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Aetna Aetna
Clinical Policy Bulletin:
Vesicoureteral Reflux Treatment by Endoscopic Injection of Bulking Agents
Number: 0534


Policy

  1. Aetna considers endoscopic injection of dextranomer/hyaluronic acid copolymer (Deflux), polydimethylsiloxane (Macroplastique), polytetrafluoroethylene (Teflon), or other bulking agents approved by the U.S. Food and Drug Administration (FDA) for vesicoureteral reflux (VUR) medically necessary for the treatment of members with primary or secondary VUR who have any of the following conditions when conservative treatments (e.g., prophylactic antibiotics and clean intermittent catheterization) have failed:

    • Children who have had a previously unsuccessful ureteral re-implantation; or
    • Children who have stopped taking their medication as a result of drug intolerance or parental non-compliance; or
    • Children whose reflux is associated with a thick-walled neuropathic bladder; or
    • Deterioration of renal parameters regardless of reflux severity; or
    • Lower grades of reflux (grades I to III); or
    • Persistent reflux in post-pubertal female members; or
    • Recurrent, poorly controlled febrile urinary tract infections.

    Aetna considers endoscopic injections of bulking agents for VUR experimental and investigational for members who do not meet these criteria because it has insufficient evidence of effectiveness for persons who do not meet these criteria.

    Note: Members whose condition does not improve after 3 treatment sessions are considered treatment failures and are not likely to respond to this therapy.  If the member fails to respond within 3 treatment sessions, further treatments are not considered medically necessary.

  2. Aetna considers endoscopic injections of autologous blood or glutaraldehyde cross-linked bovine dermal collagen (Contigen, C.R. Bard, Inc., Murray Hill, NJ; Zyplast, Collagen Corporation, Palo Alto, CA) experimental and investigational for the treatment of members with primary or secondary VUR because their effectiveness has not been established.


Background

Vesico-ureteral reflux (VUR) is predominantly a disorder of childhood and occurs when urine passes backwards from the bladder to the kidneys during micturition.  It is caused by vesico-ureteral sphincter incompetence.  Reflux can predispose patients to urinary tract infections and renal scarring.

Primary VUR is the consequence of a congenital abnormality of the uretero-vesical junction, in which a deficiency of the longitudinal muscle of the intra-vesical ureter leads to an insufficient valvular mechanism.  Secondary VUR is due to bladder obstruction and its resultant increased pressures.  Obstruction of the bladder can be anatomical or functional.  The most common anatomical cause of VUR is posterior urethral valves, which are found in approximately 50 % of VUR-afflicted boys.  On the other hand, anatomical obstructions in females are extremely rare.  Functional causes of VUR are far more common in girls; they include neurogenic bladder, non-neurogenic bladder, and bladder instability or dysfunction.  Urinary tract infections (bladder infections) and accompanying inflammation can contribute to the development of VUR by decreasing bladder compliance, increasing intra-vesical pressures, and by distorting and weakening the uretero-vesical junction.  Approximately 40 % of children with urinary tract infections experience VUR.

Persons who undergo this procedure in the hospital can usually be discharged within 24 hours.  More than 1 day's hospitalization is usually not necessary.

According to the International Classification System of VUR, reflux is graded I to V on the basis of the appearance of contrast in the ureter and upper collecting duct system during voiding cystourethrography:

Grade I Reflux into the non-dilated ureter
Grade II  Reflux into the renal pelvis, and calyces without dilation
Grade III Mild to moderate dilation of the ureter, renal pelvis, and calyces with minimal blunting of the fornices
Grade IV Moderate ureteral tortuosity and dilation of the renal pelvis, and calyces
Grade V Gross dilation of the ureter, renal pelvis, and calyces, loss of papillary impressions, and ureteral tortuosity

Because of the high rate of spontaneous resolution in patients with grade I to III VUR, surgical intervention in these patients is rarely indicated.  For patients with grade IV and V reflux, surgical correction (e.g., open ureteral re-implantation or endoscopic subureteral injection of Teflon) is highly successful.

Endoscopic Teflon therapy for VUR entails injection of polytetrafluoroethylene (Teflon) paste into the submucosa at the refluxing ureteral orifice to bolster it, thus eliminating the problem.  In most patients, endoscopic injection of Teflon is performed on an outpatient basis.  Hospitalization may be necessary if patient experiences hematuria, acute urinary retention, or pelvic pain; 1 or 2 repeat injections may be needed if the initial injection fails to correct reflux.  The long-term safety of endoscopic Teflon injection has not been clearly established.  In particular, the question of whether there is a significant risk of Teflon particle migration remains unanswered.

In a recent study comparing the long-term outcome of the endoscopic correction of VUR of various injected substances, Sugiyama and colleagues (2004) stated that autologous blood is unsuitable for clinical application because of its poor durability; and the overall success rate of endoscopic surgery with glutaraldehyde cross-linked bovine dermal collagen or hyaluronan/dextranomer co-polymer was insufficient compared with surgical re-implantation.  Furthermore, Schlussel (2004) noted that glutaraldehyde cross-linked bovine dermal collagen and hyaluronan/dextranomer copolymer do not have the long-term follow-up of Teflon.

Elder et al (2007) examined the use of endoscopic injection with dextranomer/hyaluronic acid co-polymer (Dx/HA, Deflux) as a curative option and as an alternative to antibiotic prophylaxis.  The nationally representative PharMetrics Integrated Medical and Pharmaceutical database was used to conduct this retrospective analysis.  Patients less than 11 years of age who were continuously eligible and had an International Classification of Diseases (ICD-9-CM) code for VUR were identified.  Resource utilization and outcome measures were evaluated over a 6-month pre- and 12-month post-index period.  Patients diagnosed with neuropathic bladder, posterior urethral valves, bladder exstrophy, ureterocele, or duplication anomaly were excluded.  Patients were matched 3:1, antibiotic prophylaxis to Dx/HA, by age, gender, urinary tract infections (UTIs) prior to index date, and diagnosing physician specialty. The primary outcome assessed was UTIs.  Of the matched patients, 114 received a prescription for antibiotic prophylaxis and 38 underwent endoscopic injection with Dx/HA.  The average number of UTIs per year was 0.28 in the antibiotic cohort and 0.08 in the Dx/HA cohort, respectively.  The incidence rate ratio (IRR) of 4.826 (p = 0.029) revealed that the average number of UTIs was 383 % higher for patients receiving antibiotic prophylaxis compared with patients who underwent endoscopic injection.  The retrospective nature of the analysis did not allow for treatment randomization.  Due to the stringent classification of UTIs, rates of UTIs may be under-estimated in both cohorts.  The authors concluded that treatment with endoscopic injection with Dx/HA resulted in significantly fewer UTIs compared with children receiving antibiotic prophylaxis, supporting a role for Dx/HA as a first-line treatment option for patients with VUR.

Aaronson (2005) noted that open surgery remains the gold standard for the treatment of VUR.  For children with grade-I or grade-II reflux, in whom spontaneous resolution is likely, antibiotic is usually parents' treatment of choice.  On the other hand, for children with grade-IV or grade-V reflux, in which the space available for the bulking agent is very limited, and in cases of duplex ureters, in which there is a prolongation of the upper moiety non-refluxing ureter towards the bladder neck, which limits access to the refluxing orifice, open surgery is the treatment of choice.  For children with grade-III reflux, endoscopic treatment may be considered as a treatment option.  The author also stated that endoscopic treatment should also be considered for children who have had a previously unsuccessful ureteral re-implantation; those whose reflux is associated with a thick-walled neuropathic bladder; those with mild reflux who develop symptomatic break-through infections because of antibiotic resistance; or children who have stopped taking their medication as a result of drug intolerance or parental non-compliance.

Aaronson's observations regarding the use of endoscopic treatment for VUR are in agreement with the findings of other investigators (Stehr et al, 2004; Sugiyama et al, 2004; and Heidenreich et al, 2004).  Stehr et al (2004) stated that ureteral re-implantation is the operative treatment of choice in cases with high-grade VUR.  Alternatively in cases with lower-grade VUR, injection of bulking agents under the refluxive orifice can be performed.  Sugiyama et al (2004) reported that the cure rate of endoscopic surgery with bulking agents could be improved by excluding high-grade VUR from the indications for endoscopic surgery.  Heidenreich et al (2004) stated that the current indications for the surgical correction of VUR depend on the presence or absence of renal scars.  If no scars are present, primary ureteral re-implantation is only indicated in high-grade bilateral VUR, whereas in the presence of renal scars surgical correction is indicated in low/high grade reflux at a young age.  Endoscopic subureteral injections are primarily reserved for low-grade VUR with a 1 session success rate of over 90 %.  Endoscopic subureteral injections appear to be an alternative to long-term antibiotics in grade I-III VUR.

Bae and colleagues (2010) compared cure rates and complications of Deflux and polydimethylsiloxane (Macroplastique) in the treatment of VUR.  A total of 29 boys and 42 girls (total of 115 ureters) with a mean age of 6 years who had undergone endoscopic subureteral transurethral injection for VUR were enrolled.  A single subureteral injection of Macroplastique was performed in 31 ureters in 23 children (group I; grade II: n = 4; grade III: n = 12; grade IV: n = 9; grade V: n = 6), and a single subureteral injection of Deflux was performed in 84 ureters in 48 children (group II; grade II: n = 24; grade III: n = 14; grade IV: n = 25; grade V: n = 21).  Renal ultrasound was done 1 day after injection, and voiding cysto-urethrography (VCUG) was done at 3 months.  Successful reflux correction was defined as absent or grade I reflux on follow-up VCUG.  No significant difference in success rates was observed between group I and group II [80.6 % (25/31) versus 78.6 % (66/84), respectively, p > 0.05].  The following post-operative complications developed: ureteral obstruction in 2 ureters of group I and 3 ureters of group II, asymptomatic urinary tract infection in 3 patients of group I and 2 patients of group II, and bladder calcification by erosion or mucosal necrosis in 2 patients of group I.  The authors concluded that despite differences in material properties, both Deflux and Macroplastique were safe for the treatment of children with VUR.

Aubert (2010) carried out a literature review on the use of Macroplastique in VUR.  A PubMed review of the literature since 1996 resulted in the selection of 24 studies of sufficient level of evidence to assess the effectiveness and tolerance of Macroplastique in the VUR in adults and children.  The overall success rates at 1 year, 2 years and 9-years follow-up were 86 to 93 %, 80 to 92 %, and 77 to 100 %, respectively, which confirms the maintenance of good results over time, notably in VUR grade III and above.  The success rate was similar for primary and secondary VUR except for total duplicity.  Predictive criterias of success were the surgeon's experience, the low grade of VUR, and the absence of previous injection.  In comparison with other bulking agents, the higher viscosity and absence of shrinkage of the product increase its reliability.  After more than 12 years of use, no serious complication has been reported in the literature, reflecting the good tolerance of Macroplastique on the long-term.  The author concluded that published studies on the use of Macroplastique in VUR confirmed its effectiveness, around 85 % of success for all grades, in both children and adults.  The interest of Macroplastique is linked to its higher viscosity promoting a better reliability and reproducibility of the technique and its non-resorbable nature providing a permanent result, especially valuable in high-grade VUR with anatomical anomaly of the vesicoureteral junction or in VUR secondary to permanent lower urinary tract dysfunction.

The American Urological Association's guideline on management of primary VUR in children (Peters et al, 2010) recommended that patients receiving continuous antibiotic anaphylaxis with a febrile break-through UTI be considered for open surgical ureteral re-implantation or endoscopic injection of bulking agents for intervention with curative intent.

Alizadeh et al (2012) examined the incidence and presentations of ureteral obstruction following peri-ureteral injection of polyacrylate polyalcohol copolymer (PPC) for the treatment of VUR.  From January 2010 to December 2012, a total of 88 patients (28 males, and 60 females) with 128 renal refluxing units (RRU), 131 ureters and a mean age of 6.7 +/- 5.9 years (range of 4 months to 32 years) underwent endoscopic correction of their VUR, using PPC.  Exclusion criteria were dysmorphic appearing distal ureter, extra-vesical position of the ureteral orifice, persistent urethral obstruction (e.g., after previous valve ablation) and severe bladder trabeculation, making ureteral orifice unidentifiable.  Patients were followed-up by ultrasound 1 month after the injection and then every 3 months.  Cystography was performed 3 months post-operation.  Mean follow-up time was 13.1 +/- 6.8 months (range of 3 to 27 months).  Two patterns of obstruction were observed: early, during the first 3 to 4 days post-operation, in 4 patients (4 ureters; 3 %) which was associated with transient hydro-uretero-nephrosis (HUN) in 2 patients (2 ureters; 1.5 %); and late-onset obstruction in 3 patients (4 ureters; 3 %), which appeared 3 months to 1 year after surgery.  It manifested itself by urinary tract infection and uremia in 1 patient with bilateral obstruction but was asymptomatic in the other 2.  Early obstruction was managed expectantly and resolved in 3 to 12 months; however, late-onset obstruction needed catheter placement or open ureteroneocystostomy.  The authors concluded that patients who undergo endoscopic treatment for their VUR using PPC need long-term follow-up until the safety of this substance is confirmed.

 
CPT Codes / HCPCS Codes / ICD-9 Codes
CPT codes covered if selection criteria are met:
52327
Other CPT codes related to the CPB:
74420
74450
74455
78740
HCPCS codes covered if selection criteria are met:
L8604 Injectable bulking agent, dextranomer / hyaluronic acid copolymer implant, urinary tract, 1 ml, includes shipping and necessary supplies
L8606 Injectable bulking agent, synthetic implant, urinary tract, 1 ml syringe, includes shipping and necessary supplies
Q3031 Collagen skin test
HCPCS codes not covered for indications listed in the CPB:
L8603 Injectable bulking agent, collagen implant, urinary tract, 2.5 ml syringe, includes shipping and necessary supplies
ICD-9 codes covered if selection criteria are met:
593.70 - 593.73 Vesicoureteral reflux
Other ICD-9 codes related to the CPB:
593.4 Other ureteric obstruction
593.5 Hydroureter
593.89 - 593.9 Other and unspecified disorders of kidney and ureter
595.0 - 595.9 Cystitis
596.0 Bladder neck obstruction
596.51 - 596.59 Other functional disorders of bladder
596.8 Other specified disorders of bladder
599.0 Urinary tract infection, site not specified
753.20 - 753.29 Obstructive defects of renal pelvis and ureter
753.6 Atresia and stenosis of urethra and bladder neck
771.82 Urinary tract infection of newborn
794.4 Nonspecific abnormal results of kidney function studies
V13.02 Personal history of urinary (tract) infection
V15.81 Noncompliance with medical treatment
V21.1 Constitutional states in development, puberty


The above policy is based on the following references:
  1. Elder JS, Peters CA, Arant BS Jr, et al. Pediatric Vesicoureteral Reflux Guidelines Panel summary report on the management of primary vesicoureteral reflux in children. J Urol. 1997;157(5):1846-1851.
  2. Hughes PD. Ureteric reflux in adults and children treated exclusively by endoscopic Teflon injection: A 10-year experience. Aust N Z Surg. 1999;69(12):856-859.
  3. Kershen RT, Atala A. New advances in injectable therapies for the treatment of incontinence and vesicoureteral reflux. Urol Clin North Am. 1999;26(1):81-94.
  4. Puri P, Granata C. Multicenter survey of endoscopic treatment of vesicoureteral reflux using polytetrafluoroethylene. J Urol. 1998;160(3 Pt 2):1007-1011.
  5. Kumon H, Tsugawa M, Ozawa H, et al. Endoscopic correction of vesicoureteral reflux by subureteric Teflon (polytetrafluoroethylene) injection: Review of 6-year experience. Int J Urol. 1997;4(6):541-545.
  6. Belman AB. Vesicoureteral reflux. Pediatr Clin North Am. 1997;44(5):1171-1190.
  7. Yasui T, Akita H, Sasaki S, et al. Endoscopic injection of Teflon for correction of primary vesicoureteral reflux in children. Int J Urol. 1997;4(4):349-351.
  8. Engel JD, Palmer LS, Cheng EY, Kaplan WE. Surgical versus endoscopic correction of vesicoureteral reflux in children with neurogenic bladder dysfunction. J Urol. 1997;157(6):2291-2294.
  9. Skoog SJ, Belman AB, Majd M. A nonsurgical approach to the management of primary vesicoureteral reflux. J Urol. 1987;138(4 Pt 2):941-946.
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  32. Bae YD, Park MG, Oh MM, Moon du G. Endoscopic subureteral injection for the treatment of vesicoureteral reflux in children: Polydimethylsiloxane (Macroplastique(R)) versus dextranomer/hyaluronic acid copolymer (Deflux(R)). Korean J Urol. 2010;51(2):128-131.
  33. Aubert D. Vesico-ureteric reflux treatment by implant of polydimethylsiloxane (Macroplastique): Review of the literature. Prog Urol. 2010;20(4):251-259.
  34. Ormaechea M, Ruiz E, Denes E, et al. New tissue bulking agent (polyacrylate polyalcohol) for treating vesicoureteral reflux: Preliminary results in children. J Urol. 2010;183(2):714-717.
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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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