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VESICOURETERIC REFLUX VUR
Category: Pediatric Surgery
Abstract : Vesicoureteric reflux (VUR) Definition : VUR results from abnormal retrograde flow of urine from the bladder into the upper urinary tract. Epidemiology Overall incidence in children is >10%; younger > older; girls > boys (female:male ratio 5:1); Caucasian >Afro-Carribean. Siblings of an affected child have a 40% risk of reflux, and routine screening of siblings is reco
Vesicoureteric reflux (VUR)
Definition :
VUR results from abnormal retrograde flow of urine from the bladder into the upper urinary tract.
Epidemiology
Overall incidence in children is >10%; younger > older; girls > boys (female:male ratio 5:1); Caucasian >Afro-Carribean. Siblings of an affected child have a 40% risk of reflux, and routine screening of siblings is recommended.
Pathogenesis
The ureter passes obliquely through the bladder wall (1 - 2cm), where it is supported by muscular attachments which prevent urine reflux during bladder filling and voiding. The normal ratio of intramural ureteric length to ureteric diameter is 5:1. Reflux occurs when the intramural length of ureter is too short (ratio <5:1). The degree of reflux is graded I - V . The appearance of the ureteric orifice changes with increasing severity of reflux, classically described as stadium, horseshoe, golf-hole, or patulous.
Classification
Primary reflux (1%) results from a congenital abnormality of the ureterovesical junction.
Secondary reflux results from urinary tract dysfunction associated with elevated intravesical pressures creating damage to the vesicoureteric junction. Causes include: posterior urethral valves (reflux seen in 50%); urethral stenosis; neuropathic bladder; detrusor sphincter dyssynergia.
VUR is also seen with duplex ureters. The Weigert - Meyer rule states that the lower pole ureter enters the bladder proximally and laterally, resulting in a shorter intramural tunnel which predisposes to reflux.
Complications
VUR associated with UTI can result in reflux nephro pathy with hypertension and progressive renal failure.
Presentation
Symptoms of UTI, fever, dysuria, suprapubic or abdominal pain, failure to thrive, vomiting, diarrhoea.
Investigation
- Urine analysis and culture to diagnose UTI
- Urinary tract ultrasound scan and micturating cystourethrogram (MCUG) to diagnose and grade reflux and establish reversible causes
- Urodynamics if suspicious of voiding dysfunction
- DMSA to detect and monitor associated renal cortical scarring.
Management
Correct problems contributing to secondary reflux. The majority of primary VUR grade I - II will resolve spontaneously (~85%), with 50% resolution in grade III. A period of observation with medical treatment is therefore initially recommended.
Medical treatment
Low-dose antibiotic prophylaxis should be given to keep the urine sterile and lower the risk of renal damage until reflux resolves. Anticholinergic drugs are given to treat bladder overactivity.
Surgery
Indicated for severe reflux, breakthrough UTIs, evidence of progressive renal scarring, and VUR that persists after puberty. Techniques include laparoscopic repair and open ureteric re-implantation (98% success).
- Intravesical methods involve mobilizing the ureter and advancing it across the trigone (Cohen repair) or reinsertion into a higher, medial position in the bladder (Politano - Leadbetter repair).
- Extravesical techniques involve attaching the ureter into the bladder base and suturing muscle around it (Lich - Gregoir procedure).
- Alternatively, endoscopic subtrigonal injection (STING) of collagen into the ureteric orifice has 70% success, rising to 95% with repeated treatments.
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