Endoscopic treatment of primary vesicoureteral reflux in children with two different bulking agents, high success and low complication rates: Comparison of Dexell and Vantris | Actas Urológicas Españolas (English Edition)

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Doğan, K.U. Özkan, A.G. Güler, A.E. Karakaya" "autores" => array:4 [ 0 => array:4 [ "nombre" => "A.B." "apellidos" => "Doğan" "email" => array:2 [ 0 => "drkarden@gmail.com" 1 => "abdogan@erciyes.edu.tr" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "K.U." "apellidos" => "Özkan" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "A.G." "apellidos" => "Güler" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "A.E." "apellidos" => "Karakaya" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Departamento de Cirugía Pediátrica, Facultad de Medicina, Universidad Erciyes, Kayseri, Turkey" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Cirugía Pediátrica, Facultad de Medicina, University of Sütçü İmam, Kahramanmaras, Turkey" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tratamiento endoscópico del reflujo vesicoureteral primario en niños con dos materiales diferentes. Tasa de éxito alta y tasa de complicaciones baja: comparación entre Dexell y Vantris" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1845 "Ancho" => 3333 "Tamanyo" => 275163 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Resultados detallados del tratamiento endoscópico del RVU." ] ] ] "textoCompleto" => "IntroductionAfter the description of subureteric injection in the endoscopic treatment of vesicoureteral reflux (VUR) by Matouschek in 1981, many bulking agents (Teflon, silicone, bovine collagen, etc.) have been used, but many were abandoned because of mistrust and complications.<a class="elsevierStyleCrossRefs" href="#bib0005">1–5</a> Nowadays, dextranomer/hyaluronic acid (Dx-HA) copolymer and polyacrylate-polyalcohol copolymer (PPC) are the most commonly used bulking agents in the endoscopic treatment of VUR. Although there are satisfactory results for both agents in the literature, Dx-HA and PPC have stood up with recurrence and vesicoureteral junction obstruction (VUJO) rates, respectively, most of these studies consisting of non-standardized cohorts.<a class="elsevierStyleCrossRefs" href="#bib0030">6–13</a> In this study; It was aimed to compare the endoscopic VUR management results of two different standardized primary VUR cohorts treated with Dx-HA (Dexell®; İstem Medical, Ankara, Turkey) and PPC (Vantris®; Promedon, Córdoba, Argentina), based on effectivity and safety.Material and methodsIn this study, we retrospectively analyzed 144 patients who underwent endoscopic VUR treatment with Vantris or Dexell between 2011 and 2017. Secondary VUR patients with neurogenic bladder dysfunction, severe voiding dysfunction (non-neurogenic neurogenic bladder), bladder outlet obstructions, and anatomical disorders with VUR such as primary obstructive megaureter, bladder diverticulum, ureterocele, ureteral duplication, ureteral displacement, and ectopia were excluded from the study groups to constitute a standardized cohort. Finally, the remaining 128 renal refluxing units (RRU) in 87 patients with primary VUR (64 females, 23 males) were included in the study. Our agent selection criteria are determined by the reimbursement agreement between our hospital and the social security institution. In line with this agreement, we had to use Dexell between 2011–2014 and Vantris between 2015–2017 in the endoscopic VUR treatment.Patients with persistent VUR (grade 2–5) confirmed with VCUG, and renal scarring in the renal scintigraphy were indicated for endoscopic treatment. Antibiotic prophylaxis with sulfamethoxazole/trimethoprim was started on all patients. A total of 22 continent aged patients with mild bladder-bowel dysfunction underwent bladder-bowel training before the implantation. All procedures were performed in the presence of sterile urine using a pediatric cystoscope (Karl Storz 9.5 Fr) and a standard needle (COOK Medical, Williams Cystoscopic Injection Needle). All authors have performed endoscopic procedures in this study under the consultancy of the Pediatric Urologist (KUÖ). Any implantation was not completed before obtaining an infection-free period at least three months in all VUR patients. All implantations were performed using a conventional subureteral transurethral injection (STING) technique. Since a standard volume of an agent to stop the VUR in each patient cannot be predicted, the amount of agent to be injected depends on the surgeon's clinical experience and the observational assessment of the current mucosal bulge. While there is not reported permanent obstruction after Dexell injection in the literature, high late recurrence rates nearly 20%–25% are known.<a class="elsevierStyleCrossRefs" href="#bib0030">6,7,14</a> Therefore, we injected Dexell safely in excessive volumes to have better long-term success rates by getting encouragement from the literature. On the other hand, we experienced larger mucosal bulging with Vantris at lower volumes than Dexell and injected Vantris only until sufficient mucosal bulging was observed. Moreover, the early VUJO complication reported in the literature after Vantris injection prevented us from injecting it in excessive volumes.<a class="elsevierStyleCrossRefs" href="#bib0060">12,13</a>Patients were discharged on the same day as the procedure. In the first month after the injection, all patients were followed up fortnightly by ultrasound scan for the early diagnosis of possible urethral obstruction. The frequency of the ultrasound scan was then reduced as monthly until the control VCUG procedure. Urinalysis was assessed at 3, 6, and 12 months after implantation. All patients underwent control VCUG 3-months after the procedure. If reflux did not resolve, second or third injection attempts required. The ultrasound scan was repeated semi-annually in the period of postoperative two years; however, routine late VCUG considered unnecessary in children without any symptom.Approval was obtained from the local ethics committee before study onset. The data collected were analyzed using SPSS ver. 18 (SPSS, Inc., Chicago, IL, USA). Descriptive data are expressed as means ± standard deviations. Mann–Whitney U, chi-square, and t-tests were used for statistical analyses. Values with P-values <.05 were considered statistically significant.ResultsGroup 1 contained 48 patients (34 females and 14 males) who received a subureteric injection of Dexell. Group 2 comprised 39 patients (30 females and 9 males) who received a subureteric injection of Vantris. The mean age of the patients was 5.43 ± 3.63 years in group 1 and 5.1 ± 3.44 years in group 2. There were no statistically significant differences between groups in mean age, sex, RRU side, 99mTc-DMSA uptake, and reflux grade. The mean bulking agent volume per injection therapy was 1.73 ± 0.68 mL in group 1 and 0.51 ± 0.22 mL in group 2. The statistical comparison of injection volumes of the agents cannot be performed due to the bias in the injection of Dexell that excessively implanted even after a sufficiently mucosal bulge was achieved. The characteristics and demographics of patients in the two groups are given in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. The resolution rates based on the number of RRUs after the first injection were 57.14% (40/70) in group 1 and 65.51% (38/58) in group 2 (P = .267). The overall resolution rates based on the number of RRUs for up to three endoscopic treatments were 80% (56/70) in group 1 and 94.8% (55/58) in group 2 and significantly better in group 2 (P = .012) (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). Similar success rates of two bulking agents were detected in high-grade reflux (grade 4 and 5) (P = .101). However, this might have been due to the insufficient number of grade 5 reflux patients in group 2. VUJO was not detected in both groups at the early and late follow-up period. UNC was performed for 17 RRUs (14 Dexell, 3 Vantris) in which endoscopic treatment failed. The outcomes of our endoscopic procedures are presented in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>. We did not consider performing late VCUG in the follow-up period of any asymptomatic patients. Since seven patients (14,5%) in group 1 and four (10.2%) patients in group 2 had more than one breakthrough UTI during late follow-up. They underwent late VCUG, and reflux recurrence was not detected. As a result, we did not encounter any VUR recurrences in both groups.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia>DiscussionDx-HA is a biocompatible and biodegradable substance and consists of dextranomer particles sized 80–120 microns in Dexell and 80–250 microns in Deflux. Despite the difference in particle size between Deflux and Dexell, similar overall resolution rates were obtained for both materials.<a class="elsevierStyleCrossRefs" href="#bib0070">14,15</a> PPC is a non-absorbable and synthetic material consisting of macro-particles with an average size of 300 microns. Although these bulking agents have different molecular structures and sizes, their injection volumes are determined subjectively according to the degree of reflux, the structure of the ureter, and the practitioner’s experience and observation. In the management of children with VUR using Dx-HA, many publications are presenting satisfactory success rates between 70.3%–90.7% in the literature,<a class="elsevierStyleCrossRefs" href="#bib0065">13,14,16</a> as well as the higher long-term recurrence between the rates of 21%–26%.<a class="elsevierStyleCrossRefs" href="#bib0030">6,17,18</a> During the treatment of the patients included in this study, our hypothesis was to increase the success rate and prevent a recurrence with a high dose of Dexell implantation by continuing the injection even after sufficient bulging was observed. The early and mid-term results of the study showed that we achieved an 80% success rate with Dexell, which is comparable to the literature.Most importantly, we did not see any recurrence after Dexell injection during this period, even in symptomatic seven patients who underwent late VCUG. Even if we can demonstrate that no recurrence occurs in the late follow-up, further studies should show the effect of high dose Dexell volume in reducing recurrence rates. After such a high dose of Dexell implantation, one of our concerns could be VUJO. However, there are no reports of late VUJO or kidney loss with Dexell so far. All obstructive complications secondary to Dx-HA have been reported after the implantation of Deflux, which has a larger particle size than Dexell.<a class="elsevierStyleCrossRefs" href="#bib0035">7,8,10,19</a> All of the obstructive complications related to Dexell in the literature are early and transient and have resolved spontaneously without the need for any intervention.<a class="elsevierStyleCrossRefs" href="#bib0035">7,20</a> The high recurrence rate of Dexell was attributed to the biodegradable nature of the Dx-HA.<a class="elsevierStyleCrossRef" href="#bib0105">21</a>Additionally, we speculated the high recurrence rates to the small particle size of Dexell, which cannot provide sufficient submucosal mass effect. Dexell, with its smaller particle size, has a low viscosity and high fluidity, and thus, it may not exert appropriate pressure to the distal ureter with lower volumes. This is precisely our main reason for the high volume of Dexell implantation. In an experimental study, the authors injected high and low viscosity Dexell submucosally into the trigone of rabbits. The authors found that six weeks after injection, the bulging caused by high viscosity Dexell decreased significantly more than that of the low viscosity. They also observed a significantly higher rate of foreign body reactions in high viscosity Dexell injected rabbits.<a class="elsevierStyleCrossRef" href="#bib0110">22</a> The results of the study seem to be consistent with our speculation. One of the main determinants of viscosity is the particle size of the liquid. With the smallest particle size, Dexell is expected to be the lowest viscosity agent among the bulking agents. However, apart from the particle size, the viscosity of a liquid is closely related to the ambient temperature, air pressure, and intermolecular forces.<a class="elsevierStyleCrossRef" href="#bib0115">23</a> Therefore, our speculation should be confirmed by experimental studies involving measurements of the viscosities of bulking agents.The main characteristic of the other agent, Vantris, is that it has a high mass effect due to its larger particles than Dexell. This high mass effect of Vantris which is hard to control not only provided higher success rates without recurrence up to 97.6% but also caused VUJO cases that may occur in the early and late periods.<a class="elsevierStyleCrossRefs" href="#bib0065">13,16,24–26</a> The fibrotic capsule created by stimulating the surrounding tissue contributes to the formation of VUJO.<a class="elsevierStyleCrossRefs" href="#bib0055">11,13</a> It can also be speculated that this uncontrollable high mass effect may be responsible for the fibrosis of distal ureter by reducing blood supply. With the concerns provided by this literature data and personal experiences, we adopted a prudent attitude, and we did not implant more than the volume of Vantris that produced sufficient submucosal bulging. Thus, we achieved an overall success of 94.8% without recurrence in the early and mid-term follow-up. Moreover, we did not see any VUJO within a mean follow-up period of 23,35 ± 6,28 months. Our effort not to inject a high volume of Vantris may have prevented VUJO development; however, we do not have enough data to confirm this argument. Although the data of this study were obtained with significantly different injection volumes of two bulking agents, the bias in determining the implantation amount of Dexell renders the statistical tests worthless.In this study, the cohort was constituted from primary VUR patients who received preoperative medical treatment, and many secondary parameters that could affect the results of endoscopic VUR treatment were attempted to be excluded. Success rates comparable with the literature data were achieved in this standardized and rehabilitated cohort without any complication and recurrence in the period of early and midterm follow-up. It is well known that preoperative management of bladder and bowel dysfunctions and urinary tract infection (UTI) are considered a critical component of the successful VUR treatment.<a class="elsevierStyleCrossRefs" href="#bib0070">14,16</a> Voiding dysfunctions may cause some changes in the urinary tract anatomy that are similar to those associated with neurogenic bladder abnormalities, and these changes may induce UTI and VUR.<a class="elsevierStyleCrossRef" href="#bib0135">27</a> The effect of defecation disorders such as constipation on voiding functions is well known. It has been demonstrated that even with only laxative treatment, the voiding volume increases, the amount of post voiding residual decreases, and urinary incontinence improves.<a class="elsevierStyleCrossRef" href="#bib0140">28</a> UTI causes diffuse desquamation of the epithelial wall, subepidermal edema, and massive infiltration of inflammatory cells at the bladder mucosa.<a class="elsevierStyleCrossRef" href="#bib0145">29</a> All the procedures performed under an infection-free status and 22 patients [group 1: 14 (29.1%), group 2: 8 (20.5%)] with the low-grade bladder and bowel dysfunction were treated before the procedure. If we had objective parameters, including bladder-bowel functions before and after the procedures, we could comment on the relationship between these successful results and bladder-bowel rehabilitation.This study has several limitations. The most important ones that affected the results were the retrospective nature of the study, an insufficient number of patients, the biased attitudes of authors towards agents, and lack of objective results of bladder-bowel rehabilitation. Besides, the value of the study results decreases because the potential recurrence and VUJO data that may occur in the late follow-up period are not available. However, according to us, the results of this observational study, in which mid-term results are presented, are noteworthy and may guide further research in the discussion of the endoscopic treatment of VUR. The more reliable conclusions about endoscopic VUR treatment based on the bulking agents can be obtained with prospective randomized controlled and blinded studies with a sufficient number of patients presenting long-term results. However, the high number of uncontrollable factors affecting the treatment results such as current bladder functions, practitioner experience, injection timing, technique and material, implantation volume, patient immune response, the grade of the reflux, and additional urinary anomalies will be the most challenging issues for researchers.ConclusionIn this study involving standardized primary VUR patients, Dexell and Vantris provided an effective endoscopic treatment in the early and mid-term follow up similar to the studies in the literature. We also had a safe treatment process without any VUJO and VUR recurrence. The safety of the procedures in this study can be attributed to the bladder and bowel rehabilitation efforts and the injection volumes we have speculated considering the molecular structures of the bulking agents. However, it is essential to be confirmed our results with prospective randomized controlled trials.FundingThis work has not received any funding.Conflicts of interestThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1581950" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction and objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1423942" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1581951" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción y objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Pacientes" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1423943" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusion" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Funding" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflicts of interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-03-20" "fechaAceptado" => "2020-10-26" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1423942" "palabras" => array:4 [ 0 => "Vesicoureteral reflux" 1 => "Dextranomer hyaluronic acid" 2 => "Polyacrylate-polyalcohol copolymer" 3 => "Vesicoureteral obstruction" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1423943" "palabras" => array:4 [ 0 => "Reflujo vesicoureteral" 1 => "Dextranómero/ácido hialurónico" 2 => "Copolímero de poliacrilato-polialcohol" 3 => "Obstrucción vesicoureteral" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "Introduction and objectivesTo compare the results in terms of efficacy and safety of the endoscopic management for vesicoureteral reflux (VUR) in two different standardized primary VUR cohorts treated with Dexell and Vantris. Patients128 refluxing renal units (RRU) in 87 patients with primary VUR (64 females, 23 males). Patients with secondary VUR and severe bladder and bowel dysfunction were excluded. A total of 22 continent children with mild bladder-bowel dysfunction underwent bladder-bowel training before the implantation. All procedures were performed in the presence of sterile urine using a conventional subureteral transurethral injection technique. ResultsThere were no statistically significant differences between groups in terms of mean age, sex, RRU side, 99mTc-DMSA uptake, and reflux grade. The overall resolution rates based on the number of RRUs for up to three endoscopic treatments were 80% (56/70) in Dexell group and 94.8% (55/58) in Vantris group (P = .012). No postoperative recurrences or vesicoureteral junction obstructions were seen in any group. ConclusionsDexell and Vantris provided an effective and safe endoscopic VUR treatment in the early and mid-term follow up of children with primary VUR. The effectiveness of these substances, which can produce different mass effects with different particle sizes, in safe VUR resolution, needs further investigations." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction and objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "Introducción y objetivosComparar, en términos de eficacia y seguridad, los resultados del tratamiento endoscópico del reflujo vesicoureteral (RVU) en dos cohortes diferentes de RVU primario tratadas con Dexell y Vantris. PacientesEl estudio incluyó 128 unidades de reflujo renal (URR) en 87 pacientes con RVU primario (64 mujeres, 23 hombres). Se excluyeron los pacientes con RVU secundario y disfunción vesical e intestinal severa. Un total de 22 niños mayores ya continentes, con disfunción vesico-intestinal leve, fueron sometidos a entrenamiento vesico-intestinal previo a la implantación. Todos los procedimientos se realizaron en presencia de orina estéril mediante la técnica convencional de inyección transuretral subureteral. ResultadosNo hubo diferencias estadísticamente significativas entre los dos grupos en cuanto a media de edad, sexo, lateralidad de la URR, captación de 99 m Tc-DMSA y grado de reflujo. Las tasas de resolución global con base en el número de URR con hasta tres tratamientos endoscópicos fueron del 80% (56/70) en el grupo Dexell y del 94,8% (55/58) en el grupo Vantris (P = ,012). No se observaron recidivas ni obstrucciones de la unión vesicoureteral en el postoperatorio en ningún grupo. ConclusionesDexell y Vantris proporcionaron un tratamiento endoscópico eficaz y seguro en el seguimiento a corto y medio plazo del RVU primario en niños. Se requieren más estudios para evaluar la eficacia de estas sustancias, cuyo efecto de volumen depende del tamaño de sus partículas, en la resolución segura del RVU." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción y objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Pacientes" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Doğan AB, Özkan KU, Güler AG, Karakaya AE. Tratamiento endoscópico del reflujo vesicoureteral primario en niños con dos materiales diferentes. Tasa de éxito alta y tasa de complicaciones baja: comparación entre Dexell y Vantris. Actas Urol Esp. 2021;45:545–551." ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1845 "Ancho" => 3333 "Tamanyo" => 275163 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Resultados detallados del tratamiento endoscópico del RVU." ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "RRU: renal refluxing unit, VUR: vesicoureteral reflux, DMSA: dimercaptosuccinic acid, UTI: urinary tract infection." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Variables \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Group 1 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Group 2 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">P \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Number of Patients, n \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">48 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">39 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Number of RRUs, n \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">70 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">58 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">,479 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Male/Female, n \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14/34 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9/30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">,348 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mean age, years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5,43 ± 3,63 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5,1 ± 3,44 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">,641 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Unilateral VUR, n \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">26 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">,479 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bilateral VUR, n \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RRU side, right/left \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">35/35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25/33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">,274 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">VUR Grade (RRU), n \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">II \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">III \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">IV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">V \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mean volume of bulking agents; ml \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1,73 ± 0,68 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0,51 ± 0,22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">,001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Preoperative DMSA uptake<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a>, % \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">47,15 ± 18,97 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">45,22 ± 24,25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">,614 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Postoperative DMSA uptake<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a>, % \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">46,51 ± 19,78 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">44,44 ± 25,50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">,607 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mean follow-up, month \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">28,46 ± 9,79 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">23,85 ± 6,28 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">,366 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mean operation time, minute \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17,08 ± 6,90 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18,06 ± 6,82 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">,422 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Treated voiding dysfunction before the procedure, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 (29,1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 (20,5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">,251 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Breakthrough febrile UTI after the procedure, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 (14,5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (10,2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">,394 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2709833.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Differential DMSA uptake of RRUs was reported >50% because of the renal scarring of the contralateral RRU in some of the bilateral VUR." ] ] ] "descripcion" => array:1 [ "en" => "Patients’ characteristics and demographics." ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "RRU: renal refluxing unit, VUR: vesicoureteral reflux." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">VUR grade \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Dexell, % (n/n) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Vantris, % (n/n) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">P \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2−3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">87.1% (34/39) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">97.3% (37/38) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.200 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4−5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">71% (22/31) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">90% (18/20) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.101 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">56/70 (80%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">55/58 (94.8%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.012 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2709832.png" ] ] ] ] "descripcion" => array:1 [ "en" => "The Overall success rate of Dexell and Vantris based on VUR grade and RRUs." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:29 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "[Treatment of vesicorenal reflux by transurethral teflon-injection (author’s transl)]" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "E. 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Endoscopic treatment of primary vesicoureteral reflux in children with two different bulking agents, high success and low complication rates: Comparison of Dexell and Vantris

Tratamiento endoscópico del reflujo vesicoureteral primario en niños con dos materiales diferentes. Tasa de éxito alta y tasa de complicaciones baja: comparación entre Dexell y Vantris

A.B. Doğana,

Corresponding author

drkarden@gmail.com
abdogan@erciyes.edu.tr

Corresponding author.

, K.U. Özkana, A.G. Gülerb, A.E. Karakayab

a Departamento de Cirugía Pediátrica, Facultad de Medicina, Universidad Erciyes, Kayseri, Turkey

b Departamento de Cirugía Pediátrica, Facultad de Medicina, University of Sütçü İmam, Kahramanmaras, Turkey

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        "titulo" => "Tratamiento endosc&#243;pico del reflujo vesicoureteral primario en ni&#241;os con dos materiales diferentes&#46; Tasa de &#233;xito alta y tasa de complicaciones baja&#58; comparaci&#243;n entre Dexell y Vantris"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">After the description of subureteric injection in the endoscopic treatment of vesicoureteral reflux &#40;VUR&#41; by Matouschek in 1981&#44; many bulking agents &#40;Teflon&#44; silicone&#44; bovine collagen&#44; etc&#46;&#41; have been used&#44; but many were abandoned because of mistrust and complications&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;5</span></a> Nowadays&#44; dextranomer&#47;hyaluronic acid &#40;Dx-HA&#41; copolymer and polyacrylate-polyalcohol copolymer &#40;PPC&#41; are the most commonly used bulking agents in the endoscopic treatment of VUR&#46; Although there are satisfactory results for both agents in the literature&#44; Dx-HA and PPC have stood up with recurrence and vesicoureteral junction obstruction &#40;VUJO&#41; rates&#44; respectively&#44; most of these studies consisting of non-standardized cohorts&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#8211;13</span></a> In this study&#59; It was aimed to compare the endoscopic VUR management results of two different standardized primary VUR cohorts treated with Dx-HA &#40;Dexell&#174;&#59; &#304;stem Medical&#44; Ankara&#44; Turkey&#41; and PPC &#40;Vantris&#174;&#59; Promedon&#44; C&#243;rdoba&#44; Argentina&#41;&#44; based on effectivity and safety&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0010" class="elsevierStylePara elsevierViewall">In this study&#44; we retrospectively analyzed 144 patients who underwent endoscopic VUR treatment with Vantris or Dexell between 2011 and 2017&#46; Secondary VUR patients with neurogenic bladder dysfunction&#44; severe voiding dysfunction &#40;non-neurogenic neurogenic bladder&#41;&#44; bladder outlet obstructions&#44; and anatomical disorders with VUR such as primary obstructive megaureter&#44; bladder diverticulum&#44; ureterocele&#44; ureteral duplication&#44; ureteral displacement&#44; and ectopia were excluded from the study groups to constitute a standardized cohort&#46; Finally&#44; the remaining 128 renal refluxing units &#40;RRU&#41; in 87 patients with primary VUR &#40;64 females&#44; 23 males&#41; were included in the study&#46; Our agent selection criteria are determined by the reimbursement agreement between our hospital and the social security institution&#46; In line with this agreement&#44; we had to use Dexell between 2011&#8211;2014 and Vantris between 2015&#8211;2017 in the endoscopic VUR treatment&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Patients with persistent VUR &#40;grade 2&#8211;5&#41; confirmed with VCUG&#44; and renal scarring in the renal scintigraphy were indicated for endoscopic treatment&#46; Antibiotic prophylaxis with sulfamethoxazole&#47;trimethoprim was started on all patients&#46; A total of 22 continent aged patients with mild bladder-bowel dysfunction underwent bladder-bowel training before the implantation&#46; All procedures were performed in the presence of sterile urine using a pediatric cystoscope &#40;Karl Storz 9&#46;5 Fr&#41; and a standard needle &#40;COOK Medical&#44; Williams Cystoscopic Injection Needle&#41;&#46; All authors have performed endoscopic procedures in this study under the consultancy of the Pediatric Urologist &#40;KU&#214;&#41;&#46; Any implantation was not completed before obtaining an infection-free period at least three months in all VUR patients&#46; All implantations were performed using a conventional subureteral transurethral injection &#40;STING&#41; technique&#46; Since a standard volume of an agent to stop the VUR in each patient cannot be predicted&#44; the amount of agent to be injected depends on the surgeon&#39;s clinical experience and the observational assessment of the current mucosal bulge&#46; While there is not reported permanent obstruction after Dexell injection in the literature&#44; high late recurrence rates nearly 20&#37;&#8211;25&#37; are known&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7&#44;14</span></a> Therefore&#44; we injected Dexell safely in excessive volumes to have better long-term success rates by getting encouragement from the literature&#46; On the other hand&#44; we experienced larger mucosal bulging with Vantris at lower volumes than Dexell and injected Vantris only until sufficient mucosal bulging was observed&#46; Moreover&#44; the early VUJO complication reported in the literature after Vantris injection prevented us from injecting it in excessive volumes&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Patients were discharged on the same day as the procedure&#46; In the first month after the injection&#44; all patients were followed up fortnightly by ultrasound scan for the early diagnosis of possible urethral obstruction&#46; The frequency of the ultrasound scan was then reduced as monthly until the control VCUG procedure&#46; Urinalysis was assessed at 3&#44; 6&#44; and 12 months after implantation&#46; All patients underwent control VCUG 3-months after the procedure&#46; If reflux did not resolve&#44; second or third injection attempts required&#46; The ultrasound scan was repeated semi-annually in the period of postoperative two years&#59; however&#44; routine late VCUG considered unnecessary in children without any symptom&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Approval was obtained from the local ethics committee before study onset&#46; The data collected were analyzed using SPSS ver&#46; 18 &#40;SPSS&#44; Inc&#46;&#44; Chicago&#44; IL&#44; USA&#41;&#46; Descriptive data are expressed as means&#8239;&#177;&#8239;standard deviations&#46; Mann&#8211;Whitney U&#44; chi-square&#44; and <span class="elsevierStyleItalic">t</span>-tests were used for statistical analyses&#46; Values with <span class="elsevierStyleItalic">P</span>-values &#60;&#46;05 were considered statistically significant&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0030" class="elsevierStylePara elsevierViewall">Group 1 contained 48 patients &#40;34 females and 14 males&#41; who received a subureteric injection of Dexell&#46; Group 2 comprised 39 patients &#40;30 females and 9 males&#41; who received a subureteric injection of Vantris&#46; The mean age of the patients was 5&#46;43&#8239;&#177;&#8239;3&#46;63 years in group 1 and 5&#46;1&#8239;&#177;&#8239;3&#46;44 years in group 2&#46; There were no statistically significant differences between groups in mean age&#44; sex&#44; RRU side&#44; <span class="elsevierStyleSup">99m</span>Tc-DMSA uptake&#44; and reflux grade&#46; The mean bulking agent volume per injection therapy was 1&#46;73&#8239;&#177;&#8239;0&#46;68&#8239;mL in group 1 and 0&#46;51&#8239;&#177;&#8239;0&#46;22&#8239;mL in group 2&#46; The statistical comparison of injection volumes of the agents cannot be performed due to the bias in the injection of Dexell that excessively implanted even after a sufficiently mucosal bulge was achieved&#46; The characteristics and demographics of patients in the two groups are given in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; The resolution rates based on the number of RRUs after the first injection were 57&#46;14&#37; &#40;40&#47;70&#41; in group 1 and 65&#46;51&#37; &#40;38&#47;58&#41; in group 2 &#40;<span class="elsevierStyleItalic">P</span>&#8239;&#61;&#8239;&#46;267&#41;&#46; The overall resolution rates based on the number of RRUs for up to three endoscopic treatments were 80&#37; &#40;56&#47;70&#41; in group 1 and 94&#46;8&#37; &#40;55&#47;58&#41; in group 2 and significantly better in group 2 &#40;<span class="elsevierStyleItalic">P</span>&#8239;&#61;&#8239;&#46;012&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; Similar success rates of two bulking agents were detected in high-grade reflux &#40;grade 4 and 5&#41; &#40;<span class="elsevierStyleItalic">P</span>&#8239;&#61;&#8239;&#46;101&#41;&#46; However&#44; this might have been due to the insufficient number of grade 5 reflux patients in group 2&#46; VUJO was not detected in both groups at the early and late follow-up period&#46; UNC was performed for 17 RRUs &#40;14 Dexell&#44; 3 Vantris&#41; in which endoscopic treatment failed&#46; The outcomes of our endoscopic procedures are presented in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46; We did not consider performing late VCUG in the follow-up period of any asymptomatic patients&#46; Since seven patients &#40;14&#44;5&#37;&#41; in group 1 and four &#40;10&#46;2&#37;&#41; patients in group 2 had more than one breakthrough UTI during late follow-up&#46; They underwent late VCUG&#44; and reflux recurrence was not detected&#46; As a result&#44; we did not encounter any VUR recurrences in both groups&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall">Dx-HA is a biocompatible and biodegradable substance and consists of dextranomer particles sized 80&#8211;120 microns in Dexell and 80&#8211;250 microns in Deflux&#46; Despite the difference in particle size between Deflux and Dexell&#44; similar overall resolution rates were obtained for both materials&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;15</span></a> PPC is a non-absorbable and synthetic material consisting of macro-particles with an average size of 300 microns&#46; Although these bulking agents have different molecular structures and sizes&#44; their injection volumes are determined subjectively according to the degree of reflux&#44; the structure of the ureter&#44; and the practitioner&#8217;s experience and observation&#46; In the management of children with VUR using Dx-HA&#44; many publications are presenting satisfactory success rates between 70&#46;3&#37;&#8211;90&#46;7&#37; in the literature&#44;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;14&#44;16</span></a> as well as the higher long-term recurrence between the rates of 21&#37;&#8211;26&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;17&#44;18</span></a> During the treatment of the patients included in this study&#44; our hypothesis was to increase the success rate and prevent a recurrence with a high dose of Dexell implantation by continuing the injection even after sufficient bulging was observed&#46; The early and mid-term results of the study showed that we achieved an 80&#37; success rate with Dexell&#44; which is comparable to the literature&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Most importantly&#44; we did not see any recurrence after Dexell injection during this period&#44; even in symptomatic seven patients who underwent late VCUG&#46; Even if we can demonstrate that no recurrence occurs in the late follow-up&#44; further studies should show the effect of high dose Dexell volume in reducing recurrence rates&#46; After such a high dose of Dexell implantation&#44; one of our concerns could be VUJO&#46; However&#44; there are no reports of late VUJO or kidney loss with Dexell so far&#46; All obstructive complications secondary to Dx-HA have been reported after the implantation of Deflux&#44; which has a larger particle size than Dexell&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8&#44;10&#44;19</span></a> All of the obstructive complications related to Dexell in the literature are early and transient and have resolved spontaneously without the need for any intervention&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;20</span></a> The high recurrence rate of Dexell was attributed to the biodegradable nature of the Dx-HA&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Additionally&#44; we speculated the high recurrence rates to the small particle size of Dexell&#44; which cannot provide sufficient submucosal mass effect&#46; Dexell&#44; with its smaller particle size&#44; has a low viscosity and high fluidity&#44; and thus&#44; it may not exert appropriate pressure to the distal ureter with lower volumes&#46; This is precisely our main reason for the high volume of Dexell implantation&#46; In an experimental study&#44; the authors injected high and low viscosity Dexell submucosally into the trigone of rabbits&#46; The authors found that six weeks after injection&#44; the bulging caused by high viscosity Dexell decreased significantly more than that of the low viscosity&#46; They also observed a significantly higher rate of foreign body reactions in high viscosity Dexell injected rabbits&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> The results of the study seem to be consistent with our speculation&#46; One of the main determinants of viscosity is the particle size of the liquid&#46; With the smallest particle size&#44; Dexell is expected to be the lowest viscosity agent among the bulking agents&#46; However&#44; apart from the particle size&#44; the viscosity of a liquid is closely related to the ambient temperature&#44; air pressure&#44; and intermolecular forces&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> Therefore&#44; our speculation should be confirmed by experimental studies involving measurements of the viscosities of bulking agents&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The main characteristic of the other agent&#44; Vantris&#44; is that it has a high mass effect due to its larger particles than Dexell&#46; This high mass effect of Vantris which is hard to control not only provided higher success rates without recurrence up to 97&#46;6&#37; but also caused VUJO cases that may occur in the early and late periods&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;16&#44;24&#8211;26</span></a> The fibrotic capsule created by stimulating the surrounding tissue contributes to the formation of VUJO&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;13</span></a> It can also be speculated that this uncontrollable high mass effect may be responsible for the fibrosis of distal ureter by reducing blood supply&#46; With the concerns provided by this literature data and personal experiences&#44; we adopted a prudent attitude&#44; and we did not implant more than the volume of Vantris that produced sufficient submucosal bulging&#46; Thus&#44; we achieved an overall success of 94&#46;8&#37; without recurrence in the early and mid-term follow-up&#46; Moreover&#44; we did not see any VUJO within a mean follow-up period of 23&#44;35&#8239;&#177;&#8239;6&#44;28 months&#46; Our effort not to inject a high volume of Vantris may have prevented VUJO development&#59; however&#44; we do not have enough data to confirm this argument&#46; Although the data of this study were obtained with significantly different injection volumes of two bulking agents&#44; the bias in determining the implantation amount of Dexell renders the statistical tests worthless&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">In this study&#44; the cohort was constituted from primary VUR patients who received preoperative medical treatment&#44; and many secondary parameters that could affect the results of endoscopic VUR treatment were attempted to be excluded&#46; Success rates comparable with the literature data were achieved in this standardized and rehabilitated cohort without any complication and recurrence in the period of early and midterm follow-up&#46; It is well known that preoperative management of bladder and bowel dysfunctions and urinary tract infection &#40;UTI&#41; are considered a critical component of the successful VUR treatment&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;16</span></a> Voiding dysfunctions may cause some changes in the urinary tract anatomy that are similar to those associated with neurogenic bladder abnormalities&#44; and these changes may induce UTI and VUR&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> The effect of defecation disorders such as constipation on voiding functions is well known&#46; It has been demonstrated that even with only laxative treatment&#44; the voiding volume increases&#44; the amount of post voiding residual decreases&#44; and urinary incontinence improves&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> UTI causes diffuse desquamation of the epithelial wall&#44; subepidermal edema&#44; and massive infiltration of inflammatory cells at the bladder mucosa&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> All the procedures performed under an infection-free status and 22 patients &#91;group 1&#58; 14 &#40;29&#46;1&#37;&#41;&#44; group 2&#58; 8 &#40;20&#46;5&#37;&#41;&#93; with the low-grade bladder and bowel dysfunction were treated before the procedure&#46; If we had objective parameters&#44; including bladder-bowel functions before and after the procedures&#44; we could comment on the relationship between these successful results and bladder-bowel rehabilitation&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">This study has several limitations&#46; The most important ones that affected the results were the retrospective nature of the study&#44; an insufficient number of patients&#44; the biased attitudes of authors towards agents&#44; and lack of objective results of bladder-bowel rehabilitation&#46; Besides&#44; the value of the study results decreases because the potential recurrence and VUJO data that may occur in the late follow-up period are not available&#46; However&#44; according to us&#44; the results of this observational study&#44; in which mid-term results are presented&#44; are noteworthy and may guide further research in the discussion of the endoscopic treatment of VUR&#46; The more reliable conclusions about endoscopic VUR treatment based on the bulking agents can be obtained with prospective randomized controlled and blinded studies with a sufficient number of patients presenting long-term results&#46; However&#44; the high number of uncontrollable factors affecting the treatment results such as current bladder functions&#44; practitioner experience&#44; injection timing&#44; technique and material&#44; implantation volume&#44; patient immune response&#44; the grade of the reflux&#44; and additional urinary anomalies will be the most challenging issues for researchers&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusion</span><p id="par0065" class="elsevierStylePara elsevierViewall">In this study involving standardized primary VUR patients&#44; Dexell and Vantris provided an effective endoscopic treatment in the early and mid-term follow up similar to the studies in the literature&#46; We also had a safe treatment process without any VUJO and VUR recurrence&#46; The safety of the procedures in this study can be attributed to the bladder and bowel rehabilitation efforts and the injection volumes we have speculated considering the molecular structures of the bulking agents&#46; However&#44; it is essential to be confirmed our results with prospective randomized controlled trials&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Funding</span><p id="par0070" class="elsevierStylePara elsevierViewall">This work has not received any funding&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflicts of interest</span><p id="par0075" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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            0 => "Reflujo vesicoureteral"
            1 => "Dextran&#243;mero&#47;&#225;cido hialur&#243;nico"
            2 => "Copol&#237;mero de poliacrilato-polialcohol"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction and objectives</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">To compare the results in terms of efficacy and safety of the endoscopic management for vesicoureteral reflux &#40;VUR&#41; in two different standardized primary VUR cohorts treated with Dexell and Vantris&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Patients</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">128 refluxing renal units &#40;RRU&#41; in 87 patients with primary VUR &#40;64 females&#44; 23 males&#41;&#46; Patients with secondary VUR and severe bladder and bowel dysfunction were excluded&#46; A total of 22 continent children with mild bladder-bowel dysfunction underwent bladder-bowel training before the implantation&#46; All procedures were performed in the presence of sterile urine using a conventional subureteral transurethral injection technique&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">There were no statistically significant differences between groups in terms of mean age&#44; sex&#44; RRU side&#44; <span class="elsevierStyleSup">99m</span>Tc-DMSA uptake&#44; and reflux grade&#46; The overall resolution rates based on the number of RRUs for up to three endoscopic treatments were 80&#37; &#40;56&#47;70&#41; in Dexell group and 94&#46;8&#37; &#40;55&#47;58&#41; in Vantris group &#40;<span class="elsevierStyleItalic">P</span>&#8239;&#61;&#8239;&#46;012&#41;&#46; No postoperative recurrences or vesicoureteral junction obstructions were seen in any group&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Dexell and Vantris provided an effective and safe endoscopic VUR treatment in the early and mid-term follow up of children with primary VUR&#46; The effectiveness of these substances&#44; which can produce different mass effects with different particle sizes&#44; in safe VUR resolution&#44; needs further investigations&#46;</p></span>"
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            "titulo" => "Conclusions"
          ]
        ]
      ]
      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n y objetivos</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Comparar&#44; en t&#233;rminos de eficacia y seguridad&#44; los resultados del tratamiento endosc&#243;pico del reflujo vesicoureteral &#40;RVU&#41; en dos cohortes diferentes de RVU primario tratadas con Dexell y Vantris&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pacientes</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">El estudio incluy&#243; 128 unidades de reflujo renal &#40;URR&#41; en 87 pacientes con RVU primario &#40;64 mujeres&#44; 23 hombres&#41;&#46; Se excluyeron los pacientes con RVU secundario y disfunci&#243;n vesical e intestinal severa&#46; Un total de 22 ni&#241;os mayores ya continentes&#44; con disfunci&#243;n vesico-intestinal leve&#44; fueron sometidos a entrenamiento vesico-intestinal previo a la implantaci&#243;n&#46; Todos los procedimientos se realizaron en presencia de orina est&#233;ril mediante la t&#233;cnica convencional de inyecci&#243;n transuretral subureteral&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">No hubo diferencias estad&#237;sticamente significativas entre los dos grupos en cuanto a media de edad&#44; sexo&#44; lateralidad de la URR&#44; captaci&#243;n de 99&#8239;m Tc-DMSA y grado de reflujo&#46; Las tasas de resoluci&#243;n global con base en el n&#250;mero de URR con hasta tres tratamientos endosc&#243;picos fueron del 80&#37; &#40;56&#47;70&#41; en el grupo Dexell y del 94&#44;8&#37; &#40;55&#47;58&#41; en el grupo Vantris &#40;<span class="elsevierStyleItalic">P</span>&#8239;&#61;&#8239;&#44;012&#41;&#46; No se observaron recidivas ni obstrucciones de la uni&#243;n vesicoureteral en el postoperatorio en ning&#250;n grupo&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Dexell y Vantris proporcionaron un tratamiento endosc&#243;pico eficaz y seguro en el seguimiento a corto y medio plazo del RVU primario en ni&#241;os&#46; Se requieren m&#225;s estudios para evaluar la eficacia de estas sustancias&#44; cuyo efecto de volumen depende del tama&#241;o de sus part&#237;culas&#44; en la resoluci&#243;n segura del RVU&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Introducci&#243;n y objetivos"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Pacientes"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
          ]
        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as&#58; Do&#287;an AB&#44; &#214;zkan KU&#44; G&#252;ler AG&#44; Karakaya AE&#46; Tratamiento endosc&#243;pico del reflujo vesicoureteral primario en ni&#241;os con dos materiales diferentes&#46; Tasa de &#233;xito alta y tasa de complicaciones baja&#58; comparaci&#243;n entre Dexell y Vantris&#46; Actas Urol Esp&#46; 2021&#59;45&#58;545&#8211;551&#46;</p>"
      ]
    ]
    "multimedia" => array:3 [
      0 => array:8 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 1845
            "Ancho" => 3333
            "Tamanyo" => 275163
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        ]
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0005"
            "detalle" => "Figure "
            "rol" => "short"
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Resultados detallados del tratamiento endosc&#243;pico del RVU&#46;</p>"
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      ]
      1 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0010"
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        "tabla" => array:3 [
          "leyenda" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">RRU&#58; renal refluxing unit&#44; VUR&#58; vesicoureteral reflux&#44; DMSA&#58; dimercaptosuccinic acid&#44; UTI&#58; urinary tract infection&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Variables&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Group 1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Group 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Number of Patients&#44; n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Number of RRUs&#44; n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#44;479&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Male&#47;Female&#44; n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&#47;34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&#47;30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#44;348&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mean age&#44; years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#44;43&#8239;&#177;&#8239;3&#44;63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#44;1&#8239;&#177;&#8239;3&#44;44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#44;641&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Unilateral VUR&#44; n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#44;479&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bilateral VUR&#44; n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">RRU side&#44; right&#47;left&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">35&#47;35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25&#47;33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#44;274&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">VUR Grade &#40;RRU&#41;&#44; n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>V&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mean volume of bulking agents&#59; ml&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;73&#8239;&#177;&#8239;0&#44;68&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;51&#8239;&#177;&#8239;0&#44;22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Preoperative DMSA uptake<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&#44; &#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">47&#44;15&#8239;&#177;&#8239;18&#44;97&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">45&#44;22&#8239;&#177;&#8239;24&#44;25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#44;614&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Postoperative DMSA uptake<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&#44; &#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">46&#44;51&#8239;&#177;&#8239;19&#44;78&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">44&#44;44&#8239;&#177;&#8239;25&#44;50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#44;607&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mean follow-up&#44; month&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28&#44;46&#8239;&#177;&#8239;9&#44;79&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23&#44;85&#8239;&#177;&#8239;6&#44;28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#44;366&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mean operation time&#44; minute&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17&#44;08&#8239;&#177;&#8239;6&#44;90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&#44;06&#8239;&#177;&#8239;6&#44;82&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#44;422&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Treated voiding dysfunction before the procedure&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14 &#40;29&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;20&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#44;251&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Breakthrough febrile UTI after the procedure&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;14&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;10&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#44;394&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Patients&#8217; characteristics and demographics&#46;</p>"
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          "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">RRU&#58; renal refluxing unit&#44; VUR&#58; vesicoureteral reflux&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">VUR grade&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Dexell&#44; &#37; &#40;n&#47;n&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Vantris&#44; &#37; &#40;n&#47;n&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">2&#8722;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">87&#46;1&#37; &#40;34&#47;39&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">97&#46;3&#37; &#40;37&#47;38&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#46;200&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#8722;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">71&#37; &#40;22&#47;31&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">90&#37; &#40;18&#47;20&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#46;101&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">56&#47;70 &#40;80&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">55&#47;58 &#40;94&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#46;012&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The Overall success rate of Dexell and Vantris based on VUR grade and RRUs&#46;</p>"
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      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:29 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "&#91;Treatment of vesicorenal reflux by transurethral teflon-injection &#40;author&#8217;s transl&#41;&#93;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "E&#46; Matouschek"
                          ]
                        ]
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                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Urologe A&#46;"
                        "fecha" => "1981"
                        "volumen" => "20"
                        "paginaInicial" => "263"
                        "paginaFinal" => "264"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7197421"
                            "web" => "Medline"
                          ]
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              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Migration and granulomatous reaction after periurethral injection of polytef &#40;Teflon&#41;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46;A&#46; Malizia"
                            1 => "H&#46;M&#46; Reiman"
                            2 => "R&#46;P&#46; Myers"
                            3 => "J&#46;R&#46; Sande"
                            4 => "S&#46;S&#46; Barham"
                            5 => "R&#46;C&#46; Benson"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1001/jama.1984.03340480059030"
                      "Revista" => array:6 [
                        "tituloSerie" => "JAMA&#46;"
                        "fecha" => "1984"
                        "volumen" => "251"
                        "paginaInicial" => "3277"
                        "paginaFinal" => "3281"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/6374180"
                            "web" => "Medline"
                          ]
                        ]
                      ]
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                  ]
                ]
              ]
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            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Correction of experimentally produced vesicoureteric reflux in the piglet by intravesical injection of Teflon"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "P&#46; Puri"
                            1 => "B&#46; O&#8217;Donnell"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/bmj.289.6436.5"
                      "Revista" => array:5 [
                        "tituloSerie" => "Br Med J &#40;Clin Res Ed&#41;&#46;"
                        "fecha" => "1984"
                        "volumen" => "289"
                        "paginaInicial" => "5"
                        "paginaFinal" => "7"
                      ]
                    ]
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                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0020"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Failure of subureteral bovine collagen injection for the endoscopic treatment of primary vesicoureteral reflux in long-term follow-up"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "A&#46; Haferkamp"
                            1 => "H&#46; Contractor"
                            2 => "K&#46; M&#246;hring"
                            3 => "G&#46; Staehler"
                            4 => "J&#46; D&#246;rsam"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/S0090-4295(00)00494-5"
                      "Revista" => array:6 [
                        "tituloSerie" => "Urology&#46;"
                        "fecha" => "2000"
                        "volumen" => "55"
                        "paginaInicial" => "759"
                        "paginaFinal" => "763"
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                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10792096"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Severe complications after endoscopic injection of polydimethylsiloxane for the treatment of vesicoureteral reflux in early childhood"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "C&#46; Kempf"
                            1 => "B&#46; Winkelmann"
                            2 => "J&#46; Roigas"
                            3 => "U&#46; Querfeld"
                            4 => "D&#46; M&#252;ller"
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.3109/00365599.2010.492786"
                      "Revista" => array:6 [
                        "tituloSerie" => "Scand J Urol Nephrol&#46;"
                        "fecha" => "2010"
                        "volumen" => "44"
                        "paginaInicial" => "347"
                        "paginaFinal" => "353"
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