1. VESICOURETERIC REFLUX

2. 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

3. 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

4. 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

5. 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

6. 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

7. GRADE 1

8. GRADE 2

9. GRADE 5

10. 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:

11. 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

12. 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:

13. 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:

14. 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:

15. 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:

16. 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:

17. 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:

18. 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:

19. 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

20. 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

21. 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

22. VESICOURETERIC REFLUX
Ashcraft Pediatric Surgery 6E. 2014

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

24. VESICOURETERIC REFLUX
Ashcraft Pediatric Surgery 6E. 2014

25. 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:
Ashcraft Pediatric Surgery 6E. 2014

26. 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

27. 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:

28. 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:

29. THANK YOU

30. References
Holcomb III G. W. et. Al. Ashcraft Pediatric Surgery 6E. Urinary Tract Infection and vesicoureteral Reflux
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