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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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