See how pediatric urologists administer Deflux

Administering Deflux

Endoscopic treatment with Deflux takes about 15 minutes on an outpatient basis and usually allows the child to go back to normal activities the day after it’s done.1

The patient is first placed under general anesthesia. With the patient properly positioned, a cystoscope is inserted, and the Deflux needle is inserted in the working channel of the cystoscope. Deflux is injected submucosally in the urinary bladder in proximity to the ureteral orifice or in the distal ureter. The injection of Deflux creates increased tissue bulk thereby providing coaptation of the distal ureter during filling and contraction of the bladder. The dextranomer microspheres are gradually surrounded by host connective tissue at implant site.2

Deflux is injected according to the recommended technique, after which the needle and cystoscope are withdrawn, and postoperative care is given.

Double HIT technique

Techniques for administering Deflux have evolved over time, from subureteric injection (STING) to single intraluminal HIT (Hydrodistention Implantation Technique) to tandem proximal and distal intraluminal injection sites (Double HIT).3 In recent years, the Double HIT technique (Figure 1) has increasingly become the most commonly performed technique for correction for VUR by pediatric urologists in the United States. In 2014, a study showed 92% of Deflux procedures use the Double HIT technique which has demonstrated higher efficacy rates.4

Double HIT methodology3

The Double HIT method is currently achieving the highest rates of success. The bladder is filled to less than half capacity to permit visualization of the ureter and avoid tension within the submucosal layer of the ureter secondary to overdistension. The needle is passed into the ureteral orifice (UO) and inserted at the mid ureteral tunnel at the 6 o’clock position. Sufficient bulking agent is injected to produce a bulge, which initially coapts the detrusor tunnel, while a second implant within the most distal intramural tunnel leads to coaptation of the UO. Hydrodistension (HD) is performed after each injection to monitor treatment progress; when HD ceases to dilate the UO, appropriate coaptation has been achieved.

Figure 1. Double HIT Technique5

  1. Double HIT
  2. Endoscopic injection needle placement algorithm. Numbers indicate the order of injection sites. Sites 1 and 2 represent Double HIT method. Site 3 is uncommonly used and site 4 is only used in complex cases.

Options for patient positioning

It is important to position the patient in a way that allows the thighs and abdomen to be in a flat plane. This allows the surgeon to pass the cystoscope over the leg while viewing the contralateral ureter that is laterally displaced. This may be achieved by using towel rolls or ankle support gel pads taped under the knees or pediatric stirrups in a low position as the physician sees fit.

Deflux should only be administered by qualified surgeons experienced in the use of a cystoscope and trained in subureteral injection procedures and must not be injected intravascularly as injection into blood vessels may cause vascular occlusion.

Please refer your appropriate patients with vesicoureteral reflux (VUR) to a pediatric urologist upon VUR diagnosis.

References

  1. Cerwinka WH, Scherz HC, Kirsch AJ. Endoscopic treatment of vesicoureteral reflux with dextranomer/hyaluronic acid in children. Adv Urol. 2008; 1-7. DOI: 10.1155/2008/513854
  2. Deflux prescribing information. Santa Barbara, CA: Palette Life Sciences, Inc.; 2019.
  3. Läckgren G, Kirsch AJ. Surgery illustrated – surgical atlas endoscopic treatment of vesicoureteral reflux. BJUI Int. 2010;105:1332-1347. DOI:10.1111/j.1464-410X.2010.09325.x
  4. Kirsch AJ, Arlen AM, Läckgren G. Current trends in dextranomer hyaluronic acid copolymer (Deflux) injection technique for endoscopic treatment of vesicoureteral reflux. J Pediatr Urol. 2014;84:462-468. DOI: 10.1016/j.urology.2014.04.032
  5. Molitierno JA, Scherz HC, Kirsch AJ. Endoscopic treatment of vesicoureteral reflux using dextranomer hyaluronic acid copolymer. J Pediatr Urol. 2008;4:221-228. DOI: 10.1016/j.jpurol.2007.11.015
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