Vesicoureteral reflux

Done By : Khalid Al-Qudsi Faisal Burghal

Supervised by : Dr. Osama Bani Hani

Difinition

Vesicoureteral reflux (VUR) is an abnormal backward movement of urine from the bladder into ureters or kidneys ( Upper urinary tract). 

Why Vesicoureteral reflux Is a problem ? Acute Pyeloneohritis

Multiple UTIs

Renal Scarring

Subsequent hypertension

Decreased renal function

End-stage renal disease (ESRD)

Epidemiology It is the most common urologic finding in

children Occurring in approximately 1 percent of

newborns In 30 to 45 percent of young children with

a urinary tract infection (UTI)  In neonates with prenatal hydronephrosis,

the prevalence of VUR is about 15 percent Females > Males

Male newborns > Female newborns

Etiology: Primary VUR : The most common form of reflux, Often

Unilateral It is due to incompetent or inadequate

closure of the ureterovesical junction (UVJ), which contains a segment of the ureter within the bladder wall (intravesical ureter).

The failure of this anti-reflux mechanism is due to the shortening of the intravesical ureter.The intravesical ureter length may be genetically dictated, which may explain the increased incidence in family members of patients with VUR.

Other Causes : Absence of adequate detrusor backing, Lateral displacement of the ureteral orifice, Paraureteral (Hutch) diverticulum

Spontaneous resolution of primary VUR can occur with growth. As the bladder grows, the intravesical ureter increases in length, improving the function of the anti-reflux mechanism.

Secondary VUR: Result of abnormally high pressure in the

bladder that results in failure of the closure of the UVJ during bladder contraction.

Often associated with anatomic (e.g., posterior urethral valves) or functional bladder obstruction (e.g., dysfunctional voiding and neurogenic bladder)

Often Bilateral The degree and chronicity of obstruction can

influence the severity of VUR. The management of secondary VUR is focused on

treating the primary abnormality with the rare need for direct surgical correction of the VUR

Grading  The International Reflux Study Group (IRSG) developed a

classification system that grades the severity of VUR based upon the degree of retrograde filling and dilation of the renal collecting system demonstrated by VCUG

Grade I – Reflux only fills the ureter without dilation. Grade II – Reflux fills the ureter and the collecting system

without dilation Grade III – Reflux fills and mildly dilates the ureter and the

collecting system with mild blunting of the calyces. Grade IV – Reflux fills and grossly dilates the ureter and the

collecting system with blunting of the calyces. Some tortuosity of the ureter is also present.

Grade V – Massive reflux grossly dilates the collecting system. All the calyces are blunted with a loss of papillary impression and intrarenal reflux may be present. There is significant ureteral dilation and tortuosity.

Clinical Features The clinical course and outcome vary

depending upon whether VUR presents prenatally or postnatally.

Prenatal presentation — The presence of VUR is suggested by the finding of hydronephrosis on prenatal ultrasonography

Postnatal presentation — Postnatal diagnosis of VUR usually is made after a UTI, and less commonly, it is detected after screening of family members

Signs and symptoms 

Vesicoureteral reflux in itself does not produce any symptoms. These occur when infection of the urinary tract (UTI) is present.

Older children Infection causes symptoms such as fever, pain,

unpleasant smelling urine and a burning sensation when urinating.

Other symptoms commonly experienced include: Bedwetting (nocturnal enuresis). Lower abdominal pain. Blood in the urine (haematuria) and/or pus in the urine

(pyuria).

In neonate

irritability, persistent high fever, and listlessness. In cases of VUR and febrile UTI associated with a serious underlying urinary tract abnormality, the neonate could present with respiratory distress, failure to thrive, renal failure, flank masses, and urinary ascites.

Investigation

Urine R/E Urine C/S B. urea S. creatinine X-ray KUB USG-KUB IVU Simple cystography MCUG Voiding cinefluoroscopy Radionuclide scan

Diagnosis

The diagnosis of vesicoureteral reflux (VUR) is based upon the demonstration of reflux of urine from the bladder to the upper urinary tract by either contrast voiding cystourethrogram (VCUG) or radionuclide cystogram (RNC). The VCUG provides greater anatomic detail but there is increased radiation exposure with VCUG compared to RNC

In the larger of the systematic reviews conducted by the American Urological Association (AUA), prenatal hydronephrosis was defined as a renal pelvic diameter (RPD) ≥4 mm during the second trimester and ≥7 mm during the third trimester

Ultrasound Scanning:

The bladder and kidneys are scanned to survey the anatomy and assess for any irregularities.

DSMA Renal Scan: Pictures of the kidneys are taken with a

specialised scanner following the injection of a weak radioactive solution (radioisotope) into the bloodstream via a drip in the hand or arm. The pictures taken by the scanner can assess kidney size, position and function and check for scarring of the kidneys as the result of repeated UTI’s. 

Management THERAPEUTIC INTERVENTIONS is principally

based upon the following : Identification of children with VUR Prevention of pyelonephritis Prevention of further renal damage resulting from

infection and inflammation Minimization of morbidity of treatment and follow-up Identifying and managing children with bladder and

bowel dysfunction Therapeutic interventions include medical therapy

(ie, antibiotic prophylaxis), and surgical correction

We suggest all children with grades III through V reflux be treated because they are at greatest risk for recurrent UTI, renal scarring, and hypertension.

Children with grade I to II reflux are at the lowest risk for renal scarring. In our practice, the different treatment options of observation or medical therapy (ie, antibiotic prophylaxis) are presented to the family, which plays a major role in the final therapeutic decision. We do not suggest surgical correction in these patients

MEDICAL TRETMENT (Indications) Unilateral reflux Lower grades of reflux Earlier age at presentation Male gender

MEDICAL TRETMENT

Consists of daily prophylactic administration of antibiotics. It is based upon the observation that reflux will spontaneously resolve in most cases, and the assumptions that use of continuous antibiotics results in sterile urine and the continued reflux of sterile urine does not cause renal infection

Antimicrobial agents most commonly used for prophylaxis include trimethoprim-sulfamethoxazole, trimethoprim alone, or nitrofurantoin . One daily dose is administered at bedtime. The dose is one-half to one-quarter the usual therapeutic dose for treating an acute infection. Amoxicillin and cephalosporins are not recommended because of the increased likelihood of resistant organisms , except in infants below two months of age. Adverse effects of sulfonamides, trimethoprim, or nitrofurantoin preclude their use in infants less than two months of age

Surgical treatment 

 Surgical treatment corrects the anatomy at the refluxing ureterovesical junction.

The two surgical approaches used are open surgical reimplantation and endoscopic correction

Open surgical reimplantation Highly successful procedure, with reported

correction rates of 95 to 99 percent regardless of the severity of VUR

In open reimplantation, the bladder is opened (intravesical approach) and the ureters are reimplanted by tunneling a ureteral segment through the detrusor (bladder wall muscle), thereby creating a submucosal tunnel . Alternatively, reimplantation can be done without opening the bladder (extravesical approach).

Endoscopic correction  Subureteric transurethral injection (STING

procedure), he procedure involves injecting a copolymer substance, such as dextranomer/hyaluronic acid (Dx/HA or DEFLUX), beneath the mucosa of the ureterovesical junction through a cystoscope. This injection changes the angle and perhaps fixation of the intravesical ureter, thereby correcting reflux

The success rate for correcting VUR by STING in one or more procedures ranges from 75 to almost 100 percen

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