Comment on "Subureteral Injection with Small-Size Dextranomer/Hyaluronic Acid Copolymer: Is It Really Efficient?"

We read with great interest and appreciated very much the article written by Üre et al. [1]. In their study, the authors evaluated the efficiency of subureteral small-size (80-120 μm) dextranomer/hyaluronic acid copolymer injection treatment in children affected by 1 to 4 grade vesicoureteral reflux, finding an overall success rate of 97% of the treated patients. Previously, Aydogdu et al. [2], comparing small-size dextranomer/hyaluronic acid copolymer and deflux (normal-size dextranomer/hyaluronic acid copolymer), showed no difference in effectiveness between these two agents with the advantage that small-size dextranomer/hyaluronic acid copolymer treatment was less expensive. It has been described that 80-250 μm-diameter dextranomer microspheres in a stabilized hyaluronic acid gel recruited numerous myofibroblasts around the dextranomer particles, a foreign body inflammatory reaction with a high density in CD68 positive cells, stimulating an enhancement in collagenous stroma [3]. Moreover, it has been suggested that accumulation of fibrillar collagen and subsequent extracellular matrix after normal-size dextranomer/hyaluronic acid copolymer injection might explain the tissue contraction in refluxing ureteral ending, modifying the ureteral length-to-diameter ratio and promoting the resolution of vesico-ureteral reflux [3]. We believe that it could be interesting to also study the histological changes in ureteral endings after small-size dextranomer/hyaluronic acid copolymer injection, to verify if this substance has a similar effect of refluxing ureteral tissue. Finally, in our opinion, the data of Üre et al. [1] are very interesting and we would like to congratulate the authors on their splendid paper.