer implants did not enhance with gadolinium (Fig. 9).

3.5 -year-old girl who had undergone dextranomer–hyaluronic acid copolymer injection for bilateral grade III vesicoureteral
reflux (right ureter, 1.5 mL injected; left ureter, 2.5 mL injected) 2 months earlier. MR urography was performed to evaluate
left hydronephrosis for obstruction.
A–C, T2-weighted images show bilateral bright implants (arrows) at ureterovesical junction on coronal (A), axial (B), and
sagittal (C) views.
D–F, Implants are not visualized on unenhanced T1-weighted image (D) but appear as filling defects (arrows, E and F) on
coronal (E) and sagittal (F) contrast-enhanced T1-weighted images
CONCLUSION
• Radiologic findings of implants depend on the
imaging technique, bulk-ing agent, and time
after injection. A history of VUR or an antireflux
procedure and the absence of hydronephrosis in
cases of suspected urolithiasis are important
clues to suggest implants.