VESICOURETERIC REFLUX

VESICOURETERIC REFLUX “VUR refers to the retrograde passage of urine from the bladder into the ureter.” Holcomb III.G. W. et al. Ashcraft’s pediatric Surgery 6E. Section VI. Urology

VESICOURETERIC REFLUX reflux may be present in up to 70% of infants who present with UTI. i.e the incidence rises as age decreases. Younger children tend to have the more severe degrees of reflux. Posses as clinical challenge because it is usually asymptomatic. Most patients are female and approximately 14% will be male. An increased incidence of VUR (30%) is found in those males presenting with UTI In asymptomatic infants followed up for antenatal hydronephrosis, the prevalence of reflux ranges from 15% in infants with absent or mild hydronephrosis on postnatal ultrasound, to 38% in a group of neonates with various postnatal upper tract sonographic anomalies including hydronephrosis, renal cysts, or renal agenesis

VESICOURETERIC REFLUX Pathophysiology The normal UVJ is characterized by an oblique entry of the ureter into the bladder and a length of submucosal ureter providing a high ratio of tunnel length to ureteral diameter. This anatomic configuration provides a predominantly passive valve mechanism. As the bladder fills and the intravesical pressure rises, the resulting bladder wall tension is applied to the roof of the ureteral tunnel. This results in a compression of the ureter which prevents retrograde passage of urine. This effect is supplemented by the active effects of ureterotrigonal muscle contraction and ureteral peristalsis. Ashcraft Pediatric Surgery 6E. 2014

VESICOURETERIC REFLUX CLASSIFICATION Primary reflux: refers to reflux resulting from an anatomic deformity of the ureterovesical junction without a causative urinary tract abnormality that may cause reflux congenitally deficient Ureterovescical Junction Secondary reflux: result from increased bladder pressure which destabilizes the ureterovesical junction BOO (detrusor-sphincter discoordination, posterior urethral valves) neurogenic bladder Ectopic ureter/Ureterocoele Bladder exstrophy VUR clinical guidelines. American Urological Association. 1997

VESICOURETERIC REFLUX In 1981 the International Reflux Study Committee proposed a system of five grades of reflux This system depicts the appearance of the ureter, renal pelvis, and calyces as seen on the radiographic contrast images generated by the voiding cystourethrogram. Wein. Kavoussi et al. Campbell-Walsh Urology Tenth Edition. 2012

GRADE 1

GRADE 2

GRADE 5

VESICOURETERIC REFLUX Classification Simple Reflux Complex reflux: refluxing megaureter the refluxing duplicated ureter the refluxing ureter associated with a diverticulum or ureterocele Mangement and Screening of Primary Vesicoureteral Reflux in Children. American Urological AssociationVUR Clinical Guidelines. Availible at: http://www.auanet.org/guidelines/vesicoureteral-reflux-(2010-reviewed-and-validity-confirmed-2017)

VESICOURETERIC REFLUX CLINICAL MANIFESTATION The typical patient with VUR is a child younger than 10 years old who develops a UTI either; Clinical pyelonephritis with fever, abdominal/flank pain, malaise and/or nausea, vomiting, or Cystitis with dysuria, frequency, urgency, and often urge incontinence. Neonates and infants with VUR and pyelonephritis may have nonspecific symptoms VUR clinical guidelines. American Urological Association. 1997

VESICOURETERIC REFLUX General evaluation: measurement of Height, weight, blood pressure Baseline serum creatinine – for estimate of glomerular filtration rate (GFR) if bilateral renal abnormalities are found. Urinalysis for proteinuria and bacteriuria - If indicates infection, a urine culture and sensitivity is recommended. Mangement and Screening of Primary Vesicoureteral Reflux in Children. American Urological AssociationVUR Clinical Guidelines. Availible at: http://www.auanet.org/guidelines/vesicoureteral-reflux-(2010-reviewed-and-validity-confirmed-2017)

VESICOURETERIC REFLUX General evaluation: Renal ultrasound to assess the upper urinary tract DMSA (technetium-99m-labeled dimercaptosuccinic acid) renal imaging can be obtained to assess the status of the kidneys for scarring and function Mangement and Screening of Primary Vesicoureteral Reflux in Children. American Urological AssociationVUR Clinical Guidelines. Availible at: http://www.auanet.org/guidelines/vesicoureteral-reflux-(2010-reviewed-and-validity-confirmed-2017)

VESICOURETERIC REFLUX MANAGEMENT Goals: prevent recurring febrile UTIs prevent renal injury minimize the morbidity of treatment and follow-up. Mangement and Screening of Primary Vesicoureteral Reflux in Children. American Urological AssociationVUR Clinical Guidelines. Availible at: http://www.auanet.org/guidelines/vesicoureteral-reflux-(2010-reviewed-and-validity-confirmed-2017)

VESICOURETERIC REFLUX PREVENTING RECURRING FEBRILE UTIs & PREVENT RENAL INJURY In the child < 1 year of age Continuous antibiotic prophylaxis is recommended for; VUR with a history of a febrile urinary tract infection or In the absence of a history of febrile urinary tract infections, VUR grades III–V who is identified through screening Mangement and Screening of Primary Vesicoureteral Reflux in Children. American Urological AssociationVUR Clinical Guidelines. Availible at: http://www.auanet.org/guidelines/vesicoureteral-reflux-(2010-reviewed-and-validity-confirmed-2017)

VESICOURETERIC REFLUX PREVENTING RECURRING FEBRILE UTIs & PREVENT RENAL INJURY The Child >1 year old, Continuous antibiotic prophylaxis is recommended for; The Child with BBD- also the treatment of bladder/bowel dysfunction is indicated, preferably before any surgical intervention for VUR is undertaken behavioural therapy Biofeedback (>5 YEARS) anticholinergic medications/ alpha blockers treatment of constipation may be considered for the child with a history of urinary tract infections and VUR in the absence of bladder/bowel dysfunction Mangement and Screening of Primary Vesicoureteral Reflux in Children. American Urological AssociationVUR Clinical Guidelines. Availible at: http://www.auanet.org/guidelines/vesicoureteral-reflux-(2010-reviewed-and-validity-confirmed-2017)

VESICOURETERIC REFLUX MINIMIZE THE MORBIDITY OF TREATMENT AND FOLLOW-UP  annual-monitoring of blood pressure, height, and weight is recommended. annual-Urinalysis for proteinuria and bacteriuria. urine culture and sensitivity if the urinalysis is suggestive of infection. Ultrasonography is recommended every 12 months to monitor renal growth and any parenchymal scarring. Mangement and Screening of Primary Vesicoureteral Reflux in Children. American Urological AssociationVUR Clinical Guidelines. Availible at: http://www.auanet.org/guidelines/vesicoureteral-reflux-(2010-reviewed-and-validity-confirmed-2017)

VESICOURETERIC REFLUX MINIMIZE THE MORBIDITY OF TREATMENT AND FOLLOW-UP Voiding cystography between 12 and 24 months with longer intervals in those with higher grades of VUR [grades III-V], bladder/bowel dysfunction, and older age i.e.  lower rates of spontaneous resolution  Follow-up cystography after one year of age in patients with VUR grades I-II DMSA imaging is recommended when a renal ultrasound is abnormal when there is a greater concern for scarring (i.e. breakthrough urinary tract infection or grade III-V VUR) an elevated serum creatinine First point: these patients tend to have a high rate of spontaneous resolution and boys have a low risk of recurrent urinary tract infection. Mangement and Screening of Primary Vesicoureteral Reflux in Children. American Urological AssociationVUR Clinical Guidelines. Availible at: http://www.auanet.org/guidelines/vesicoureteral-reflux-(2010-reviewed-and-validity-confirmed-2017)

VESICOURETERIC REFLUX Absolute indications for surgical correction of VUR include : Progressive renal injury documented failure of renal growth breakthrough pyelonephritis intolerance or noncompliance with antibiotic suppression Ashcraft Pediatric Surgery 6E. 2014

VESICOURETERIC REFLUX Relative indications for correction of VUR are: High grade (IV–V) reflux in young children after a year of conservative follow-up Pubertal age with nephropathy at diagnosis Parental preference Failure to spontaneously resolve with watchful waiting Ashcraft Pediatric Surgery 6E. 2014

VESICOURETERIC REFLUX Goals of ureteral reimplantation include: adequate ureteral exposure and mobilization meticulous preservation of the blood supply creation of a valvular mechanism whose submucosal tunnel length to ureteral diameter ratio exceeds 4 : 1. Ashcraft Pediatric Surgery 6E. 2014

VESICOURETERIC REFLUX Ashcraft Pediatric Surgery 6E. 2014

VESICOURETERIC REFLUX The Leadbetter–Politano ureteral reimplantation Ashcraft Pediatric Surgery 6E. 2014

VESICOURETERIC REFLUX Ashcraft Pediatric Surgery 6E. 2014

VESICOURETERIC REFLUX Following open surgical or endoscopic procedures for VUR, a renal ultrasound should be obtained to assess for obstruction. Complications of surgery Persistent reflux Diverticula formation ureteral obstruction haematuria Mangement and Screening of Primary Vesicoureteral Reflux in Children. American Urological AssociationVUR Clinical Guidelines. Availible at: http://www.auanet.org/guidelines/vesicoureteral-reflux-(2010-reviewed-and-validity-confirmed-2017) Ashcraft Pediatric Surgery 6E. 2014

VESICOURETERIC REFLUX Natural History of VUR is extremely variable ranges from; spontaneous resolution without nephropathy silent scar formation recurrent pyelonephritis with hypertension and end-stage renal desease Younger children are thought to have better prognoses for resolution of VUR, particularly infant males in the first year of life. This may be due to a heightened degree of trigonal growth but the diminishing prominence of UDCs (uninhibited contractions) with age is also likely detrusor Ashcraft Pediatric Surgery 6E. 2014

Bladder/bowel dysfunction (BBD complex of symptoms The term describes children with abnormal lower urinary tract symptoms of storage and/or emptying urinary incontinence/ overactive bladder and urge incontinence/ voiding postponement, underactive bladder, and voiding dysfunction dysuria urinary tract infections (UTI), urinary frequency or infrequent voiding constipation and encopresis VINCENTS CURTSY-holding maneuver (posturing to prevent wetting Mangement and Screening of Primary Vesicoureteral Reflux in Children. American Urological AssociationVUR Clinical Guidelines. Availible at: http://www.auanet.org/guidelines/vesicoureteral-reflux-(2010-reviewed-and-validity-confirmed-2017)

VESICOURETERIC REFLUX The appropriate approach to the management of the child with VUR and BBD has not been defined, yet the child with this combination of conditions may be at greater risk of renal injury due to infection. Mangement and Screening of Primary Vesicoureteral Reflux in Children. American Urological AssociationVUR Clinical Guidelines. Availible at: http://www.auanet.org/guidelines/vesicoureteral-reflux-(2010-reviewed-and-validity-confirmed-2017)

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References Holcomb III G. W. et. Al. Ashcraft Pediatric Surgery 6E. Urinary Tract Infection and vesicoureteral Reflux. 2014. Wein. Kavoussi et al. Campbell-Walsh Urology Tenth Edition. Infection and Inflammation of the Pediatric Genitourinary Tract 2012 VUR clinical guidelines. American Urological Association. 1997 Carpenter et al. The RIVUR Trial: Profile and Baseline Clinical Associations of Children With Vesicoureteral Reflux. July 2013