Vesicoureteric Reflux leading to nephropathy

Vesicoureteric Reflux leading to nephropathy

1. Introduction The vesicoureteral reflux represent the retrograde reflux of urine from the bladder back into ureter , pelvis and collecting sytem . Under normal circumstances the ureterovesical junction prevents reflux of urine , particularly at the time of voiding .

2. Anatomy In order to under stand the causes of VUR , the Knowledge of anatomy of ureterovesical junction is compulsory . It comprises of two parts Mesodermal Endodermal

3. Mesodermal 1. Ureter and Superficial Trigone : The smooth musculature of renal calyces , pelvis and extravseical ureter is composed of helical oriented fibres that allows the peristalsis, as the ureter adnvances towards the bladder the fibres becomes longitudinal , and joins the same fibres of opposite side and form the roof and superficial trigone that moves caudally, passes over the neck of bladder and attaches at verumontanum in males and inside the external urethra in females. 2. Waldeyers sheath and deep trigone : 2 to 3 cm above the bladder an external layer of smooth muscle fibres surrounds the ureter and passes through the vesical wall , its roof fibres diverge with its floor fibres and connects the contralateral side to form deep trigone , which ends at the bladder neck .

4. Endodermal The vesical detrusor muscles bundles are intertwined and converge on internal orifice and becomes oriented into 3 layers. Internal longitudinal : it continues into the urethra submucosally , upto caudal part of prostate in males and just beneath the external urethra in females. Middle circular : it is thickened anteriorly and ends at bladder neck. Outer longitudinal : The muscle bundles of outer longitudinal layer take a circular and spiral course at the external surface of female urethra and incorporated in peripheral prostatic tissue in male . It constitutes true vesicourethral sphincter .

5. Aetiology Primary causes ( anatomical deficiencies ) Congenital UVJ incompetence: discordant trigone induced closure of UVJ. Ureteral abnormalities A)Ureteral duplication : The ureter to lower renal pole is abnormally short and incompetent. B)ectopic ureteral orifice : abnormal orifice opening at trigonal , vesical neck or in urethra . C ) ureterocele : ureterocele involving single ureter rarely cause reflux, however ureterocele involving upper pole ureter causes moderate dilation of intra mural part of ureter which results in dilation of ureteral hiatus .

6. Secondary causes Bladder and bowel dysfunction : Abnormal Voiding habbits causes reflux. Inhibition of urge to void causes , abnormal high pressure voiding , bladder overactivity and poor bladder compliance. Functional constipation also deteriorate the bladder function and causes reflux. Functional constipation plus LUTS is known as BBD. High pressure voiding : High pressure voiding conditions such as , neurogenic bladder , trabeculated bladder , interstitial cystitis , tuberculosis , carcinoma , schistosomiasis and radiotherapy , all causes reflux. Hostile bladder after cystitis : due to edema of trigon , ureterovesical complex , which alleviate after treatment of infection . Pregnancy: Females of childhood reflux and UTIS , may have VUR during pregnancy due to hormonal induced loss of tone of ureterovesical comolex . Prune Belly syndrome : B/L cryptorchidism and failure of normal development muscles of abdominal wall , ureter and bladder .

7. Epidemiology 25 to 40% of children having UTIS and 8% of adults with bacteriuria have VUR . VUR is estimated 27% in siblings and 36% in offsprings of diagnosed person . After 1 year of age females have twice as likely to be found haing VUR as compared to males .

8. Clinical findings Signs and smptoms : Presents in one of two ways , prenatal Hydronephrosis yor UTIs , otherwise patient is as asymptomatic. Infants presents with failure of thrive , lethargic , vomiting, diarrhea and poor appetite . Children presents with high grade fever , chills , anorexia , nausea , vomiting and LUTS ( Dysuria , urgency, haematuria )

9. Physical examination Reflux without UTI has no findings . In presence of UTI s / Pyelonephritis , supra pubic and costovertebral angle tenderness noted . All patients should ne evaluated for secondary causes , phimosis , uncircumcised children has folds high chances of UTI s . All children should be evaluated for spinal dimpling , spina bifida and Hypertension.

10. Investigations Laboratory findings : Serial Urine complete monitoring is not recommended unless the patient has febrile UTI . HOWEVER , urinalysis for proteinuria along with RFTS is recommended if there is bilateral cortical abnormalities or suspected renal failure . Radiology: Imaging Is mainstay for diagnosis and screening . Renal bladder Ultrasound : it is most common modality. All children under 2 years of age having febrile UTI should have RBU. Voiding Cystourethrogram is gold standard in diagnosis and categorization of grade of reflux

11. Management Medical Treatment Antibiotics for febrile UTI s as well as Contiuous Antibiotic prophylaxis with amoxillin and trimethoprim- sulfamethoxazole In half doses has approved decrease the onset of recuurent UTIs and renal scarring . Patients with Bowel bladder dysfunction are high risk for UTIs and renal damage , treated with Behavioral therpy , Anti cholinergics and laxatives .

12. Evaluation of medical treatment Cystograms ( 12 to 18 months apart ) Periodic RBU Radionucleotide scan ( DMSA ) to check the renal scarring and comparison with the first scan to check progression of disease . (

13. Surgical Treatment Indications Recurrent UTIs / Pyelonephritis Medical non adherence Breakthrough infections with resistant bacteria .

14. Types of surgery Endoscopic Treatment : use of biocompatible material Deflux ( dextranomer and hyaluronic acid ) is injected in submucosal part of ureteric orifice , which causes coaptation of ureteric orifice and intramural ureter . 2) Temporary urinary diversion : Patients , typically infants , who have recurrent UTI s and high grade VUR get benefit from vesicostomy . This allows somatic growth along with bladder growth and anatomical parameters , which increase the success of ultimate ureter reimplantation . 3) Ureteral Reimplantation ( 95 to 100% success rate )

15. Open procedures Cohen Cross trigonal : It is simple , common and safe , however there is difficulty in assessing the ureters endoscopically when child is old . Politano-Leadbetter technique : it includes supra hiatal reimplantation Glen –Anderson technique : Infra hiatal reimplantation . Lich Gregoir extra vesical approach : it should be use when there is one sided VUR , because risk of urinary retention if B/L vur repair done by extravesical approach .

16. Recommendations

17. Natural History 80% resolution after 5 years in patients with Grade 1& 2 VUR. 30-50% resolution after 5 years in patients with grade lll to V.

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