1. 臨床情境個案教學 膀胱輸尿管逆流
郭士銘 醫師
三軍總醫院 外科部 小兒外科

2. Case Summary
A 1 year-old boy with high fever 39.5℃ and irritable crying on urination for one day.
Full term with NSD, no any systemic disease or major operation history.
No URI or AGE symptoms.
2018/6/16

3. 單兵該如何處理？
2018/6/16

4. Physical examination: Right-sided flank knocking pain (+)
Blood routine:
WBC: N/L:87/10
Urine routine:
WBC:50-60/HPF, Nitrite:(+)
2018/6/16

5. Possible Problems
A. Acute UTI.
B. Acute pyelonephritis.
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6. Next… Admission for empire IV antibiotic treament.
Check urine culture.
Discharge after well-controlled condition and OPD follow up
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7. At OPD… A. Check urine routine. B. Prophylactic oral antibiotics.
C. Image study.
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8. VCUG
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9. Treatment Gr.I~II : antibiotic prophylaxis
Gr.III~IV : surgery if recurrent UTI or renal function decrease > 10% or proceeding renal scarring
Gr.V : surgery

10. 2018/6/16

11. Surgery
Extravesical: Lich-Gregoir (1964) and Hodgson’s modification (detrusorrhaphy)
Intravesical: Politano-Leadbetter (1958), Paquin (1959), Hutch (1963), Glenn-Anderson (1967), Cohen (1975)

12. STING procedure
1984 O’Donnell & Puri - endoscopic injection of Teflon submucosally below and behind the ureteral orifice.
Teflon → Collagen → Deflux ™ (Dextranomer/Hyaluronic acid copolymer )

13. 2018/6/16

15. 2018/6/16

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18. 謝謝
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19. 2018/6/16

20. Introduction 17%~40% UTI with vesicoureteral reflux.
Resultant pyelonephritis.
Renal scarring, proteinuria, secondary renal hypertension, end-stage renal disease (ESRD).

21. Incidence 1%~3% in children. 8%~45% familial heritage.
Girl > boy, but boy > girl in Taiwan

22. Clinical manifestrations
Fever, fatique, anorexia, vomiting; dysuria, frequency, urgency, hematuria, flank pain.
Renal hypertension, chronic renal failure

23. Diagnosis Abdominal Sonography Intravenous urography (IVU+PV)
Void-cystoureterogram (VCUG)
DMSA renal scan

24. Pathophysiology Anti-reflux mechanism:
Angulation of ureter at vesical hiatus
Submucosal tunnel length : ureteral diameter = 4~5 : 1
Sufficient detrusor muscle support

27. Indications Grade II~IV of reflux Bladder neck incontinence
Alternative of antibiotic prophylaxis

28. Protocol
1st Sting → Renal Sonogram (6 wks) → VCUG (12 wks) → 2nd Sting
Usually limit to 2 injections, but have occasionally done 3
Sucess rate > 70%

29. Advantage
Minimal invasive
No hospitalization
Minimal side effects

30. Parental preference Endoscopic treatment: 80%
Antibiotics prophylaxis: 5%
Open surgery: 2%
Could not decide: 13%
- Capozza N, et al. BJU International 92:285-8, 2003

31. 謝謝
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