endoscopic injection of bulking agents for the treatment of vesicoureteral reflux and introducing a new material: acellular lyophilized prepuce as a natural scaffold

Context: endoscopic therapy has been introduced for vesicoureteral reflux (vur) treatment from the early 1980s and emerged as the first-line treatment in all grades of vur. various materials have been used for the endoscopic suburethral application, and their curative role has been characterized by different potential. in this study, we aimed to summarize the global experience with the various bulking agents used for endoscopic treatment of vur, especially the cure and complication rates, and review our newly introduced bulking agent. evidence acquisition: the current literature and our experience on the outcome of endoscopic treatment with different bulking agents were reviewed. results: various foreign materials have been used for endoscopic suburethral injections, and their success rate has been different from 40 to ≤ 90 percent. dextranomer/hyaluronic acid copolymer (dx/ha), currently the most common bulking agent used for vur resolution, is an artificial material that helps to grow collagen and fibroblasts. activation of the immune reaction and the formation of granuloma pseudocysts are impediments after the injection of this agent. therefore, despite the better consequences in comparison to other agents, the use of this material might be associated with the risk of appearance of serious and persistent complications. conclusions: our newly designed decellularized prepuce tissue as a biocompatible tissue-engineered bulking agent, is comparable to dx/ha regarding low immunoreaction and inflammatory responses with lower price. so, it could be a proper candidate for future randomized clinical trials to investigate the potential of clinical application of the current bulking agent; moreover, it can be an appropriate alternative for dx/ha.