Vesicoureteral reflux Jabbari A, MD Tabriz University of Medical Sciences

روشهای بررسی ریفلاکس اهداف درس: آشنایی با ریفلاکس ادراری در کودکان نحوه برخورد با بیماران ریفلاکس روشهای بررسی ریفلاکس درمان ریفلاکس روش ارزیابی : تئوری بیشتر بصورت MCQ عملی بصورت استفاده از فرمهای Logbook

Definition Vesicoureteral reflux (VUR) represents the retrograde flow of urine from the bladder to the upper urinary tract.

Prevalence The prevalence of reflux was estimated 30% for children with UTI and 17% without infection. Reflux may be present in up to 70% of infants who present with UTI. In infancy VUR in male > female. In childhood VUR in female > male. Reflux is relatively uncommon in adult males.

Reflux in female children of African has 10-fold lower frequency . Prevalence of VUR in siblings is 32%, or as high as 100% in identical twins. Genetic mode of transmission may be autosomal dominant.

Etiology Primary Reflux Congenital defect in the structure and therefore function of the UVJ. Secondary Reflux Obstructional voiding etiologies: - The most common anatomic obstruction of the bladder in the pediatric population is PUV. - The most common structural obstruction is ureterocele.

Grading of Reflux

Diagnosis and Evaluation of Vesicoureteral Reflux The high repeat UTI rate after a first UTI has prompted a recommendation for some form of VUR work-up. Radiographic investigation for VUR: children younger than 5 years old all children with a febrile UTI Any male with a UTI regardless of age or fever, unless sexually active

The mainstay of renal imaging in VUR management is ultrasonography. - Ultrasound lends to quantitative assessment of renal dimensions, which can be used to follow renal growth over time. - Ultrasonography also images the degree of corticomedullary differentiation in the kidney. The gold standard for imaging functioning renal parenchyma is scintigraphy using DMSA.

Pathophysiology of Acquired Scarring Renal scarring is a sequela of infectious pyelonephritis. Reflux facilitates the ascension of microorganisms from the bladder to the kidneys. The greatest risk for postinfectious renal scarring occurs within the first year of life Patients younger than 4 years are more prone to developing scarring after a single UTI than older children

complications HTN Impaired Renal Growth Renal Failure and Somatic Growth

Associated Anomalies and Conditions Ureteropelvic Junction Obstruction The incidence of VUR associated with UPJO ranges from 9% to 18%. high-grade reflux being five times more likely to be associated with UPJO than lower grades. Ureteral Duplication VUR is the most common abnormality associated with complete ureteral duplications. Bladder Diverticula Renal Anomalies The cardinal renal anomalies associated with reflux are multicystic dysplastic kidney (MCDK) and renal agenesis Megacystis-Megaureter Association

Natural History and Management Spontaneous Resolution Most cases of low-grade reflux (grade 1 and 2) will resolve. 80% of grade 1, 2 may resolve spontaneously, Grade 3 reflux will resolve in approximately 50% of cases Diagnosis at age 5, as well as in infancy, is associated with a similar resolution rate (20% per year), regardless of age.

Principles of Management 1. Spontaneous resolution of reflux is very common. 2. High-grade reflux is less likely to resolve spontaneously. 3. Sterile reflux is benign. 4. Extended use of prophylactic antibiotics is benign. 5. Success of (open) surgical correction is very high.

Surgical Indications: Patients > 1 y/o Patients 1-5 y/o, bilateral, grade 5 with renal scar Patients 6-10 y/o bilateral , grade 3, 4 with renal scar Patients 6-10 y/o unilateral or bilateral, grade 5 with or without renal scar

Medical Management: maintaining urinary sterility through the judicious use of single daily low-dose antimicrobial prophylaxis. - For 2 m> the most commonly used medications are TMP and amoxicillin. - After 2 months of age, the antibiotic of choice becomes TMP-SMX - Nighttime single low dose Ab (1/4 dose)

Postoperative Evaluation Success rate with uncomplicated ureteroneocystostomy approaches 100%. Ultrasound is necessary at 6 to 12 weeks postoperatively. VCUG if dysfunctional bladder postoperative hydronephrosis UTI

Complications of Ureteral Reimplantation Persistent Reflux Contralateral Reflux Obstruction

Endoscopic Treatment of Vesicoureteral Reflux Antibiotics for 3 months when a follow-up ultrasound and VCUG are obtained. If reflux is persistent, a repeat injection can be considered 6 months after the initial injection. If there is still no resolution, then open surgery is recommended.