Deflux Injections – What it is and how it corrects VUR
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What is Endoscopic Treatment of Vesicoureteral Reflux, and how does it correct a child’s reflux?
Endoscopic treatment of VUR (commonly known as Deflux injection) is an outpatient surgery using a bulking agent to correct reflux. During the surgery, the doctor uses a cystoscope to look into the bladder. A cystoscope is a thin, lighted instrument that is used to view areas of the urethra and bladder that can not easily be seen on x-ray. The cystoscope is entered through the urethra and into the bladder. During this procedure, the surgeon will use very small instruments to inject a bulking agent (Deflux) into the lining of the bladder where the ureter enters into the bladder. By doing this, the surgeon creates a new valve that prevents the back flow of urine into the kidneys.
Deflux is a gel substance made from two types of sugar-based molecules (polysaccharides) called dextranomer and hyaluronic acid. These materials work well because they do not cause significant reactions to the body. Hyaluronic acid is actually produced naturally within the body. Because of this, the injected agent breaks down over time, leaving a permanent bulge of tissue which serves as the new valve. The urine can still pass from the ureter into the bladder, but because of the new valve, the urine cannot freely flow back into the ureters. It’s kind of like a door that only swings one way.
Deflux injection has shown the best results in children with grade II, III and in some cases of grade IV. The higher the grade of reflux, the less effective the injection will be. Most studies show the overall success rate of Deflux injection to be 80% or better after the first injection. Some children may require a second or third injection. With multiple injections, the success rate moves into the 90 th percentile.
Children may not be good candidates for Deflux if they have kidney failure, voiding dysfunction or other bladder or kidney abnormalities. Children with grade V are usually better candidates for ureteral reimplant. In some cases, like our little Lizzie, Deflux is done after a reimplantation has failed. Studies show high success rates, depending on the reason for the failure of the reimplantation. If the reflux is secondary to an underlying condition(which we are still investigating for Lizzie), surgery may not be effective until the underlying condition is corrected.
Deflux injection can be a good alternative to long term antibiotics and may be a good option for children with breakthrough infection. There are many advantages to having Deflux instead of open surgery. For one, it is much less invasive than reimplantation surgery. Endoscopic treatment with Deflux, does not require an incision, therefore recovery time and risk of complication are lessened. Deflux is done as an outpatient surgery, so your child can go home the same day, where reimplantation patients may have a 2-5 day hospital stay. Another plus is that having Deflux does not prevent the child from having surgery later if needed. Of course there is also a down side to Deflux. Deflux is less successful than the reimplantation (especially in the higher grades), and Deflux injections do not have a lot of long term studies available because it is a relatively new procedure. This procedure was approved by the FDA for use in the United States in 2001.
During the surgery, your child will undergo general anesthesia, so they will be completely asleep for the procedure. The doctor will perform the surgery as described above, and the time will depend on if the procedure is unilateral (one ureter) or bilateral (both ureters) but should generally take less than 30 minutes. When the surgery is complete, the child will go to recovery where you can be with them. As the child wakes up, they will monitor them for a short time, but your child should be able to go home that same day.
After going home, your child may have some bleeding in the urine which is normal for this procedure. General anesthesia and Deflux injection are generally low risk, but complications can occur. Complications can include blockage of the ureter (from too much injection), or infection from surgery.
If your child has any of the following symptoms after surgery, you should contact your doctor immediately:
- Temperature over 101.4 degrees F
- Excessive Vomiting
- Severe pain
Deflux Injection – Why it may be a good option
Not all children are good candidates for Deflux, but for those that are, Deflux can be a good alternative to ureteral reimplantation for the treatment of VUR. Deflux is a bulking agent that is injected around the ureter opening to prevent urine from backing up into the kidneys. The success rate after the first injection is about 85%. That number increases with multiple injections.
Studies have shown that having a Deflux injection lowers incidence of UTI and has an 85-90% resolution rate of VUR. If it is used as a first line treatment, Deflux is more effective than prophylactic antibiotics in reducing recurrent UTI. According to one study, patients on prophylaxis were 79% more likely to develop a breakthrough infection than those who had Deflux. That’s a pretty good argument for using Deflux as a first line of treatment in lower grades of VUR.
Another benefit to Deflux is recovery time. The injection itself takes only about 10-20 minutes, and is usually done as an outpatient surgery. The child can usually go back to normal activities the next day. That’s a pretty big difference from the surgery. Reimplantation surgery is usually 2-3 hours and recovery takes a while because of the incision, catheter and bladder spasms. Another positive is that by doing Deflux first, you are not ruling out any treatments later. Some open surgeries can prevent later treatment options.
While Deflux is a great option, for some children reimplantation surgery is a much better option. This was the case for us. Lizzie had grade 5 VUR, with multiple recurrent infections, and that meant open surgery. When we later discovered that her reimplant failed, Deflux became an option for us, and she had a Deflux injection at the age of 11 months, along with a vesicostomy. Because we did the vesicostomy surgery at the same time, I can’t say what having outpatient Deflux is like. I can say that even with the other surgery, Lizzie recovered very quickly.
We won’t know for sure if Lizzie’s Deflux was successful until we can do another VCUG. It may be another year or so until we know, because of the difficulty of doing a VCUG with an ostomy. We are hopeful that the Deflux has at least helped the VUR, but we realize that another injection or two may be necessary because the grade of her reflux is so high.
If you think your child might be a good candidate for Deflux, you should talk to your doctor. You may also want to look at the links on this page for more information on Deflux.
