Vesicouretric reflux

causes of vur and management modalities

1. VUR Resident: Dr SD Sanyal Moderator: Lt Col MS Vinod Cl Spl Surg & Paediatric Surgeon

2. Introduction Vesicoureteral reflux (VUR) represents the retrograde flow of urine from the bladder to the upper urinary tract Galen and da Vinci: - First references to VUR by Western medicine - UVJ as a mediator of unidirectional flow of urine from the kidneys to the bladder Hutch(1952): Relationship between VUR and chronic pyelonephritis in paraplegic patients Hodson (1959):UTI and renal scarring carried a high likelihood of VUR in children

3. Inheritance & Genetics The prevalence of reflux is higher in siblings     There is a tendency for an autosomal dominant pattern of inheritance    Probably many genes are involved:   - PAX2 - GDNF-RET - UPK3 - AGTR2-ACE  

4. Anti-Reflux Mechanism Functional integrity of the ureter : - Antegrade peristalsis Anatomic composition of the UVJ : - 5:1 ratio of tunnel length to ureteral diameter in nonrefluxing junctions ( Paquin , 1959 ) Functional compliance of the bladder

5. Etiology Primary Reflux: - fundamental deficiency in the function of the UVJ - bladder and ureter remain normal - reflux occurs despite an adequately low-pressure urine storage profile in the bladder - length-diameter ratio is almost always less than that described by Paquin - inadequate tunnel length has greater implication

6. Etiology Secondary reflux: - normal function of the UVJ being overwhelmed - bladder dysfunction : congenital, acquired, or behavioral - considered secondary if absence was documented at some point before its detection

7. Etiology Anatomical causes: - PUV’s - Prostatomegaly - Ureteroceles - Ureteral duplication Neuro -functional causes: - Neurogenic bladder – Spina bifida - Infant voiding patterns - Dysfunctional voiding - Uninhibited bladder contractions - Constipation

8. International classification(VCUG)

9. Radionuclide Classification(DRCG) grade 1 = grade I of the international grading system grade 2 = grade II-III grade 3 = grade IV-V

10. Clinical features Features of recurrent UTI: - Fever - Flank pain - probability of finding VUR in children with UTI is 29% to 50% Renal failure Palpable renal mass

11. Diagnosis & Evaluation Urine microscopy & culture: - Infant: placement of an adhesive urine collection bag over the genitalia - Patients who void spontaneously : clean voided midstream catch - Topical cleansing of the area to reduce contamination and false-positive culture - Repeated catheterization for the acquisition of specimens - SPC

12. Diagnosis & Evaluation Radiographic evaluation: - Indications: children younger than 5 years all children with a febrile UTI any male with a UTI regardless of age or fever, unless sexually active

13. Diagnosis & Evaluation Imaging modalities : - USG - DRCG - VCUG - Scintigraphy

14. Diagnosis & Evaluation Other modalities: - Uroflowmetry & urodynamic studies - Cystoscopy & PI Cystogram

15. Sonography Quantitative assessment of renal dimensions : - used to monitor renal growth - impact of any intercurrent febrile episode on renal growth - need for further assessment of renal function by scintigraphy or the need for correction of reflux Degree of corticomedullary differentiation Imaging of perfusion abnormalities : - Renal resistive index measurements - Contrast-enhanced harmonic ultrasound

16. VCUG Provides information on : - functional dynamics - structural anatomy Parameters observed: Static films - bladder contour - presence of diverticula - ureteroceles - grade of reflux - configuration & blunting of calyces - bladder neck anatomy - urethral patency - intrarenal reflux

17. VCUG B. Dynamic films: - Passive/active reflux C. Delayed or postvoid films: - Crucial in documenting clearance of contrast from the upper tracts - Dilated PCS + Retained contrast = PUJO Contraindicated in active cystitis - Exceptions: In children with a h/o recurrent pyelonephritis and repeatedly negative voiding studies in the intercurrent periods

18. DRCG Radiation exposure 1% of VCUG Little anatomic detail is afforded Ideal for: - screening - monitoring the natural history - surgical follow-up of reflux Greater sensitivity in grades II to V reflux Grade I reflux into distal ureter  poorly detected

19. Scintigraphy DMSA: - detection of reflux-associated renal damage - acute pyelonephritic changes - follow-up of reflux SPECT: - 3D images

20. Uroflowmetry & Urodynamic study For establishing bladder functioning Lack of smoothness of the flow-velocity curve = incomplete relaxation of the bladder outlet during voiding delays the natural history of reflux resolution or even perpetuate reflux Increased PVRU may be a risk factor for UTI

21. Cystoscopy Routine use is not mandated Role immediately prior to surgery for confirming: - orifice position - duplication - proximity of diverticula to the orifice - urethral patency - endoscopic Mx (DEFLUX) PIC: - to detect reflux under GA in pts with febrile UTIs but a normal VCUG

22. Associated anomalies PUJ Obstruction - incidence of VUR associated with PUJO = 9% - 18% - the incidence of PUJO in patients with reflux = 0.75% to 3.6% - incidence with high-grade reflux = five times more likely than lower grades of reflux

23. Radiological findings

24. Associated anomalies 2. Ureteral duplication: - VUR is the most common abnormality associated - reflux occurs most commonly into the lower pole

25. Associated anomalies 3. Bladder diverticulae : - outpouching of mucosa between detrusor muscle bundles without any true muscle backing itself - Cause of reflux: paraureteral diverticulum large paraureteral diverticulum could expand within Waldeyer's fascia and cause ureteral obstruction/ project forward into the bladder and obstruct the bladder outlet

26. Associated anomalies 4. Renal anomalies: - Renal agenesis: 46% association - MCDK: 28% association - Presence mandates VCUG 5. Megacystis-Megaureter syndrome: - More common in males - Differentiation from PUV

27. Associated anomalies 6. Pregnancy associated reflux : - Women with hypertension and an element of renal failure are particularly at risk 7. Other anomalies: - VACTERL anomalies - CHARGE syndrome - Imperforate anus

28. Natural history Spontaneous resolution: - At birth, the probability of spontaneous resolution of primary reflux is inversely proportional to the initial grade - If a patient is encountered at a later age, resolution from any point in time forward will depend on the initial grade of reflux

29. Natural history Resolution by grade: - Most cases of low-grade reflux (grade I and II) will resolve : 63-85% - Grade III reflux will resolve in approximately 50% of cases - Higher-grade reflux (grades IV and V and bilateral grade III) : 9-25%

30. Natural history Resolution with age : - Age has greater significance than grade - Most prevalent in neonates and young children and will demonstrate the greatest tendency to resolve in this group

31. Management Principles of management: 1.    Spontaneous resolution of reflux is very common  2.    High-grade reflux is less likely to resolve spontaneously 3.     Extended use of prophylactic antibiotics & “ Watchful waiting” 4.     The success rate with surgical correction is very high

32. Treatment guidelines

33. Medical management Watchful waiting Antibiotic prophylaxis: - Amoxycillin < 2mths - Co- trimoxazole > 2mths - Alternatives: Nitrofurantoin / Pro- biotics Breakthrough pyelonephritis - indication for termination of medical mgt

34. Indications for surgery ABSOLUTE INDICATIONS : Breakthrough urinary tract infections Failure of medical management - patient noncompliance - persistance of reflux with prolonged medical management. - progressive deterioration in renal function. Ureteral obstruction assoc with VUR Refluxing ureter opening into bladder diverticulum Cystoscopic observation of golf hole orifice RELATIVE INDICATIONS : Presence of massive reflux – gr IV & V Reflux associated with paraureteral diverticulum In girls whose reflux persists after they have reached the full somatic growth potential at puberty. Parental preference

35. Surgical management The principles of surgical correction :   -   Exclude secondary reflux   - Adequate ureteral mobilization and protection of the ureteral blood supply    -   A generous submucosal tunnel should be fashioned   - Attention should be directed to angulation and twisting - Bladder tissues must be handled gently - Always consider bladder function preoperatively, as well as in all cases of persistent or recurrent reflux   - Indications for correction of reflux are the same regardless of whether the planned approach is open, endoscopic, or laparoscopic.

36. Surgical modalities Endoscopic management Ureteric reimplantation open laparoscopic SUCCESS RATE > 90% for all open surgical procedures

37. Classification According to approach : Intravesical Extravesical Combined According to the position of the sub mucosal tunnel in relation to the original hiatus : Suprahiatal Infrahiatal

38. Cohen’s Transtrigonal Intravesical , infrahiatal procedure Simple, safe and most commonly used Avoids complications of neo-hiatus formation Good for small capacity bladder Success > 95% Problem : D ifficult retrograde catheterization of ureters .

39. Cohen’s Transtrigonal

40. Surgical procedures Politano-Leadbetter : - Intravesical-Suprahiatal Glenn Anderson: - Intravesical-Infrahiatal Lich-Gregoir : - Extra- vesical

41. Endoscopic management Injection of a bio- compatible bulking agent beneath intravesical portion of ureter in sub-mucosal tunnel Elevates the intra- vesical ureter  narrowing of lumen Prevents regurgitation of urine & allows antegrade flow

42. Technique

43. Endoscopic management ADVANTAGES OPD based treatment less morbidity, no mortality No surgical scar Success rate almost equivalent to open surgery for primary reflux. DISADVANTAGES Cost Lower success rate compared to surgery for high grade reflux

44. Indications Primary reflux Secondary reflux - Dysfn voiding - Neurogenic bladder - Duplex system Failed open re-implant

45. Surgical outcomes Success rates: Open - 98 % Endoscopic – 80-89%

46. Complications Early: - Haematuria - Urosepsis Late: - Reflux: Persistant /Transient/ Contralateral - Ureteral obstruction

47. Follow up Discharged on uro -prophylaxis Monitoring of pt’s - BP - renal function - urine analysis Follow up USG and urine c/s after 1 mth VCUG after 3 mnths Discontinuation of uroprophylaxis on resolution of reflux DMSA after 1 yr

48. Thank You