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Examining the Outcome and Cost of the Double Hydrodistension-Implantation Technique (double-HIT) in Dextranomer/Hyaluronic Acid injection (Deflux)
Renee Silvis, MS1, Katherine Herbst, M.Sc.1, John H. Makari, MD2, Fernando A. Ferrer, MD3, Christina Kim, MD3.
1Connecticut Children's Medical Center, Hartford, CT, USA, 2Connecticut Children's Medical Center/University of Connectictut Medical Center, Hartford/Farmington, CT, USA, 3Connecticut Children's Medical Center/University of Connecticut Health Center, Hartford/Farmington, CT, USA.

Deflux injection is a less invasive option than other corrective vesicoureteral reflux (VUR) interventions. Earlier data had lower reported success with Deflux, but improved outcomes have been reported with the double-HIT technique.1 Our study investigated how the technique and volume injected during Deflux affected the success rates and cost at our institution.
Prospectively collected data on 23 patients (36 ureters) who underwent Deflux between 2010- 2012 was analyzed. Patients with failed prior surgeries or no follow-up imaging and ureters treated for risk of VUR were excluded. Resolution was defined as no reflux reported on follow-up voiding cystourethrogram (VCUG). Cost of was defined as cost of Deflux gel ($1809/vial in 2010, $1899/vial in 2011-12) multiplied by number of vials opened. Comparisons between double-HIT and all other techniques (STING/HIT) were made using t-test or Mann-Whitney U.
The majority of patients were female (87%) with a mean surgical age of 6.1 years (SD +/- 3.0 yrs). The majority of patients undergoing double-HIT had pre-surgical VUR grade three or higher, while the majority of patients undergoing STING/HIT had pre-surgical VUR grades II-III. However, sample size was not adequate to adjust for VUR grade when comparing between groups. There was no significant difference in resolution rates between the groups (p=.716), but amount of gel injected (p=.001) and cost (p=.005) were significantly higher for double-HIT.
Although our current data indicates similar resolution rates between Double HIT and other injection techniques, a larger sample size is required to substantiate this finding.
It is not surprising that the average volume injected is significantly higher with double-HIT, increasing the cost of the procedure an average of $1,212.88/ureter. If all the patients in our series had underwent STING/HIT rather than double-HIT, a savings of $27,896 in gel could have been realized.
Although only cost of gel was analyzed in this study, and total procedure cost is multi-factorial. We simply started an analysis based on the injection style. The potential for cost savings encourages further investigation to identify evidence-
based benefits of the double-HIT technique .
Ureters64% (23)36% (13)
Pre-Surgical VUR Grade I4% (1)23%(3)
Pre-Surgical VUR Grade II18% (4)38% (5)
Pre-Surgical VUR Grade III65% (15)38% (5)
Pre-Surgical VUR Grade IV13% (3)0% (0)
Resolution Rate70% (16)77% (10)0.716
Median Gel Injected (ml)1.25 (0.7-3.7)1.00 (0.3-2.0)0.001
Mean Cost3,542.822329.940.005

Adv Urol. 2008; 2008: 513854.
Published online 2008 June 5. doi:  10.1155/2008/513854
PMCID: PMC2441859
1. Wolfgang H. Cerwinka,* Hal C. Scherz, and Andrew J. Kirsch. Endoscopic Treatment of Vesicoureteral Reflux with Dextranomer/Hyaluronic Acid in Children

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