Vesico ureteral reflux

1. Mohammad Ihmeidan PGY2
Campbell ,Urology 12th edition

2. Vesicoureteral reflux (VUR) represents the retrograde flow
of urine from the bladder to the upper urinary tract

3. Demography
Prevelance
The prevalence of reflux estimated to be
approximately 1–3% of children.
And estimated 30% of children under the age of 5 years who
develop a urinary tract infection (UTI) have VUR

4. Gender
More common in females (85%)
But males tend to have more severe VUR (76%)

5. Age
Even in the presence of infection or asymptomatic
bacteriuria, reflux is more common in younger patients
Incidence of Reflux in Patients with Urinary Tract
Infections
AGE (yr) INCIDENCE (%)
<1 70
4 25
12 15
Adults 5.2

6. Race
1. One difference established over several studies is the
relative 10-fold lower frequency of reflux in female
children of Africandescent.
2. In addition, reflux resolved sooner in this
population.

7. Inheritance
Sibling Reflux
Prevalence of VUR in siblings to be approximately 32%
However, the prevalence may be as low as 7% in older
siblings or as high as 100% in identical twin siblings.
This finding supports the notion that VUR can be an
inherited condition and that the genetic mode of
transmission may be autosomal dominant.

8. Genesinvolved
Probably many genes are involved:
- PAX2
- GDNF-RET
- UPK3
- AGTR2-ACE

9. FunctionalAnatomyofthe AntirefluxMechanism
 integrity of the ureter
 the anatomic composition of the ureterovesical
junction (UVJ)
 the functional dynamics of the bladder.

10. Paquin’s early dissections of the UVJ in children
revealed an approximately 5 : 1ratio of tunnel length
to ureteral diameter in non refluxing junctions
compared with a 1.4 : 1ratio in refluxing UVJs.

12. Causesof VUR
Primary Reflux:
-fundamental deficiency in the function of the UVJ
-bladder and ureter remain normal or non
contributory.
-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( ie :5:1)

13. Secondary reflux:
-normal function of the UVJ being overwhelmed
-bladder dysfunction : congenital, acquired, or
behavioral.

14. Anatomical causes:
PUV’s - The most common anatomic obstruction of
the bladder in the pediatric population is posterior
urethral valves (PUVs).
Reflux is present in 48% to 70% of PUV patients .
- Ureterocele
- Ureteral duplication

15. Neuro-functional causes:
- Neurogenic bladder– Spina bifida
- Dysfunctional voiding
- Uninhibited bladder contractions is the most common
urodynamic abnormality associated with reflux in
neurologically normal children.
In one study of 37 girls with “primary” reflux, 75%
had uninhibited contractions.
- Constipation

16. Grading of VUR

17. Radionuclide
Classification(RNC)
Low grade =grade 1-3
High grade = grade 4-5
RNC does not provide discrete images of the ureteral
and calyceal architecture required to assign reflux
grade, classifying reflux by RNC is difficult.

19. Clinical features
Features of recurrent UTI:
- Fever
- Flank pain
- pyuria.
Palpable renal mass
Delayed growth
Asymptomatic

20. Evaluating UTI
The probability of finding VUR in children with a UTI
is 29% to 50%.
For this reason, radiographic investigation for VUR has
generally been directed to children younger than 5
years old, all children with febrile UTI, and any male
with a UTI regardless of age or fever

21. Assesment of lower urinarytract
Cystographic imaging
The voiding cystourethrogram (VCUG) and
radionuclide cystogram (RNC) are the two
common forms of direct cystography and constitute
the present-day gold standard approaches to reflux
detection.

22. VCUG
Provides information on:
- functional dynamics
- structural anatomy

23. Parameters observed:
A. Static films
bladder contour
diverticula
ureterocele
 - grade of reflux
 - configuration & blunting ofcalyces
 - bladder neckanatomy
 - urethral patency.

24. B. Dynamic films:
- active reflux
C. Delayed or postvoidfilms:
- Crucial in documenting clearance of contrast from
the uppertracts
- Dilated PCS + Retained contrast =PUJO

25. Grade I- ureter only

26. Grade ii-ureter, pelvis, calyces, no dilation,
normal calyceal fornices

27. Grade iii-mild or moderate dilation and/or tortuosity of the
ureter, and mild or moderate dilation of the pelvis, but no or
slight blunting of the fornic

28. Grade IV- moderate dilation and/or tortuosity of the ureter and mild dilation of
renal pelvis and calyces; complete obliteration of sharp angle of fornices but
maintenance of papillary impressions in majority of calyces, but no or slight
blunting

29. Grade V- gross dilation and tortuosity of ureter; gross dilation of
renal pelvis and calyces; papillary impressions are no longer
visible in majority of calyces

30. Radionuclide cystogram
Radiation exposure 1% of VCUG
Little anatomic detail is afforded
Ideal for:
- screening
- monitoring the natural history of disease.
- follow-up after anti-reflux surgery
Greater sensitivity in grades II to Vreflux
Grade I reflux into distal ureter  poorly detected

31. Uroflowmetry & Urodynamicstudy
Full pressure-volume urodynamic studies of the bladder are not
required routinely in all reflux patients, a minimal survey of
bladder emptying characteristics can be obtained by
uroflowmetry.
In refluxing patients, it is important to establish whether the
bladder outlet is functioning relatively normally or harbors
more resistive characteristics .
Lack of smoothness of the flow-velocity curve shows incomplete
relaxation of the bladder outlet that delays the natural history of
reflux resolution or even promots reflux.

32. Top down approach
The top-down approach is an interesting concept based on
the notion that only clinically relevant reflux with potential
to cause renal injury is worthy of uncovering.
Only a dimercaptosuccinic acid (DMSA) renal scan is
obtained following febrile UTI, with cystography reserved
only for patients with abnormal scintigraphy.
Children with a negative DMSA require no further
evaluation unless they develop recurrent UTI, in which case a
VCUG should be obtained.

33. Cystoscopy
Routine use is NOT mandated.
Arecently developed, although still controversial cystoscopic
modality termed the PICtechnique (Positioning of the
Instillation of Contrast at the UO) purports to detect reflux
under general anesthesia in patients with a history of febrile UTI
but a normal VCUG.
Can identify :
- orifice position
- duplication
- proximity of diverticula to the orifice
- urethral patency

34. Assessmentof the upperurinary tract.
Renal Sonography
Quantitative assessment of renal dimensions :
-used to monitor renal growth
Degree of corticomedullary differentiation .

35. RenalScintigraphy
DMSA:
- detectionof reflux-associated renal damage
- acute pyelonephriticchanges
- follow-up of reflux

36. Associatedanomalies
1. 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

37. Ureteral duplication:
-VUR is the most common abnormality associated
with complete ureteral duplication.
- reflux occurs most commonly into the lower pole.
This relationship is based on the studies of Weigert
and Meyer, who documented the more lateral and
proximal insertion of the lower pole ureter
associated with a shorter intramural ureter at VUJ.

38. 3-Bladder diverticulae:
- Outpouching of mucosa between detrusor muscle
bundles without any true muscle backing itself
-paraureteral diverticulum
>causes reflux
4.Renal anomalies:
- Renal agenesis
- Multicystic dysplastic kidney )MCDK(

39. Natural history andmanagement
Spontaneous resolution:
-At birth, the probability of spontaneous resolution of
primary reflux is inversely proportional to the initial
grade

40. Resolution bygrade:
-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 Vand bilateral grade III) :
9-25%

41. Resolution with age :
-Age has greater significance than grade
-Most observed in neonates and young children and will
demonstrate the greatest tendency to resolve in this group
The study by Skoog and colleagues (1987) observed that
30% to 35% of subjects resolved their reflux each year.
Younger patients (<12 months old) resolved more quickly,
The traditional period of observation for resolution is 5
years, probably because the greatest proportion of growth
and anatomic remodeling of the UVJ is complete.

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

43. “watchful waiting” while maintaining urinary
sterility through the judicious use of single daily low-
dose antimicrobial prophylaxis.
Often, antibiotics are given as once per day and
preferably at night.
Nighttime dosing allows for antibiotic concentration
in the bladder urine over the longest period .
Breakthrough febrile UTIs or pyelonephritis while on
antibiotic prophylaxis are generally considered an
indication for termination of watchful waiting and
correcting the reflux

44. Once the radiographic resolution of reflux has been
documented,antibiotic prophylaxis is terminated,
usually a few days after the cystogram.
This also is the precise time for reinforcing a lifelong
adoption of good toileting and bladder behaviors.

45. Surgicalmanagement
ABSOLUTE INDICATIONS :
 Breakthrough urinary tractinfections
 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

46.  RELATIVE INDICATIONS :
Presence of massive reflux –IV&V
Reflux associated with paraureteral diverticulum
In girls whose reflux persists after they have
reached the puberty.
Parental preference

47. The principles of surgical correction :
- Exclude secondary reflux
- Adequate ureteral mobilization without tension and protection
of the ureteral bloodsupply
- Agenerous submucosal tunnel should be fashioned
- Attention should be directed to prevent angulation and twisting
- Bladder tissues must be handled gently
-attention to muscular backing of ureter to achieve effective
anti- refux mechanism.
-creation of submucosal tunnel that satisfy 5:1 ratio of length and
width recommended byPaquin.
-

48. Follow up
Discharged on uro-prophylaxis
Monitoring of pt’s
- BP
- renal function
- urine analysis
Follow up USG and urine c/s after 6-12 weeks.
VCUG after 3mnths
Discontinuation of uroprophylaxis on resolution of reflux
DMSA after 1yr (notmandatory)

49. complications
Persistent Reflux.
Early reflux following ureteroneocystostomy is usually not a
significant clinical problem and commonly resolves by 1year on
repeat cystography.
Contralateral reflux
Seen in 5-11%cases
There was no difference noted among the various surgical
techniques, but there was a significant trend toward development
of contralateral reflux with the higher grades of ipsilateral
corrected reflux and correction of reflux in duplex systems.

50. Prophylactic bilateral reimplantation for unilateral
reflux, to avoid contralateral reflux, is not warranted
on the basis of the high spontaneous resolution rates.
Obstruction
Due to odema , clot ,twisting or kinking of ureter.
Diagnosis made by USG showing severe HDUN.
PCN or stenting has to be done.
Redo surgery may be required

51. Endoscopicmanagement
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

53. ADVANTAGES
Less morbidity, no mortality
No surgical scar
DISADVANTAGES
Cost
Lower success rate compared to surgery for high
grade reflux

54. Agents used for Endoscopic Correction of Vesicoureteral Reflux
Nonautologous Materials
Polytetrafluoroethylene (PTFE)
Cross-linked bovine collagen
Polydimethylsiloxane
Dextranomer hyaluronic copolymer (Deflux)
Coaptite
Autologous Materials
Chondrocytes
Fat
Collagen
Muscle

55. Deflux
DX/HA is biodegradable, the carrier gel is reabsorbed
DX/HA loses about 23% of its volume beyond 3 months of
follow-up
It is currently the preferred agent for endoscopic correction in
most centers.

56. PolytetrafluoroethylenePaste
(TeflonPaste)
Teflon paste is relatively inexpensive; it is viscous
Less used now because of concerns regarding distant
migration of the PTFE particles.
Malizia demonstrated in experimental studies that the
particles can migrate to regional lymph nodes and to
Distant organs including the lung and the brain

57. Polydimethylsiloxane (Macroplastique)
Polydimethylsiloxane (PDS) is a solid silicone
elastomer that has been used as a soft tissue bulking
agent.
The main advantage of PDS is that it is a permanent
material that remains well encapsulated, causing
minimal local inflammatory changes.

58. Thank You