The management of Transplant kidney vesicoureteral reflux in the paediatric population is a heavily debated issue and Deflux® injection to manage VUR is both widely described in the literature and commonly practised. In this paper, these authors have put forth their experience to support their case as to why as an institution they do not recommend Deflux as first-line treatment of VUR in the transplant patient. VUR resulting in febrile urinary tract infections remains a problem in the transplant population, leading to repeated hospitalisations and increased morbidity. Revision of the vesicoureteral anastomosis can be a surgical challenge due to scar tissue and tenuous vascularity of the transplant ureter. Therefore, alternative options such as endoscopic injection of Deflux at the neo-orifice and surveillance with prophylactic antibiotics have emerged as potential treatment modalities for transplant ureter VUR.
The authors reviewed their experience of the management of VUR in the transplant ureter, comparing outcomes of various modalities. A retrospective chart review of all renal transplant patients from January 2002 to January 2017 was conducted. All patients with VUR on voiding cystourethrogram (VCUG) after surgery were identified. VUR was seen in 35/285 (12.3%) transplant patients after a non-refluxing ureteroneocystostomy. VUR was managed with surveillance in17/35 (49%), intravesical Deflux injection in 11/35 (31%), and immediate redo ureteral reimplantation in 7/35 (20%). Ten out of 11 patients undergoing Deflux injection had a postoperative VCUG. All patients developed VUR recurrence; the majority showed immediate failure and only 1/10 showed late recurrence. Of the immediate failures, 3/9 patients were maintained on prophylactic antibiotics, and 6/9 patients underwent ureteral re-implantation.
In these six patients undergoing re-implantation after failed Deflux, three (50%) patients required additional surgeries: one patient developed recurrence of reflux and two patients developed ureterovesical junction obstruction. In contrast, no complications were seen in patients undergoing primary ureteral re-implantation. Although low numbers and a retrospective design limit the study, the results differ significantly from the published Deflux series in the treatment of transplant kidney VUR. In fact, post-Deflux redo ureteral re-implantation was associated with an increased risk of postoperative complication. Therefore the authors conclude that the use of Deflux in the post-transplant setting has poor results and as an institution do not recommend Deflux as first-line treatment of VUR in the transplant patient.