Vesicoureteric Reflux- commonest cause for pediatric UTI

VESICO URETERIC REFLUX

AN OVERVIEW


Dr.B.SELVARAJ MS;Mch; FICS;

NEONATAL & PEDIATRIC SURGEON

SVMCH & RC

PONDICHERRY- 605102 INDIA

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Definition & Etiology

Pathophysiology & Clinical Features

Appropriate investigations

Management - Medical & Surgical

OBJECTIVES

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DEFINITION

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Retrograde flow of urine from bladder into upper urinary tract due to incompetent VU Junction

VUR is important because of it’s association with renal dysfunction & parenchymal scarring in UTI


General pediatric population 1 to 2% only

In children with UTI 30 to 50%

30 to 60% of children with VUR have renal scarring

Female: Male ratio= 5:1

Incidence

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Anatomy of VU Junction

Ureter continues as superficial trigone

Waldeyer’s fascia continues as deep trigone

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Paquin’s Urophysiological Law

Urophysiological Law: Submucosal tunnel ureteric length: diameter of ureter should be 5:1

If the ratio is below�Reflux

If the ratio is above�Obstruction S

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Stephen’s Ureteral Bud Theory

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ETIOLOGY

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

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Pathophysiology

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�ESRD

Reflux,UTI & Pyelonephritis scarring�Well known Triad in Pediatric urology

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VESICO URETERIC REFLUX IRSC Grading

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IRSC Grading

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Clinical Features

In Neonates & Infants usally 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 oldery chidren� Urgency, frequency and incontinence of urine

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USG abdomen

MCU or VCUG

DMSA Scan & NVCUG

Cystoscopy

INVESTIGATIONS

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USG Abdomen

Grd 5 VUR

Hydronephrosis+

Hydroureter+

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MCU or VCUG

Gd 1 VUR

Lt VUR Gd 1

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MCU or VCUG

Gd 2 VUR

Bilateral VUR Gd 2

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MCU or VCUG

Gd 3 VUR

Bilateral VUR Gd 3

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MCU or VCUG

Gd 4 VUR

Bilateral VUR Gd 4

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MCU or VCUG

Gd 5 VUR

Bilateral VUR Gd 5

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PUV with VUR

Gd 4 VUR

PUV with VUR

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Neurogenic Bladder with VUR

Gd 3 VUR

Neurogenic Bladder+

VP shunt+

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DMSA Scan

Tch99 DMSA Scan

(Dimercaptosuccinic Acid)

Renal Scarring

Differential Function

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NVUCG

Tch 99 Sulfur colloid VCUG

Grading not possible

Suitable for F/U

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Cystoscopy

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Management- Conservative

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In Gr 1,2&3 Primary VUR

Triple micturition with 2mts interval

Intermittent Antibiotics whenever surveillance culture+ve

In Gr 1,2&3 VUR with LUTO

Clean intermittent catheterisation

Eliminates residual urine & intravesical pressure

Intermittent Antibiotics whenever surveillance culture+ve

Conservatively treated patients should undergo regular VCUG to

R/o failure of treatment

Indications for Surgery

Absent intravesical submucosal tunnel� Lateral ectopic ureter

Persistent or recurrent UTI despite antibacterial prophylaxis

Progressive renal scarring

Renal growth arrest

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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 Gr 5

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Endoscopic Sting Procedure

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Principles of Antireflux Surgery

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Never a surgical emergency� so urine should be sterilised first

Intravesical ureter newly reconstructed must be compressible

It should be adequately supported posteriorly by detrusor muscle

Intravesical ureter length should be atleast 5 times it’s diameter

� Paquin’s urophysiological Law

Politano Leadbetter Operation

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Cohen’s Transtrigonal Reimplantation

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Glen Anderson Ureteral Advancement

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Lich- Gregoir Operation

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Complications after Surgery

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If ureteric hiatus in bladder wall is too wide� Paraureteric Vesical Diverticulum develops

Ureteric stenosis because of ureteric ischemia

Contralateral reflux�division of ureterotrigonal attachment on one side relaxes insertion of opposite ureter

Intravesical ureter length should be atleast 5 times it’s diameter

� Paquin’s urophysiological Law�If not followed recurrence


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TAKE HOME MESSAGE

Male children with one episode of UTI and female children with 2 or more episodes of UTI should be thoroughly investigated to rule out possibility of VUR

In children with repeated episodes of UTIs should do DMSA scan to find out the differential function of both kidneys and to rule out any renal scarring

Treatment options are conservative antibiotic prophylaxis,Endoscopic Sting Procedure or open/Laparoscopic Antireflux surgeries which sould be tailor made for each patient

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Vesicoureteric Reflux- commonest cause for pediatric UTI

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