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

2. 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

3. 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.

4. 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

5. Classification of Vesicoureteral Reflux

6. 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

7. 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

8. 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

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

10. 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

11. Diagnostic Evaluation
USG abdomen
MCU or VCUG
DMSA Scan
Cystoscopy

12. USG abdomen
Grade V VUR
Hydronephrosis and Hydroureter present

13. MCU or VCUG
Grade I VUR – Left side

14. MCU or VCUG
Grade II VUR – Bilateral

15. MCU or VCUG
Grade III VUR – Bilateral

16. MCU or VCUG
Grade IV VUR – Bilateral

17. MCU or VCUG
Grade V VUR – Bilateral

18. PUV with VUR Neurogenic Bladder with VUR

19. DMSA Scan (Dimercaptosuccinic Acid)
Renal Scarring
Differential Function

20. Cystoscopy

21. 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.

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

23. 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.

24. 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).

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

26. Thank you