SAGE-Hindawi Access to ResearchInternational Journal of NephrologyVolume 2011 Article ID 276308 5 pagesdoi1040612011276308

Research Article

The Value of PIC Cystography in Detecting De Novo andResidual Vesicoureteral Reflux after DextranomerHyaluronicAcid Copolymer Injection

B W Palmer M Hemphill K Wettengel B P Kropp and D Frimberger

Section of Pediatric Urology Department of Urology University of Oklahoma Health Sciences Center 920 Stanton L Young BlvdWP-3150 Oklahoma City OK 73104 USA

Correspondence should be addressed to D Frimberger dominic-frimbergerouhscedu

Received 28 January 2011 Revised 1 April 2011 Accepted 6 May 2011

Academic Editor Michael J Ross

Copyright copy 2011 B W Palmer et al This is an open access article distributed under the Creative Commons Attribution Licensewhich permits unrestricted use distribution and reproduction in any medium provided the original work is properly cited

The endoscopic injection of DxHA in the management of vesicoureteral reflux (VUR) has become an accepted alternative toopen surgery In the current study we evaluated the value of cystography to detect de novo contralateral VUR in unilateral cases ofVUR at the time of DxHA injection and correlated the findings of immediate post-DxHA injection cystography during the sameanesthesia to 2-month postoperative VCUG to evaluate its ability to predict successful surgical outcomes The current study aimedto evaluate whether an intraoperatively performed cystogram could replace postoperative studies But a negative intraoperativecystogram correlates with the postoperative study in only 80 Considering the 75ndash80 success rate of DxHA implantationthe addition of intraoperative cystograms cannot replace postoperative studies In patients treated with unilateral VUR PICcystography can detect occult VUR and prevent postoperative contralateral new onset of VUR

1 Introduction

The role of endoscopic injection of dextranomerhyaluronicacid copolymer (DxHA) has expanded as an alternativeto open surgery to a treatment option for observationprotocols using prophylactic antibiotics Deflux has beenFDA approved since 2001 as a treatment option for grade2ndash4 vesicoureteral reflux (VUR) in single systems with noaccompanying urological malformations in children aboveone year of age The operative ease of technique shortprocedure and recovery time as well as repeatability ofinjections have popularized the technique with surgeons andparents alike Reports of expanded use to patients of all agesand grades of VUR even in the presence of duplicationureterocele or other lower tract anomalies are publishedworldwide [1 2] In a statement of the AUA board ofdirectors from October 2007 it was determined that ldquoIt isthe current position of the American Urological Associationthat endoscopic injection of the dextranomerhyaluroniccompound Deflux is an option in the management ofpediatric vesicoureteral reflux (VUR)rdquo [3 4]

The initial success rate was quoted as 68 [5] and is stillmentioned on the current website [6] of the manufacturingcompany (Q-MED Scandinavia Inc) In the meantimethe original subureteric injection technique (STING) hasevolved to the intraureteric injection technique intro-duced by the Atlanta group Using this hydrodistention-implantation technique (HIT) the authors reported successrates of 89 [7] However the reported worldwide successrates differ considerably (55ndash89 [7 8]) Unpublisheddata from our institution show an overall radiographicsuccess rate of 75 for patients and 84 for renal unitsafter the first injection These numbers include all grades ofVUR and a variety of urological malformations Althoughthe success rates continuously improve the numbers of mostinstitutions still differ significantly from the traditional 98for open reimplants Since up to 25 of patients will haveremaining VUR after DxHA injection we still performvoiding cystograms 2 months after surgery

Positional instillation of contrast (PIC) cystography wasdeveloped to detect occult VUR in patients with recurrenturinary tract infections (UTI) after a negative standard

2 International Journal of Nephrology

Figure 1 Positive unilateral HPC after Deflux injection showingresidual VUR

voiding cystogram It has a higher sensitivity than standardvoiding cystogram (VCUG) and can detect occult VUR[9] Parents can be advised that in case of a positivePIC DxHA injection can be performed during the sameanesthesia In the current study we compared two differentPIC techniques and evaluated two different scenarios Firstwhether PIC cystography or high-pressure cystograms wereuseful to detect de novo contralateral VUR in the caseof preoperative unilateral VUR and second whether PICcystography when performed intraoperatively immediatelyafter DxHA injection can predict a successful surgicaloutcome by correlating the results with a standard 2-monthpostprocedure VCUG

2 Material and Methods

A retrospective chart review was performed on all intraop-erative cystograms performed at the time of DxHA injec-tions at our institution from 2005ndash2007 IRB approval wasobtained DxHA injections were performed for all grades ofVUR and included complex cases such as duplicated systemsIn case of preoperative unilateral reflux a PIC cystogramwas performed on the contralateral unaffected side beforeDxHA injection If positive bilateral injection took placeIf negative only the affected side was treated The injectionswere done using the HIT technique as described by Kirschet al [7] DxHA was injected until a sufficient moundand good ureteral coaptation was observed At this point acystogram was performed Two techniques for intraoperativecystograms were studied The first group underwent a high-pressure cystogram (Figure 1) The outflow portion of the 10french off set cystoscope (Wolf Germany) was placed at thebladder neck filling the bladder with contrast material (Cys-tografin) to 100 cm water pressure until voiding occurredaround the cystoscope ensuring complete bladder fillingThe second group underwent standard PIC cystography [8]with the outflow portion of the cystoscope directed at theureteral orifice at a 100 cm water pressure for 5 seconds(Figure 2) Radiographic views for both tests were performedin anterior-posterior and lateral as well as upper tract viewsThe intraoperative cystogram was noted to be positive if anygrade of VUR was present (Figure 3) In cases of a positive

Figure 2 Negative unilateral PIC cystogram after Deflux injectionshowing resolution of VUR

Figure 3 Positive unilateral positional infusion contrast (PIC)cystogram before Deflux injection showing de novo VUR

study on the contralateral side or for remaining VUR afterinjection DxHA was reinjected The cystogram was thenrepeated until resolution of the VUR was seen The patientswere left on prophylactic antibiotics and followed up at 4weeks postoperatively with an ultrasound and 2 monthspostoperatively with a VCUG The correlations of the intra-and postoperative study as well as the detection of de novoVUR were noted

3 Results

Altogether 116 patients and 177 renal units (RU) weretreated and available for evaluation Out of the 116 patients34 were found preoperatively to have unilateral and 82bilateral VUR New contralateral VUR (de novo) for the34 preoperative unilateral refluxing patients was foundintraoperatively in 27 RU (Figure 4(c)) The high-pressureintraoperative cystogram (Group 1) was performed in 86RUs and the standard PIC (Group 2) in 91 RUs There wasno statistically significant difference between groups 1 and 2for the detection of de novo VUR (Figure 4(b))

For both groups only 5 RU were found to have remainingVUR intraoperatively after DxHA injection (2 in Group1 and 3 in Group 2) All 5 patients were reinjectedand had a subsequent negative intraoperative cystogram

International Journal of Nephrology 3

Follow up

Negative RUS(n = 116)

(RU = 177)

VCUG

Positive(n = 28)

(RU = 36)

Negative VCUG(n = 88)

(RU = 141)

(a)

Deflux

(n = 116) (RU = 177)

(unilateral = 55)(bilateral = 61)

HPC(RU=86)

NegativeHPC

(RU = 84)

PositiveHPC

(RU = 2)

PIC(RU = 91)

NegativePIC

(RU = 88)

PositivePIC

(RU = 3)

(b)

VUR (n = 116)

Unilateral VUR(n = 34)

PIC

Negative(n = 7)

Positive(n = 27)

Bilateral VUR(n = 82)

(c)Figure 4

4 International Journal of Nephrology

No intra- or postoperative complications were noted Nopatient had a UTI in the follow-up period Postoperativepain management if necessary consisted of Ibuprofen orAcetaminophen according to parental preference In allpatients the postoperative US at four weeks were negative forhydronephrosis or any other new abnormality The DxHAdeposits were seen in the bladder in all cases At 2 monthspostoperative standard VCUG detected 20 RU (23) to bepositive for VUR in Group 1 and 16 RU (18) positive forVUR in Group 2 Altogether 36 RU were positive for anallover success rate of 80 for RU and 75 for patients(Figure 4(a)) There was no statistical difference between thegroups The grade of VUR age and gender of patient as wellas amount of Deflux injected did not influence the result

4 Discussion

Vesicoureteral reflux remains a common disease and espe-cially for lower grades the prospect of spontaneous resolutionis good But the data on the value of daily prophylacticantibiotics remain controversial and most parents are con-cerned about their long-term use The discussion becomesevident by the current multi-institutional NIH-fundedRIVUR study which aims to evaluate the role of prophylacticantibiotic in VUR In addition to prolonged antibiotic useparents and patients alike dread the yearly necessary voidingcystogram to check for resolution Therefore to avoid thedaily antibiotics and the yearly VCUG many parents con-sider surgical treatment options The endoscopic injection ofDxHA is an attractive management alternative for parentsWhen presenting the surgical options all parents are enthu-siastic about the minimal invasive nature of the procedurewith low complication possibilities and fast recovery timesHowever the 20ndash25 lower success rate of the endoscopicprocedure in comparison to the open surgery is a concern

Although DxHA can be reinjected it requires furthertesting anesthesia and time spent away from school or workTherefore it would be highly desirable to develop a methodto check the success of the Deflux injection intraoperativelyPIC cystography is used to detect occult VUR in patients witha negative standard voiding study who suffer from recurrentUTIs According to Rubenstein et al the procedure is a100 sensitive and 91 specific in identifying VUR andcan therefore detect occult VUR [9] Tareen et al recentlyconfirmed the findings in 5 patients [10] In a study on39 patients with febrile UTIs and negative voiding studiesfrom 4 different institutions PIC cystograms were performedand VUR identified in 82 of these patients Additionallythe authors noted that orifices that were patulous laterallydisplaced or positive for hydrodistention were much morelikely to be positive for VUR than normal orifices [11]Pinto et al also performed intraoperative PIC cystogramsand found that 23 of patients had a positive postoperativeVCUG despite a negative intraoperative PIC study [12] andPalmer confirmed these results [13] The authors concludedthat PIC cystography was not useful to raise the success rateof Deflux injection

In the current study we used two different cystogramtechniques the standard PIC study and a high-pressure

cystogram filling the bladder until irrigation fluid leakedaround the cystoscope Even with this aggressive cystogramtechnique only an 80 correlation between a negativeintraoperative cystogram and postoperative cystogram wasachieved The success rate of 75 for patients and 80 forRU could not be improved Several reasons for the intra-operative negative study are possible At time of injection arelative wound edema might increase the coaptation of theureteral orifice temporarily giving a negative intraoperativestudy result Other possibilities include decrease in the sizeof the injected DxHA deposit over time also thought to beresponsible for long-term failure after DxHA injection [14]Finally DxHA deposits can migrate from their injected posi-tion This phenomenon has been noted during cystoscopyat the time of the planned second injection of Deflux afterinitial failure The DxHA deposits tend to migrate mediallyand toward the bladder neck causing long-term failure ofinjection

Elmore et al reported the onset of new contralateralVUR after DxHA implantation in approximately 13 of126 patients with preoperatively unilateral VUR [15] In thecurrent study 34 out of 116 patients were preoperativelydiagnosed with unilateral VUR only Twenty seven ofthese 34 patients demonstrated a positive PIC cystographyintraoperatively and were successfully injected with DxHANone of these de novo detected refluxing units were positivefor VUR in the postoperative cystograms

5 Conclusion

A negative intraoperative cystogram correlates with the post-operative VCUG in only 80 Considering that the successrates of DxHA injections are commonly between 75ndash80the addition of intraoperative cystograms cannot replacepostoperative studies In patients treated with unilateralVUR PIC cystography can detect occult reflux and preventpostoperative contralateral new onset of VUR

References

[1] P A Merguerian A Taenzer K Knoerlein L McQuistonand D Herz ldquoVariation in management of duplex systemintravesical ureteroceles a survey of pediatric urologistsrdquo TheJournal of Urology vol 184 no 4 pp 1625ndash1630 2010

[2] T W Hensle E A Reiley C Ritch and A Murphy ldquoTheclinical utility and safety of the endoscopic treatment ofvesicoureteral reflux in patients with duplex uretersrdquo Journalof Pediatric Urology vol 6 no 1 pp 15ndash22 2010

[3] httpwwwauanetorgcontentguidelines-and-quality-carepolicy-statementsuuse-of-Deflux-in-the-management-of-vesicoureteral-refluxcfm

[4] C A Peters S J Skoog B S Arant et al ldquoSummary ofthe AUA guideline of management of primary vesicoureteralreflux in childrenrdquo The Journal of Urology vol 184 no 3 pp1134ndash1144 2010

[5] G Lackgren N Wahlin E Skoldenberg et al ldquoLong-termfollowup of children treated with dextranomerhyaluronicacid copolymer for vesicoureteral refluxrdquo The Journal ofUrology vol 166 no 5 pp 1887ndash1892 2001

[6] httpwwwdefluxcomcountryusaq=node24accessdate6202011

International Journal of Nephrology 3

Follow up

Negative RUS(n = 116)

(RU = 177)

VCUG

Positive(n = 28)

(RU = 36)

Negative VCUG(n = 88)

(RU = 141)

(a)

Deflux

(n = 116) (RU = 177)

(unilateral = 55)(bilateral = 61)

HPC(RU=86)

NegativeHPC

(RU = 84)

PositiveHPC

(RU = 2)

PIC(RU = 91)

NegativePIC

(RU = 88)

PositivePIC

(RU = 3)

(b)

VUR (n = 116)

Unilateral VUR(n = 34)

PIC

Negative(n = 7)

Positive(n = 27)

Bilateral VUR(n = 82)

(c)Figure 4

4 International Journal of Nephrology

No intra- or postoperative complications were noted Nopatient had a UTI in the follow-up period Postoperativepain management if necessary consisted of Ibuprofen orAcetaminophen according to parental preference In allpatients the postoperative US at four weeks were negative forhydronephrosis or any other new abnormality The DxHAdeposits were seen in the bladder in all cases At 2 monthspostoperative standard VCUG detected 20 RU (23) to bepositive for VUR in Group 1 and 16 RU (18) positive forVUR in Group 2 Altogether 36 RU were positive for anallover success rate of 80 for RU and 75 for patients(Figure 4(a)) There was no statistical difference between thegroups The grade of VUR age and gender of patient as wellas amount of Deflux injected did not influence the result

4 Discussion

Vesicoureteral reflux remains a common disease and espe-cially for lower grades the prospect of spontaneous resolutionis good But the data on the value of daily prophylacticantibiotics remain controversial and most parents are con-cerned about their long-term use The discussion becomesevident by the current multi-institutional NIH-fundedRIVUR study which aims to evaluate the role of prophylacticantibiotic in VUR In addition to prolonged antibiotic useparents and patients alike dread the yearly necessary voidingcystogram to check for resolution Therefore to avoid thedaily antibiotics and the yearly VCUG many parents con-sider surgical treatment options The endoscopic injection ofDxHA is an attractive management alternative for parentsWhen presenting the surgical options all parents are enthu-siastic about the minimal invasive nature of the procedurewith low complication possibilities and fast recovery timesHowever the 20ndash25 lower success rate of the endoscopicprocedure in comparison to the open surgery is a concern

Although DxHA can be reinjected it requires furthertesting anesthesia and time spent away from school or workTherefore it would be highly desirable to develop a methodto check the success of the Deflux injection intraoperativelyPIC cystography is used to detect occult VUR in patients witha negative standard voiding study who suffer from recurrentUTIs According to Rubenstein et al the procedure is a100 sensitive and 91 specific in identifying VUR andcan therefore detect occult VUR [9] Tareen et al recentlyconfirmed the findings in 5 patients [10] In a study on39 patients with febrile UTIs and negative voiding studiesfrom 4 different institutions PIC cystograms were performedand VUR identified in 82 of these patients Additionallythe authors noted that orifices that were patulous laterallydisplaced or positive for hydrodistention were much morelikely to be positive for VUR than normal orifices [11]Pinto et al also performed intraoperative PIC cystogramsand found that 23 of patients had a positive postoperativeVCUG despite a negative intraoperative PIC study [12] andPalmer confirmed these results [13] The authors concludedthat PIC cystography was not useful to raise the success rateof Deflux injection

In the current study we used two different cystogramtechniques the standard PIC study and a high-pressure

cystogram filling the bladder until irrigation fluid leakedaround the cystoscope Even with this aggressive cystogramtechnique only an 80 correlation between a negativeintraoperative cystogram and postoperative cystogram wasachieved The success rate of 75 for patients and 80 forRU could not be improved Several reasons for the intra-operative negative study are possible At time of injection arelative wound edema might increase the coaptation of theureteral orifice temporarily giving a negative intraoperativestudy result Other possibilities include decrease in the sizeof the injected DxHA deposit over time also thought to beresponsible for long-term failure after DxHA injection [14]Finally DxHA deposits can migrate from their injected posi-tion This phenomenon has been noted during cystoscopyat the time of the planned second injection of Deflux afterinitial failure The DxHA deposits tend to migrate mediallyand toward the bladder neck causing long-term failure ofinjection

Elmore et al reported the onset of new contralateralVUR after DxHA implantation in approximately 13 of126 patients with preoperatively unilateral VUR [15] In thecurrent study 34 out of 116 patients were preoperativelydiagnosed with unilateral VUR only Twenty seven ofthese 34 patients demonstrated a positive PIC cystographyintraoperatively and were successfully injected with DxHANone of these de novo detected refluxing units were positivefor VUR in the postoperative cystograms

5 Conclusion

A negative intraoperative cystogram correlates with the post-operative VCUG in only 80 Considering that the successrates of DxHA injections are commonly between 75ndash80the addition of intraoperative cystograms cannot replacepostoperative studies In patients treated with unilateralVUR PIC cystography can detect occult reflux and preventpostoperative contralateral new onset of VUR

References

[1] P A Merguerian A Taenzer K Knoerlein L McQuistonand D Herz ldquoVariation in management of duplex systemintravesical ureteroceles a survey of pediatric urologistsrdquo TheJournal of Urology vol 184 no 4 pp 1625ndash1630 2010

[2] T W Hensle E A Reiley C Ritch and A Murphy ldquoTheclinical utility and safety of the endoscopic treatment ofvesicoureteral reflux in patients with duplex uretersrdquo Journalof Pediatric Urology vol 6 no 1 pp 15ndash22 2010

[3] httpwwwauanetorgcontentguidelines-and-quality-carepolicy-statementsuuse-of-Deflux-in-the-management-of-vesicoureteral-refluxcfm

[4] C A Peters S J Skoog B S Arant et al ldquoSummary ofthe AUA guideline of management of primary vesicoureteralreflux in childrenrdquo The Journal of Urology vol 184 no 3 pp1134ndash1144 2010

[5] G Lackgren N Wahlin E Skoldenberg et al ldquoLong-termfollowup of children treated with dextranomerhyaluronicacid copolymer for vesicoureteral refluxrdquo The Journal ofUrology vol 166 no 5 pp 1887ndash1892 2001

[6] httpwwwdefluxcomcountryusaq=node24accessdate6202011

4 International Journal of Nephrology

No intra- or postoperative complications were noted Nopatient had a UTI in the follow-up period Postoperativepain management if necessary consisted of Ibuprofen orAcetaminophen according to parental preference In allpatients the postoperative US at four weeks were negative forhydronephrosis or any other new abnormality The DxHAdeposits were seen in the bladder in all cases At 2 monthspostoperative standard VCUG detected 20 RU (23) to bepositive for VUR in Group 1 and 16 RU (18) positive forVUR in Group 2 Altogether 36 RU were positive for anallover success rate of 80 for RU and 75 for patients(Figure 4(a)) There was no statistical difference between thegroups The grade of VUR age and gender of patient as wellas amount of Deflux injected did not influence the result

4 Discussion

Vesicoureteral reflux remains a common disease and espe-cially for lower grades the prospect of spontaneous resolutionis good But the data on the value of daily prophylacticantibiotics remain controversial and most parents are con-cerned about their long-term use The discussion becomesevident by the current multi-institutional NIH-fundedRIVUR study which aims to evaluate the role of prophylacticantibiotic in VUR In addition to prolonged antibiotic useparents and patients alike dread the yearly necessary voidingcystogram to check for resolution Therefore to avoid thedaily antibiotics and the yearly VCUG many parents con-sider surgical treatment options The endoscopic injection ofDxHA is an attractive management alternative for parentsWhen presenting the surgical options all parents are enthu-siastic about the minimal invasive nature of the procedurewith low complication possibilities and fast recovery timesHowever the 20ndash25 lower success rate of the endoscopicprocedure in comparison to the open surgery is a concern

Although DxHA can be reinjected it requires furthertesting anesthesia and time spent away from school or workTherefore it would be highly desirable to develop a methodto check the success of the Deflux injection intraoperativelyPIC cystography is used to detect occult VUR in patients witha negative standard voiding study who suffer from recurrentUTIs According to Rubenstein et al the procedure is a100 sensitive and 91 specific in identifying VUR andcan therefore detect occult VUR [9] Tareen et al recentlyconfirmed the findings in 5 patients [10] In a study on39 patients with febrile UTIs and negative voiding studiesfrom 4 different institutions PIC cystograms were performedand VUR identified in 82 of these patients Additionallythe authors noted that orifices that were patulous laterallydisplaced or positive for hydrodistention were much morelikely to be positive for VUR than normal orifices [11]Pinto et al also performed intraoperative PIC cystogramsand found that 23 of patients had a positive postoperativeVCUG despite a negative intraoperative PIC study [12] andPalmer confirmed these results [13] The authors concludedthat PIC cystography was not useful to raise the success rateof Deflux injection

In the current study we used two different cystogramtechniques the standard PIC study and a high-pressure

cystogram filling the bladder until irrigation fluid leakedaround the cystoscope Even with this aggressive cystogramtechnique only an 80 correlation between a negativeintraoperative cystogram and postoperative cystogram wasachieved The success rate of 75 for patients and 80 forRU could not be improved Several reasons for the intra-operative negative study are possible At time of injection arelative wound edema might increase the coaptation of theureteral orifice temporarily giving a negative intraoperativestudy result Other possibilities include decrease in the sizeof the injected DxHA deposit over time also thought to beresponsible for long-term failure after DxHA injection [14]Finally DxHA deposits can migrate from their injected posi-tion This phenomenon has been noted during cystoscopyat the time of the planned second injection of Deflux afterinitial failure The DxHA deposits tend to migrate mediallyand toward the bladder neck causing long-term failure ofinjection

Elmore et al reported the onset of new contralateralVUR after DxHA implantation in approximately 13 of126 patients with preoperatively unilateral VUR [15] In thecurrent study 34 out of 116 patients were preoperativelydiagnosed with unilateral VUR only Twenty seven ofthese 34 patients demonstrated a positive PIC cystographyintraoperatively and were successfully injected with DxHANone of these de novo detected refluxing units were positivefor VUR in the postoperative cystograms

5 Conclusion

A negative intraoperative cystogram correlates with the post-operative VCUG in only 80 Considering that the successrates of DxHA injections are commonly between 75ndash80the addition of intraoperative cystograms cannot replacepostoperative studies In patients treated with unilateralVUR PIC cystography can detect occult reflux and preventpostoperative contralateral new onset of VUR

References

[1] P A Merguerian A Taenzer K Knoerlein L McQuistonand D Herz ldquoVariation in management of duplex systemintravesical ureteroceles a survey of pediatric urologistsrdquo TheJournal of Urology vol 184 no 4 pp 1625ndash1630 2010

[2] T W Hensle E A Reiley C Ritch and A Murphy ldquoTheclinical utility and safety of the endoscopic treatment ofvesicoureteral reflux in patients with duplex uretersrdquo Journalof Pediatric Urology vol 6 no 1 pp 15ndash22 2010

[3] httpwwwauanetorgcontentguidelines-and-quality-carepolicy-statementsuuse-of-Deflux-in-the-management-of-vesicoureteral-refluxcfm

[4] C A Peters S J Skoog B S Arant et al ldquoSummary ofthe AUA guideline of management of primary vesicoureteralreflux in childrenrdquo The Journal of Urology vol 184 no 3 pp1134ndash1144 2010

[5] G Lackgren N Wahlin E Skoldenberg et al ldquoLong-termfollowup of children treated with dextranomerhyaluronicacid copolymer for vesicoureteral refluxrdquo The Journal ofUrology vol 166 no 5 pp 1887ndash1892 2001

[6] httpwwwdefluxcomcountryusaq=node24accessdate6202011

International Journal of Nephrology 5

[7] A J Kirsch M Perez-Brayfield E A Smith and H C ScherzldquoThe modified sting procedure to correct vesicoureteral refluximproved results with submucosal implantation within theintramural ureterrdquo The Journal of Urology vol 171 no 6 pp2413ndash2416 2004

[8] U Altug M Cakan S Yilmaz and F Yalcinkaya ldquoAre therepredictive factors for the outcome of endoscopic treatment ofgrade III-V vesicoureteral reflux with dextranomerhyaluronicacid in childrenrdquo Pediatric Surgery International vol 23 no6 pp 585ndash589 2007

[9] J N Rubenstein M Maizels S C Kim and J T B HoustonldquoThe pic cystogram a novel approach to identify ldquooccultrdquovesicoureteral reflux in children with febrile urinary tractinfectionsrdquo The Journal of Urology vol 169 no 6 pp 2339ndash2343 2003

[10] B U Tareen D Bui D R McMahon and P F Nasrallah ldquoRoleof positional instillation of contrast cystography in the algo-rithm for evaluating children with confirmed pyelonephritisrdquoUrology vol 67 no 5 pp 1055ndash1057 2006

[11] J D Edmondson M Maizels S A Alpert et al ldquoMulti-institutional experience with PIC cystographymdashincidence ofoccult vesicoureteral reflux in children with febrile urinarytract infectionsrdquo Urology vol 67 no 3 pp 608ndash611 2006

[12] K J Pinto J Pugach and J Saalfield ldquoLack of usefulness ofpositioned instillation of contrast cystogram after injectionof dextranomerhyaluronic acidrdquo The Journal of Urology vol176 no 6 pp 2654ndash2656 2006

[13] L S Palmer ldquoThe role of intraoperative cystography followingthe injection of dextranomerhyaluronic acid copolymerrdquo TheJournal of Urology vol 179 no 3 pp 1118ndash1121 2008

[14] A Stenberg and G Lackgren ldquoA new bioimplant for theendoscopic treatment of vesicoureteral reflux experimentaland short-term clinical resultsrdquo The Journal of Urology vol154 no 2 pp 800ndash803 1995

[15] J M Elmore A J Kirsch R H Lyles M R Perez-Brayfield and H C Scherz ldquoNew contralateral vesicoureteralreflux following dextranomerhyaluronic acid implantationincidence and identification of a high risk grouprdquo The Journalof Urology vol 175 no 3 pp 1097ndash1100 2006

• Introduction
• Material and Methods
• Results
• Discussion
• Conclusion
• References