Vesicoureteral Reflux Dr. Mohamed Haseen Basha Assistant professor (Pediatrics) Faculty of Medicine Al Maarefa College of Science and Technology

Vesicoureteral Reflux Normally the long submucosal and intra vascular segment of the ureter at the ureterovesical junction closes when bladder contracts, effectively preventing VUR. VUR implies the passage of urine into the ureter and kidney during micturition. VUR is important because of it’s association with renal dysfunction & parenchymal scarring in UTI

Vesicoureteral Reflux Vesicoureteral reflux (VUR) is the retrograde passage of urine from the bladder into the upper urinary tract due to incompetent VU Junction. It is the most common urologic anomaly in children, occurring in approximately 1 percent of newborns, and as high as 30 to 45 percent of young children with UTI. 30 to 60% of children with VUR have renal scarring In neonates with antenatal hydronephrosis, the prevalence of VUR is about 15 percent. Young children and infants (< 2 years) were more likely to have VUR than older children based on the natural course of spontaneous resolution of VUR with growth in most affected patients.

Pathogenesis Primary VUR, the most common form of reflux, is due to incompetent or inadequate closure of the ureterovesical junction (UVJ). This is the most common type of VUR and is usually detected shortly after birth. Secondary VUR is a result of abnormally high pressure in the bladder that results in failure of the closure of the UVJ during bladder contraction. Secondary VUR is often associated with anatomic (eg, posterior urethral valves) or functional bladder obstruction

Classification of Vesicoureteral Reflux

Etiology of VUR Primary or Congenital Lateral ectopy of ureter Posterior urethral valve Congenital Neuropathic bladder Congenital urethral stricture Secondary or Iatrogenic Ureteral meatotomy TURP & TURT Unroofing of Ureterocele Failed ureteral reimplantation

Clinical manifestations In Neonates & Infants : Usually asymptomatic or 1 or 2 attacks of UTI - Failure to thrive Fever, chills and costovertebral tenderness in acute pyelonephritis In cases of obstruction or neurogenic bladder Palpable hydronephrotic kidney or distended bladder In old children: Urgency, frequency and incontinence of urine

Grading of VUR Grade I: VUR into a non dilated ureter. Grade II: VUR into the upper collecting system without dilation. Grade III: VUR into dilated ureter and/or blunting of calyceal fornices. Grade IV: VUR into a grossly dilated ureter. Grade V: Massive VUR, with significant ureteral dilation and tortuosity and loss of the papillary impression. Mild Moderate Severe

Risk Factors for Renal Scarring Recurrent febrile UTI Delay in treatment of acute infection Dysfunctional elimination Obstructive malformations VUR

Pathogenesis of Renal scarring in VUR VUR High pressure urine into ureters & Kidneys Stasis of urine because of postvoidal residual urine Stasis of urine good nidus for superadded infection Refluxed infected urine Pyelonehritis Renal scarring Reflux uropathy and ESRD

Diagnostic Evaluation USG abdomen MCU or VCUG DMSA Scan Cystoscopy

USG abdomen Grade V VUR Hydronephrosis and Hydroureter present

MCU or VCUG Grade I VUR – Left side

MCU or VCUG Grade II VUR – Bilateral

MCU or VCUG Grade III VUR – Bilateral

MCU or VCUG Grade IV VUR – Bilateral

MCU or VCUG Grade V VUR – Bilateral

PUV with VUR Neurogenic Bladder with VUR

DMSA Scan (Dimercaptosuccinic Acid) Renal Scarring Differential Function

Cystoscopy

Treatment of VUR Goal : to minimize infections, renal injury and other complications of reflux. In newborn & infants, prophylactic antibiotics. In older children, bowel and bladder management. Good perineal hygiene, and timed and double voiding are also important aspects of medical treatment. Bladder dysfunction is treated with the administration of anticholinergics.

American Urology Association treatment algorithm of VUR. VUR: vesicoureteric reflux; NASHA/Dxgel: non-animal stabilized hyaluronic acid/dextranomer gel.

Endoscopic injections Deflux is a gel that is used in endoscopic injections to treat VUR. Deflux consists of two types of sugar-based molecule called dextranomer and hyaluronic acid. Both materials are also biocompatible, which means that they do not cause significant reactions within the body. Hyaluronic acid is produced and found naturally within the body.

Surgical Management Indications for Surgery Poor patient & parental compliance with non op treatment Persistent ipsilateral reflux following corrective surgery Failure of submucosal tunnel growth for 2 to 4 yrs Intra Renal Reflux Grade IV Progressive renal scarring Persistent or recurrent UTI despite antibacterial prophylaxis There are three types of surgical procedures Endoscopic (STING/HIT procedures) Laparoscopic Open procedures (Cohen procedure, Leadbetter-Politano procedure).

Follow up Annual evaluation Blood pressure Weight, Height VCU Urine culture

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