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Vesicoureteral reflux

Done By : Khalid Al-Qudsi
Faisal Burghal
Supervised by : Dr. Osama Bani Hani

  .Difinition  Vesicoureteral reflux (VUR) is an abnormal backward movement of urine from the bladder into ureters or kidneys ( Upper urinary tract).

Why Vesicoureteral reflux Is a problem ?  Acute Pyeloneohritis  Multiple  Renal UTIs Scarring  Subsequent  Decreased  End-stage hypertension renal function renal disease (ESRD) .

the prevalence of VUR is about 15 percent .Epidemiology  It is the most common urologic finding in children  Occurring in approximately 1 percent of newborns  In 30 to 45 percent of young children with a urinary tract infection (UTI)   In neonates with prenatal hydronephrosis.

The failure of this anti-reflux mechanism is due to the shortening of the intravesical ureter. Paraureteral . which contains a segment of the ureter within the bladder wall (intravesical ureter).The intravesical ureter length may be genetically dictated. Lateral displacement of the ureteral orifice.Etiology: Primary VUR :     The most common form of reflux. Other Causes : Absence of adequate detrusor backing. which may explain the increased incidence in family members of patients with VUR. Often Unilateral It is due to incompetent or inadequate closure of the ureterovesical junction (UVJ).

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..g. Often associated with anatomic (e. posterior urethral valves) or functional bladder obstruction (e.g. The management of secondary VUR is focused on treating the primary abnormality with the rare need for direct surgical correction of the VUR .Secondary VUR:      Result of abnormally high pressure in the bladder that results in failure of the closure of the UVJ during bladder contraction. dysfunctional voiding and neurogenic bladder) Often Bilateral The degree and chronicity of obstruction can influence the severity of VUR.

 Grade II – Reflux fills the ureter and the collecting system without dilation  Grade III – Reflux fills and mildly dilates the ureter and the collecting system with mild blunting of the calyces.Grading   The International Reflux Study Group (IRSG) developed a classification system that grades the severity of VUR based upon the degree of retrograde filling and dilation of the renal collecting system demonstrated by VCUG  Grade I – Reflux only fills the ureter without dilation. Some tortuosity of the ureter is also present. All the calyces are blunted with a loss of papillary impression and intrarenal reflux may be present.  Grade IV – Reflux fills and grossly dilates the ureter and the collecting system with blunting of the calyces. . There is significant ureteral dilation and tortuosity.  Grade V – Massive reflux grossly dilates the collecting system.

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Clinical Features  The clinical course and outcome vary depending upon whether VUR presents prenatally or postnatally. it is detected after screening of family members . and less commonly.  Prenatal presentation — The presence of VUR is suggested by the finding of hydronephrosis on prenatal ultrasonography  Postnatal presentation — Postnatal diagnosis of VUR usually is made after a UTI.

 Older children  Infection causes symptoms such as fever.  Blood in the urine (haematuria) and/or pus in the urine (pyuria). pain. unpleasant smelling urine and a burning sensation when urinating.  Other symptoms commonly experienced include:  Bedwetting (nocturnal enuresis). . These occur when infection of the urinary tract (UTI) is present.Signs and symptoms   Vesicoureteral reflux in itself does not produce any symptoms.  Lower abdominal pain.

flank masses. persistent high fever.In neonate  irritability. and listlessness. renal failure. failure to thrive. and urinary ascites. . the neonate could present with respiratory distress. In cases of VUR and febrile UTI associated with a serious underlying urinary tract abnormality.

urea S.Investigation  Urine R/E  Urine C/S  B. creatinine  X-ray KUB  USG-KUB  IVU Simple cystography  MCUG Voiding cinefluoroscopy  Radionuclide scan .

Diagnosis  The diagnosis of vesicoureteral reflux (VUR) is based upon the demonstration of reflux of urine from the bladder to the upper urinary tract by either contrast voiding cystourethrogram (VCUG) or radionuclide cystogram (RNC). The VCUG provides greater anatomic detail but there is increased radiation exposure with VCUG .

 In the larger of the systematic reviews conducted by the American Urological Association (AUA). prenatal hydronephrosis was defined as a renal pelvic diameter (RPD) ≥4 mm during the second trimester and ≥7 mm during the third trimester .

.Ultrasound Scanning:  The bladder and kidneys are scanned to survey the anatomy and assess for any irregularities.

position and function and check for scarring of the kidneys as the result of repeated UTI’s.DSMA Renal Scan:  Pictures of the kidneys are taken with a specialised scanner following the injection of a weak radioactive solution (radioisotope) into the bloodstream via a drip in the hand or arm. The pictures taken by the scanner can assess kidney size.  .

antibiotic prophylaxis).Management  THERAPEUTIC INTERVENTIONS is principally based upon the following :  Identification of children with VUR  Prevention of pyelonephritis  Prevention of further renal damage resulting from infection and inflammation  Minimization of morbidity of treatment and follow-up  Identifying and managing children with bladder and bowel dysfunction  Therapeutic interventions include medical therapy (ie. and surgical correction .

antibiotic prophylaxis) are presented to the family. renal scarring. In our practice. We suggest all children with grades III through V reflux be treated because they are at greatest risk for recurrent UTI.  Children with grade I to II reflux are at the lowest risk for renal scarring. the different treatment options of observation or medical therapy (ie. We do not suggest surgical correction in these patients . which plays a major role in the final therapeutic decision. and hypertension.

MEDICAL TRETMENT (Indications)  Unilateral reflux  Lower grades of reflux  Earlier age at presentation  Male gender .

It is based upon the observation that reflux will spontaneously resolve in most cases. and the assumptions that use of continuous antibiotics results in sterile urine and the continued reflux of sterile urine does not cause renal infection  .MEDICAL TRETMENT Consists of daily prophylactic administration of antibiotics.

Adverse effects of sulfonamides. One daily dose is administered at bedtime. or nitrofurantoin . The dose is onehalf to one-quarter the usual therapeutic dose for treating an acute infection. or nitrofurantoin preclude their use in infants less than two months of age . except in infants below two months of age. trimethoprim. trimethoprim alone. Amoxicillin and cephalosporins are not recommended because of the increased likelihood of resistant organisms . Antimicrobial agents most commonly used for prophylaxis include trimethoprim-sulfamethoxazole .

Surgical treatment    Surgical treatment corrects the anatomy at the refluxing ureterovesical junction.  The two surgical approaches used are open surgical reimplantation and endoscopic correction .

with reported correction rates of 95 to 99 percent regardless of the severity of VUR  In open reimplantation. thereby creating a submucosal tunnel . the bladder is opened (intravesical approach) and the ureters are reimplanted by tunneling a ureteral segment through the detrusor (bladder wall muscle). Alternatively.Open surgical reimplantation  Highly successful procedure. . reimplantation can be done without opening the bladder (extravesical approach).

thereby correcting reflux  The success rate for correcting VUR by STING in one or more procedures ranges from 75 to almost 100 percen . beneath the mucosa of the ureterovesical junction through a cystoscope. This injection changes the angle and perhaps fixation of the intravesical ureter. such as dextranomer/hyaluronic acid (Dx/HA or DEFLUX).Endoscopic correction   Subureteric transurethral injection (STING procedure). he procedure involves injecting a copolymer substance.

Thank You .