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Vesico Ureteric Reflux

  1. Vesico-ureteric reflux is retrograde passage of urine from the bladder into the ureter. Vesicoureteric reflux may be primary or secondary.
  2. Primary vesicoureteric reflux is common in childhood, and is believed to be due to a developmental deficiency in the muscle layer of the ureterotrigonal region.
  3. Most common cause idiopathic.
  4. Other congenital causes of vesicoureteric reflux include complete ureteric duplication (reflux typically occurs into the ureter of the lower pole moiety), ectopic ureter, prune belly syndrome, and congenital periureteric diverticulum. Q
  5. Acquired causes include bladder wall oedema or fibrosis, prostatectomy, bladder neck incision, and ureteric reimplantation.
  6. It can be unilateral or bilateral.
  7. Vesicoureteric reflux may lead to renal damage by allowing reflux of infected urine from the bladder to the kidney, which results in pyelonephritis, or by allowing transmission of bladder voiding pressures to the kidneys, causing hydronephrosis and reflux nephropathy. Q
  8. Patients may present with pyelonephritis, cystitis or uraemic symptoms. Asymptomatic pyelonephritis may be discovered as an incidental finding on routine urinalysis.
  9. The incidence of vesicoureteric reflux in healthy children is under 1%, but is 20 – 50% in children with urinary tract infection. The definitive test for the diagnosis of reflux is conventional contrast cystography. Films are taken during bladder filling, during voiding and after voiding.
Grades are as follows:
  1. Grade I reflux, contrast refluxes into the ureter only, opacifying part (IA) or all of the ureter. In the latter case, the ureter may be of normal calibre (IB) or dilated (IC).
  2. Grade II reflux, contrast reaches the renal pelvis, which is not dilated. Ureteric opacification may be incomplete (IIA), incomplete with focal dilatation (IIB), or complete (IIC).
  3. Grade III reflux, contrast reaches the renal pelvis, with mild dilatation of the ureter and pelvicaliceal system (IIIA), or moderate dilatation with early forniceal blunting (IIIC).
  4. Grade IV reflux, there is moderate pelviureteroectasis, with obliteration of the forniceal angles but preservation of the papillary impressions. The forniceal angles may be partially (IVA) or completely obliterated. In the latter case, the ureter may be tortuous (IVB) and there may be extensive pelviectasis (IVC).
  5. Grade V reflux, there is moderate to severe pelviureteroectasis, with near complete (VA) or complete obliteration of the papillary impressions. The latter may be associated with severe (VB) or extreme (VC) collecting system dilatation.
  6. Reflux may also be demonstrated by voiding radionuclide cystography; it is sometimes detected by US Vesicoureteric reflux may be unilateral, bilateral or intermittent.
  7. Children with lower grades of primary vesicoureteric reflux can often be successfully managed with medical treatment, with spontaneous resolution as they grow up. Other children may require surgery.
  1. Clinical features
    1. Clinical features are those of urinary tract infection. Suspicion should be raised after a single infection in boys or two in girls.
    2. Other features include: Incontinence/ frequency/ dysuria/ abdominal pain
  2. Investigation
    1. The diagnostic investigation is micturating cysto urethrogram (MCU).
    2. DMSA or DTPA may be helpful to assess renal function and scarring.
Most sensitive investigation is radionuclides scan
  1. Complications
    1. Vesico-ureteric reflux can lead to scarring and destruction of the kidney.
Children with out renal scaring at diagnosis:
Diagnosis mode at infancy i.e. <1 yrs - all grades I - V – Anti biotics
Children 1 – 5 yrs – U/L &/or B/L grade I-IV, or U/L grade III - V – antibiotics
Children 6 – 10 yrs – U/L &/or B/L grade I-II, and U/L grade III - IV – antibiotics
  1. Treatment
    1. Nonoperative
      When reflux is related to an underlying problem such as constipation, infrequent voiding, abnormal bladder activity, or blockages such as strictures or valves, the predisposing factor should be corrected first and the reflux then re-evaluated. Mild-to-moderate degrees of reflux (grades 1 to 3) have a good chance of spontaneous resolution with age in over 80% of children. After a 1- to 2-year interval of treatment with antibiotics, reflux is reevaluated with
    2. VCUG and the kidneys with ultrasonography to be certain they are growing properly and no   interval damage has occurred. Q
      1. During the course of nonoperative management, any fever, unexplained illness, or urinary tract
      2. symptoms (burning, frequency, urgency, foul odor, bloody urine, or unusual urinary accidents) must be aggressively evaluated with urine analysis and urine culture to make certain that it is not a urinary infection.
      3. A breakthrough urinary infection, in spite of preventive antibiotics, is a dangerous situation indicating that there is not enough time for spontaneous resolution and that the next step should be surgical correction of reflux.
    3. Surgical CorrectionSurgical option of choice is Unilateral or bilateral uratric reimplantation.
      Indicatio of Sx-
      1. Persistent U/L grade IV – V or B/L III – V after antibiotic therapy.
      2. B/L grade V age 1 – 5 years.
      3. Persistent grade III – V in whom antibiotic has not kept them infection free
      4. B/L grade III – IV 6-10 yrs of age
      5. Grade V 6-10 yrs
      6. Correction of reflux (called ureteral reimplantation) is recommended for high grades of reflux, for reflux that fails to resolve on its own despite monitoring over several years, and for patients with breakthrough infections.
      7. The traditional surgical approaches have high degrees of success and usually involve opening the bladder and creating a new, longer tunnel for the ureter to pass through the bladder wall.
      8. If the ureter is very wide due to high grade reflux, it is narrowed to make a successful flap valve with at least a 4:1 ratio of tunnel length to ureter width
      9. Other alternative procedures to correct reflux are injection of bulking agent at the ureteral opening with scope and laparoscopic correction of reflux.
      10. Standard antireflux ureteral implantation procedure include Transtrigonal (COHEN Procedure), Intravesical (Lead better, Palitano)
Micturating Cysto urography
A micturating cystourogram is used to investigate:
  1. recurrent urinary tract infections in children, or a single urinary tract in a young child
  2. disturbed bladder function in adults
  3. suspected vesico-ureteric reflux
  4. Bladder diverticula
The patient is catheterized and the bladder filled with contrast. The patient is then screened whilst voiding.
penta-acetic acid - DTPA - labelled with 99m technetium can be used to image the renal tract, and is useful for functional assessment.
It is filtered the glomeruls and not reabsorbed.

Normal images
Sequential images are obtained at 5-20 second intervals over a period of 20-30 minutes. A renogram is constructed by plotting activity of the isotope against time in selected regions. Three phases are recognized:
  1. Vascular phase - a rapidly rising curve of activity due to arrival of isotope in the kidney from the bloodstream. It is usually of about 30 seconds duration. 
  2. filtration phase - a more slowly rising curve denoting concentration of isotope as it passes into the collecting system
  3. Excretory phase - a declining curve denoting that isotope is no longer being delivered to the kidney but continues to pass down the ureter
Images in disease
Characteristic patterns include:
  1. Prolonged vascular phase in renal artery stenosis. 
  2. Prolonged excretory phase in upper urinary tract obstruction. Administration of frusemide distinguishes a truly obstructed kidney from one that is hydronephrotic but not obstructed. In the latter, frusemide causes a diuresis with a rapid decline in activity.

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