Cystoscopic Deflux Injection

Cystoscopic Deflux injection

What is Deflux Injection?

Deflux is a bulking gel that is composed of dextranomer and hyaluronic acid. It is used to block the urine flow into the ureter that is located in the bladder to prevent the urine that is present in the bladder to flow backwards to the ureter and the kidney (VUR). This is a minimally invasive procedure which is performed with the help of a cystoscope.

Indications

Deflux injection is normally applied to:

• Vesicoureteral reflux II-IV.
• Children with recurrent UTIs.
• Patients failed to respond to antibiotics.
• Cases of parents choosing a less invasive procedure than open surgery and laparoscopic surgery.
• Some adult VUR cases

Methods Employed

• STING Technique- one injection beneath the ureteral orifice.
• Technique in HIT- Injection within the tunnel to be more successful.
• Double HIT Technique- two injections to enhance the size of the implant and enhance outcomes.

Deflux injection procedure

The Deflux Injection Procedure (Cystoscopic Dextranomer/Hyaluronic Acid Injection) of managing VUR is described in a clear and step by step, surgeon style manner as revealed below.

Deflux Injection Procedure (Step-by-step):

Pre‑operative Preparation

• The anaesthesia plan will require fasting on the part of the patient.  
• Most commonly it is done by general anaesthesia mostly in children.  
• Preventative doses of antibiotics are normally administered.  
• Bladder drainage is started prior to emptying.

Positioning and Setup

• The patient is in the lying position with his legs open.  

• The region near the urethra opening is wiped using sterile cloth.  

• There is a prepared cystoscope (8-9.5Fr in children).

Cystoscopy

• The cystoscope is inserted through the urethra into the bladder. 

The surgeon checks:  

• Bladder lining  
• Both ureters' openings 
• Swelling, inflammation, abnormalities.  
• The ureter aperture to be treated is well visible.

Technique Selection

It can be done through three chief ways:

• STING Technique: inject under the ureter orifice at 6 o clock position.  
• Technique HIT: Fill the bladder, open the ureter with water, and insert the needle into the ureter tunnel. This is preferable to better grades.  
• Double-HIT Technique: the most used. 2 injections; one in the deep part of the tunnel and the other one under the ureter orifice.

Injection of Deflux

• The gel (deflux) is loaded in a 1ml syringe with 23-25G endoscopic needle. 

Steps:  

• Pass the needle through the channel of the cystoscope.  
• Insert the tip of the needle where the injection has been selected (STING, HIT, or Double-HIT).  
• Add very slowly Deflux until a volcano-shaped mound is obtained.  
• Aim: to make a bulge, which seals the ureter hole, prevents reflux and yet allows normal urine to pass.  
• Normal volume: 0.3-1Ml/ ureter based on grade.  
• Indications that the injection was effective: a good mound, the aperture elevated, tapered a volcano-like appearance.

Completion

• Do not forcefully eject the needle, this may cause backflow.  
• Make sure that the implant and opening appear well.  
• Empty the bladder.  
• No catheter is usually required.  
• Remove the cystoscope.

Duration

• The entire process is typically 15-30 minutes.  
• In day-care patients, the individual returns home the same day when he is awake.

Post‑operative Care

• Mild burning during urinating and 24-48 hours are normal.  
• Drink plenty of fluids.  
• No vigorous exercise in 24-48 hours.  
• Depending on the protocol, a short-course of antibiotics can be administered.

Follow‑Up

• Conduct ultrasound at 4-6 weeks to eliminate blocks or swelling of kidney.  

VCUG is not a necessity unless:  

• Symptoms remain  
• UTI happens again  
• Success rates: 70-90 percent, and the technique and grade of VUR.

Deflux Injection Success rate

Overall Success Rate

• The success rate after one or two injections ranges between 70 and 90 per cent as per the grade of VUR and method.

Pediatric Deflux injection procedure

• Minimally invasive endoscopic therapy with injecting of Deflux gel at the ureter end to prevent reflux.

Pre-Operative Preparation (Pediatric)

• The child starves based on the regulations of anaesthesia.  
• In children, it is necessary to use general anaesthesia as it is a safe procedure.  
• IV antibiotics are administered as a single dose.  
• Starting is done before the bladder is emptied.  

Preoperative evaluation includes:  

• Ultrasound  
• VCUG to confirm VUR  
• Urine culture (this will have to be sterilized prior to this)

Positioning & Equipment

• The child is lying on his or her back, with open legs.  
• Wipe and wrap the area of the urethra.  
• Apply a pediatric cystoscope (8-9.5Fr) having a channel.  
• Load the Deflux syringe using a 23-25gauge needle.

Cystoscopy

• The cystoscope is inserted through the urethra into the bladder. 

Check includes:  

• Bladder lining  
• Both ureter openings  
• Inflammatory signs or issues.  
• The ureter hole is visible clearly through water.

Selection of the Injection Method

The surgeons are the ones who decide on the most successful method:  

• HIT Technique- most prevalent among children. Open the ureter with water. Insert the needle in the tunnel and inject Deflux.  
• Double -HIT Technique - most effective in children. Two injections: deep intratunnelary and another one under the ureter opening.  
• STING Technique- an older technique, which involves a single submucosal injection at 6o clock and less effective with high-grade VUR.

Injection Steps

• The cystoscope channel is used to insert the needle.  

First injection (HIT):  

• Insert the needle into the tunnel.  
• The injection should be done gradually until the tunnel caves in and the whole seals.  

Second injection (Double‑HIT):  

• Insert the needle immediately beneath the ureter aperture ( 6 0 clock).  
• Continue injecting until a volcano-shaped mound is created.  
• Normal volume: 0.3 to 1mL/ ureter, depending on grade, and tunnel length.  
• Positive outcome indicators: the aperture appears elevated and shut. A firm mound is made.

Completion

• Draw the needle slowly to prevent back-leak.  
• Re-examine cystoscope to ensure that mound is stable.  
• Empty the bladder.  
• Most children do not require any catheter.  
• The procedure takes 15–25 minutes.

Post-Surgical Intervention (Pediatrics)

• The child takes minutes to wake up and normally goes back home the same day.  
• It is normal to experience mild burning during urination of 24-48 hours.  
• Drink fluids.  
• Do not run, bike, or perform any other rigorous exercise for 24-48 hours. 
• Microdose of oral antibiotics can be administered.

Follow‑Up

• Check on an ultrasound at 4-6 weeks to determine blockage or swelling of the kidney.  
• VCUG is performed in case of the persistence of the symptoms or the reappearance of UTIs.  
• The success of children in the long-term is high.

Success Rate in Pediatrics

• 85-90% using HIT/ Double-HIT method.  
• Reduced high grade VUR (Grade IV-V).  
• Approximately 20-30 per cent might require a second jab.

Recovery after Deflux injection

Deflux injection is a relatively day-care operation that raises few objections, thus, recovery is normally fast and easy.

First 24 Hours Recovery (Immediate)

Discharge  

• The majority of the patients (children and adults) return home on the same day.  
• There is no catheter that is normally required.

Common Mild Symptoms  

These are normal for 24–48 hours:  

• Burning while urinating  
• Mild lower belly pain  
• Pale urine (blood in color)
• Strong urge to urinate  

These symptoms spontaneously subside.

Pain Management  

• No serious pain relievers are required usually.  
• Suffice to say, paracetamol (acetaminophen).

Activity Restrictions  

Children  

• One day at home play quietly.  
• Go back to school/nursery the following day.  
• No cycling, jumping, running, or rough playing in 48 hours.  

Adults  

• One day later normal activity may be conducted.  
• Stay out of exercise in 2-3 days.  

Diet & Fluids  

• You may immediately take a regular diet.  
• Take plenty of fluids in 48 hours to assist in burning.  

Antibiotics  

• A lot of physicians prescribe a course of antibiotics of 5-7 days.  
• Others administer low dose antibiotics until the follow up scan.  
• Do as your surgeon bids you.  

Best hospital for Deflux injection India

• Artemis Hospital, Gurgaon
• Medanta-The Medicity, Gurgaon
• Fortis Memorial Research Institute, Gurgaon
• Max Hospital, Saket

Conclusion

Deflux injection is a safe, least invasive, and useful remedy against vesicoureteral reflux and it is particularly effective in the children. It is performed through an endoscopic method known as HIT or Double -HIT. The operation is very successful, painless, no external incisions and recovery is quick. The following day, most of the children are able to perform normal activities. Complications are rare. Other children with high-grade reflux may require an additional injection. Deflux is an excellent substitute to open operation or laparoscopic reimplantation of the urinary tracts and reduces hospitalization and post-operative pain. All in all, Deflux is a good and child-friendly agent when it comes to the management of VUR.  

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FAQ

1. Is Deflux a long lasting treatment?  

• Yes. The body has got its own tissue that wraps the gel after injecting, which provides permanent effects of bulking. Other children might have to take a second injection.  

2. Does that mean that my child will require antibiotics following the procedure?  

• Some surgeons prescribe a brief course of antibiotic of 5-7 days. Others persist with low dose antibiotics up to follow up scan.  

3. Does Deflux compare with Ureteric reimplantation?  

• The surgery of reimplantation of ureters is slightly more successful (95-99%).  
• Deflux is far less invasive, heals quicker and does not involve open surgery.  

4. Is it possible to repeat Deflux injection?  

• Yes. In case the reflux persists, a second injection will be simple and much more effective.  

5. What is the safety of Deflux on children?  

• Very safe. It has a long record of safety usage and has few complications with a long positive track record across the world.  

6. Is Deflux associated with impairment of future kidney?  

• No. This also reduces the risk of reflux and urinary tract infections, helping to maintain kidney function in the long term.