VESICOURETERAL REFLUX

By | 30 March 2021

VESICOURETERAL REFLUX

Normally, some mechanisms allow the urine to be expelled from the bladder in one direction during urination. Vesicoureteral reflux is referred to as a part of urine to escape towards the ureter and/or kidneys during urination due to malfunctions in this mechanism due to any reason.

The most common cause of renal failure in our country is still urinary tract infections due to vesicoureteral reflux.

How is VUR disease diagnosed?

Vesicoureteral reflux often presents with febrile urinary tract infection or prenatal hydronephrosis. The diagnosis is made during the evaluation made for urinary system infection. The first evaluation test performed on a child with urinary tract infection is urinary ultrasonography. The most important test that gives the most important information in a child with suspected VUR is the X-ray taken during the introduction of a stained fluid with the help of a thin catheter into the bladder called voiding cystourethrography or voiding cystourethrography.

In the figure, in voiding cystography, the escape of opaque material into the bladder from the ureter (the channel connecting the kidney to the bladder) towards the kidney is seen from the 1st to 5th degrees (from left to right).

The preferred method for determining kidney function and damage to kidney tissue is DMSA, or kidney scintigraphy. With the joint use of voiding cystography (voiding cystourethrography) and DMSA renal scintigraphy, an estimate of the natural course of reflux can be made.

How common is VUR?

Reflux is seen in only 1-2% of all children, but 25-40% of children with kidney inflammation have reflux. There is accompanying reflux in 17-37% of kidney swelling (hydronephrosis) detected before birth. Therefore, it should be recommended that every child with a febrile urinary tract infection should be screened for reflux.

Vesicoureteral Reflux Grading:

Grade 1: Contrast material that fills the bladder only reaches the distal part of the ureter during urination. This degree of VUR constitutes 8% of all cases.

Grade 2: Contrast material goes up to the renal calyxes. However, there is no dilatation in the urinary system. 37% of the cases are at this stage.

Grade 3: Despite moderate dilatation in the ureter, renal pelvis, and calyxes, the renal calyces are not blunted yet. 25-37% of the cases are in this group.

Grade 4: In addition to dilatation in the ureter, renal pelvis, and calyces, the renal calyxes are blunted. 14-24% of the cases are in this group.

Grade 5: There are advanced hydroureteronephrosis and a curved ureter on the side of reflux. 5% of the cases are in this group.

VUR Treatment

The basis of the treatment is based on early diagnosis and close follow-up, and in this way, it is aimed to protect the kidney tissue. Since the reflux can pass by itself as the child grows, the first step in treatment is to encourage all patients to drink high amounts of fluid until they reach the age of one, ensuring complete emptying of the bladder and preventing infections with low-dose antibiotic protection. In this period, circumcision of male babies is recommended as a preventive measure against infection.

Vesicoureteral reflux (VUR) can pass by 50% within the first 2 years. In cases where it is necessary, successful VUR treatment can be performed by 85% in experienced hands by endoscopically injecting some special filling materials into the urinary tract. However, the situation is slightly different in children presenting with a febrile urinary tract infection. The degree of reflux, the age of the child, and the level of kidney damage are important in deciding treatment. The level of damage in the kidney can be measured numerically and visually with nuclear medicine examination (static renogram – DMSA). Usually, it resolves spontaneously until the age of 5, depending on the degree of vesicoureteral reflux. Close follow-up and treatment of urination disorder, if any, accelerate this process even more.

When is surgical treatment required in vesicoureteral reflux?

Continuing bacteriuria despite grade IV and grade V reflux antimicrobial therapy

• Presence of diseases causing secondary vesicoureteral reflux (such as bladder diverticulum, ureterocele, ureter duplication)

Nephralgia (flank pain due to reflux)

Stopped kidney growth, increased kidney damage, and/or scarring

Poor medical treatment

Advanced age reflux

• Children with damaged kidneys, high-grade reflux, and over 5 years old usually need surgical treatment.

Surgical correction of reflux can be performed by endoscopic, robotic, laparoscopic, or open surgery. The gold standard of surgical treatment is that the urinary tract is stitched back into the bladder in a new way. Children have to stay in the hospital for at least one night after the operation. The success rate in experienced hands is over 95%. The endoscopic treatment that has emerged in recent years is the injection of a special silicone-like substance into the urinary tract with leakage. With this method called STING, the success rate is between 60 and 85%, even if the child returns to his home or school immediately after the procedure. STING can be tried twice and if no results are obtained, the classical surgical method should be preferred instead of more sessions.

It has been shown that reflux is inherited. Reflux has been detected in 30% of children with reflux in their siblings, and in 70% of children with reflux in their parents. For this reason, siblings and future children of children with renal reflux should also be evaluated in terms of reflux.