NEAUA - Examining the Outcome and Cost of the Double Hydrodistension-Implantation Technique (double-HIT) in Dextranomer/Hyaluronic Acid injection (Deflux)

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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.

INTRODUCTION AND OBJECTIVES:
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.
METHODS:
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.
RESULTS:
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.
CONCLUSIONS:
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 .
double-HIT STING/HIT P-Value
Ureters 64% (23) 36% (13)
Pre-Surgical VUR Grade I 4% (1) 23%(3)
Pre-Surgical VUR Grade II 18% (4) 38% (5)
Pre-Surgical VUR Grade III 65% (15) 38% (5)
Pre-Surgical VUR Grade IV 13% (3) 0% (0)
Resolution Rate 70% (16) 77% (10) 0.716
Median Gel Injected (ml) 1.25 (0.7-3.7) 1.00 (0.3-2.0) 0.001
Mean Cost 3,542.82 2329.94 0.005

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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