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BJU International 2000 85 (1), 168
CASE REPORTS
Migration of PTFE paste particles to the kidney after treatment for vesico–ureteric reflux
H.
Steyaert, C.
Sattonnet*, C.
Bloch†, F.
Jaubert‡, P.
Galle¶ and J.S.
Valla
Department of Pediatric Surgery, * Anatomopathology and † Nephrology of the Lenval Foundation for Children, Nice, ‡ Department of Anatomopathology, Necker Children’s Hospital, ¶ H. Mondor Hospital, Paris, France
Case report
Comment  References Authors An 18–month–old girl was admitted for left pyelonephritis; voiding cysto–urethrography (VCUG) showed left stage III reflux and IVU showed symmetrical excretion with a size asymmetry (right 8.2 cm, left 6.3 cm). Follow–up under prophylactic antibiotics was started, with no recurrent UTIs documented. A VCUG assessment one year later showed persistent stage III reflux. She was treated using submucosal injections of PTFE paste (0.5 mL PTFE). The postoperative course was unremarkable. A VCUG 6 months later showed that the reflux had resolved. The child, regularly followed for asthma, had no further UTIs. When aged 9 years, she presented with chronic left flank pain. Ultrasonography showed a very small left kidney and the intravesical PTFE was no longer identifiable. VCUG again confirmed the good long–term result of the cure of reflux, but MAG–3 scintigraphy showed reduced left renal function (< 10%). An endoscopic left–sided nephroureterectomy was performed and the postoperative course was uneventful, with complete pain relief. Macroscopic examination of the kidney (6 ×3 × 2 cm, with a 7.5 cm ureter) revealed upper cortical cicatricial depressions and total cortical atrophy of the inferior pole. Microscopically, the cortical atrophy was caused by chronic pyelonephritis and, in the inferior pole, an evolutive gigantocellular resorption process (granulomatous) developed through contact with exogenous round particles (5–100 µm) with finely crenellated borders, slightly birefringent in polarized light (Fig. 1a,b). Spectrometric analysis confirmed that these particles were PTFE.
Comment
Case report  References Authors The endoscopic treatment of reflux by injection with submucosal PTFE paste was introduced by Matouschek in 1981 [1]. A problem with this technique is that it introduces foreign bodies, and thus raises questions of local and general tolerance [2]. The migration of the PTFE particles to the lungs and brain has been confirmed experimentally [3]. Cases of acute pneumopathy, with PTFE in lung biopsies, have been described in adults [4]. In children, migration to the terminal ureter and the perivesical lymphatic vessels, with no clinical consequences, has been reported; we have encountered three such cases. The clinical consequences of particle migration are unknown; long–term follow–up studies are rare [5]. Thus the present case represents the first of clinical symptomatology and destruction of the kidney associated with presence of PTFE in the renal parenchyma. The relationship among these three elements remains to be confirmed and there are several questions.
There are several possible routes by which the particles could migrate. The first is through the injection track, with secondary intraparenchymal infiltration by the PTFE particles. There was a pelvic and peritubular distribution of the particles but this proposal supposes that the urothelium is breached, so that the PTFE becomes incorporated into the tissues. Furthermore, the delay between injection and symptoms (7 years) seems too long for this route. The second route is vascular, probably not lymphatic but venous. However, no PTFE was found in either the perirenal lymphatics or the renal vessels. Why there was more PTFE in the lower part of the kidney is unclear by this hypothesis. The third and most likely route is intraparietal, with the migration of isolated particles, or those within macrophages, into the ureteric wall from the injection site and up to the renal parenchyma. It would take many years for PTFE to accumulate by this route and may explain the abundance of PTFE in the renal pelvis.
It is unclear whether the PTFE or the reflux nephropathy destroyed the kidney. On initial IVU, there was undoubtedly renal damage on the refluxing side, with a smaller kidney (–1.5 sd). The reflux resolved after the endoscopic procedure, but it is known that pyelonephritic lesions may develop even after the radical correction of reflux [6], and several theories have been proposed to account for this [7]. However, the destruction of the whole inferior pole was not explained by the (histologically) chronic pyelonephritic lesions and thus there may be some destructive, aggravating role for the PTFE particles. The destruction may be a direct toxic effect: this seems improbable because PTFE is known to be biocompatible and there was no tissue necrosis where there was contact with the particles. The destruction may be indirect, through an auto–immunological process: this mechanism is also difficult to support because there were no histological signs of an autoimmune reaction. Lastly, there may have been some urodynamic modification; the presence of PTFE in the wall of the collecting tubes, the papillae and the calyces could lead to fibrosis and excessive rigidity of the wall with chronic ulceration, leading to anomalies which sustained the harmful effect of an intraparenchymal urinary reflux. This last mechanism seems to be the most likely. We conclude that significant migration of PTFE paste is possible not only in lymph nodes but also in distant organs, particularly the kidney, and may possibly exacerbate chronic inflammatory (and fibrotic?) destruction of this organ [8]. Long–term follow–up of patients treated with PTFE is mandatory.
References
Case report Comment Authors
Authors
Case report Comment References
H. Steyaert, Adjoint anatomopathology.
C. Sattonnet.
C. Bloch, Adjoint nephrology.
F. Jaubert, Chief anatomopathology.
P. Galle, Physician.
J. S. Valla, Chief Paediatric Surgery. Correspondence: Dr H. Steyaert, Fondation Lenval, 57, Av. de l, Californie, F 06200 Nice, France.
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| Steyaert, H., Sattonnet, C., Bloch, C., Jaubert, F., Galle, P. & Valla, J.S. Migration of PTFE paste particles to the kidney after treatment for vesico–ureteric reflux.
BJU International 2000
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Steyaert, H
Sattonnet, C
Bloch, C
Jaubert, F
Galle, P
Valla, J
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