Vesicoureteral reflux: A new treatment algorithm (original) (raw)

2018

It is still unclear what the exact aetiology is behind VUR. The basis for VUR is considered to be primarily genetic, with a 30-50% incidence of VUR in first-degree relatives of patients. A metanalysis of articles in literature revealed a mean incidence of reflux in siblings in all studies as 32%. In a study on 215 index patients with VUR, the incidence of sibling VUR is maximal in patients who are younger than 3 years. The study recommends screening all siblings who are younger than 3 years of index patients with high grades (III to V) of VUR.

Vesicoureteral reflux: biophysical laws and voiding disfunction (comment)

Some simple mathematical formulae to calculate the volumes of proximal pyeloureteral reflexive systems are presented, and the results are compared to bladder capacity values. Using the results of the calculi, the author discusses possible implications of severe urinary sequestration in the pyeloureteral systems. Using geometrical and topological approximations we calculate the volumes of ureters and renal pelvises, applying in vivo measurements obtained from conventional ultrasound, retrograde cystourethrograms and topographic anatomic references. Approximations use 2 decimals and assumed π value was 3.14. Ureteral and pyelic volumes are calculated, respectively, from the mathematical formula for the cylinder and cone volumes. Dolicomegaureter are compensated using proportional calculi. Bladder volumes are estimated from conventional formulae. Proximal urinary sequestration is compared between infants and older children with VUR. Mechanisms of direct induction of bladder urodynamic failure from VUR are suggested. Sequestration of urine in the ureter and renal pelvis can be estimated from mathematical formulae in patients with VUR. The values used derive from ultrasound examinations, CUM and topographical anatomical references. Primary VUR can determine urodynamic problems. Urine sequestration in the proximal urinary system is worse in infants than in older children.

Vesicoureteral reflux: biophysical laws and voiding disfunction

The management of vesicoureteral reflux in the setting of posterior urethral valve with emphasis on bladder function and renal outcome: A single center cohort study

Urology, 2014

To represent our experience in the management of posterior urethral valves and concomitant vesicoureteral reflux (VUR). METHODS A total of 326 children with posterior urethral valve who had underwent valve ablation/bladder neck incision were studied, and those who had persistent VUR and were categorized under 3 main groups were followed up. Group 1 (n ¼ 71) received prophylactic antibiotic, group 2 (n ¼ 50) underwent Deflux injection (2 a) (n ¼ 28): Deflux injection alone, group 2 b (n ¼ 22) Deflux with concomitant autologous blood injection (HABIT), and group 3 (n ¼ 19) underwent ureteroneocystostomy before referral and was followed up conservatively. VUR resolution, incidence of urinary tract infections (UTI), and bladder function were assessed. RESULTS Mean duration of follow-up was 3.8 years; VUR resolution occurred in 66.1%, 86.0%, and 94.0% of groups 1-3, respectively (P ¼ .013). Resolution rate in group 2 b was significantly higher than group 2 a (90.9% vs 78.5%). Patients in group 2 experienced a longer UTI-free period compared with others (P <.05). Urodynamic studies demonstrated significant decrease in maximum voiding detrusor pressure and detrusor overactivity in all groups (P <.001). Children in group 3 ended up with lower compliance compared with others (P <.001). After toilet training, only 2.8%, 21.4%, 13.6%, and 27% children were diagnosed with lower urinary tract dysfunction in groups 1-3, respectively (P ¼ .027). Myogenic failure developed only in 3 boys in group 3. CONCLUSION Ablation/bladder neck incision leads to significant improvement in VUR status in part because of improvement in bladder function. After successful valve removal, conservative therapy can be regarded as the mainstay of reflux treatment, whereas HABIT is recommended for high grade VUR associated with febrile UTI or deterioration in renal function. UROLOGY 83: 199e205, 2014.

Predictive factors of resolution of primary vesico-ureteric reflux: a multivariate analysis

Bju International, 2006

The two papers in this section evaluate different diseases in children, but the two subjects are of considerable importance: nocturnal enuresis and VUR.The two papers in this section evaluate different diseases in children, but the two subjects are of considerable importance: nocturnal enuresis and VUR.OBJECTIVETo identify independent factors predicting the resolution of primary vesico-ureteric reflux (VUR) in a cohort of medically managed children.To identify independent factors predicting the resolution of primary vesico-ureteric reflux (VUR) in a cohort of medically managed children.PATIENTS AND METHODSBetween 1977 and 2003, 506 children were diagnosed with VUR and were conservatively managed and prospectively followed. All of the children were maintained on antibiotic prophylaxis. Follow-up imaging consisted of voiding cysto-urethrography (VCUG) or a direct isotope cystogram at intervals of 2–3 years. The predictive factors used are based on the patient data at the time of entry in the protocol. The dependent variable was VUR resolution. The criterion for resolution was based on a single negative VCUG or direct isotope cystogram. A survival analysis identified variables significantly associated with VUR resolution. Cox's regression model was applied to identify variables independently associated with the dependent variable.Between 1977 and 2003, 506 children were diagnosed with VUR and were conservatively managed and prospectively followed. All of the children were maintained on antibiotic prophylaxis. Follow-up imaging consisted of voiding cysto-urethrography (VCUG) or a direct isotope cystogram at intervals of 2–3 years. The predictive factors used are based on the patient data at the time of entry in the protocol. The dependent variable was VUR resolution. The criterion for resolution was based on a single negative VCUG or direct isotope cystogram. A survival analysis identified variables significantly associated with VUR resolution. Cox's regression model was applied to identify variables independently associated with the dependent variable.RESULTSAfter adjustment, four variables remained as independent predictors of VUR resolution: nonwhite race, relative risk (95% confidence interval) of 1.5 (1.1–1.9; P = 0.009); mild grade of VUR, 3.3 (2.1–5.3; P < 0.001); absence of renal damage, 3.3 (2.4–4.5; P < 0.001); and absence of dysfunctional voiding, 2.0 (1.4–3.1; P < 0.001). For mild VUR, three variables were significantly associated: male gender, 1.7 (1.1–2.6; P = 0.012); absence of renal damage, 3.4 (1.8–6.4; P < 0.001); and unilateral VUR, 1.6 (1.1–2.3; P = 0.004). For moderate/severe VUR, three variables were significantly associated: nonwhite race, 1.7 (1.1–2.6; P = 0.01); absence of renal damage, 3.0 (2.0–4.4; P < 0.001); and absence of dysfunctional voiding, 2.8 (1.4–5.5; P = 0.004).After adjustment, four variables remained as independent predictors of VUR resolution: nonwhite race, relative risk (95% confidence interval) of 1.5 (1.1–1.9; P = 0.009); mild grade of VUR, 3.3 (2.1–5.3; P < 0.001); absence of renal damage, 3.3 (2.4–4.5; P < 0.001); and absence of dysfunctional voiding, 2.0 (1.4–3.1; P < 0.001). For mild VUR, three variables were significantly associated: male gender, 1.7 (1.1–2.6; P = 0.012); absence of renal damage, 3.4 (1.8–6.4; P < 0.001); and unilateral VUR, 1.6 (1.1–2.3; P = 0.004). For moderate/severe VUR, three variables were significantly associated: nonwhite race, 1.7 (1.1–2.6; P = 0.01); absence of renal damage, 3.0 (2.0–4.4; P < 0.001); and absence of dysfunctional voiding, 2.8 (1.4–5.5; P = 0.004).CONCLUSIONFew factors are amenable to intervention to modify the natural history of VUR. According to our findings, there are only two possible interventions: avoiding renal scars and managing voiding dysfunction.Few factors are amenable to intervention to modify the natural history of VUR. According to our findings, there are only two possible interventions: avoiding renal scars and managing voiding dysfunction.

Vesicoureteral Reflux in Conjunction With Posterior Urethral Valves

The Journal of Urology, 2009

Purpose: We evaluated the link between primary kidney function and vesicoureteral reflux in patients with posterior urethral valves. We also analyzed the timing of the resolution of reflux after release of urethral obstruction. Materials and Methods: We retrospectively analyzed records and x-ray results for 200 patients with posterior urethral valves treated at our institution between 1953 and 2003. Of these patients 197 were evaluated for vesicoureteral reflux. Results: Bilateral vesicoureteral reflux was present in 73 patients (37%) and unilateral reflux in 54 (27%). Of 99 cases of posterior urethral valves diagnosed postnatally the diagnosis was made at a younger age when reflux was present (p Ͻ0.001). Patients with reflux (especially bilateral) had significantly higher serum creatinine levels at presentation and 6 and 12 months postoperatively compared to patients without reflux. In unilateral cases the split functions of refluxing kidneys were significantly decreased. Reflux resolved spontaneously at a median of 1.28 years (range 0.04 to 15.16) after treatment of posterior urethral valves, resolving more rapidly in patients with unilateral disease. Among 200 poorly functioning kidneys 35 with reflux (18%) were removed. Conclusions: In patients with posterior urethral valves vesicoureteral reflux is often associated with poorly functioning kidneys. Accordingly patients with bilateral reflux have decreased overall kidney function. Reflux resolves in half of ureters within 2 years after valve ablation. Reflux resolves more rapidly in unilateral cases.

Medical versus Surgical Management of Vesico Ureteral Reflux

2008

Vesico ureteral reflux is the abnormal retrograde flow of urine from the bladder into the ureter and possibly the kidney. There are 2 types of reflux: Primary reflux – which is caused by a congenital abnormality at the ureterovesical junction Secondary reflux – occurs when high pressure in the bladder causes a breakdown of the normal antireflux mechanism at the ureterovesical junction that occurs in children with posterior urethral valves or neurogenic bladders. This also happens in children who have complete ureteral duplication with or without a ureterocoele. T his article focuses on primary vesico ureteral reflux and the approach to this entity. Primary vesico ureteral reflux can and should be treated conservatively (except Grade V bilateral reflux) with very selective indications for surgical intervention. The advantages and the disadvantages are discussed in detail together with details of both these modes in the treatment of reflux, and recommendations for therapy, follow up

Incidence and Progress of Vesicoureteric Reflux after Primary Fulguration of Posterior Urethral Valves

Bangladesh Journal of Endosurgery, 2013

Introduction: Posterior urethral valve (PUV) is the most frequent cause of urethral obstruction in male child. These lesions may result in lifelong disabilities with incontinence and decreased renal function despite optimal medical management. Primary fulguration without upper tract diversion is the preferred modality of treatment in most cases of PUV. Regular follow-up is needed to check completion of valve fulguration, renal function, status of hydronephrosis, vesicoureteric reflux (VUR), urinary tract infection (UTI), and bladder function. Materials and Methods: An interventional study among 30 purposively selected patients of PUV was conducted from December 2009 to July 2011. Most of the patients presented with weak urinary stream, dribbling of urine, straining at micturition, UTI, and palpable bladder. All children were subjected to ultrasonography (USG), blood urea, serum creatinine, routine urine examination, and culture studies. Structured questionnaire was used to collect information regarding improvement or disappearance of VUR and renal functional status before and after primary fulguration of PUV. Results: Ages ranged from 10 days to 14 years; 16 were between 1year and 14 years (53.3%), 11(36.7%) were infants, and the rest 03(10%) were neonates. Average serum creatinine levels were found gradually decreasing significantly (p < 0.01) in subsequent follow-ups. Average blood urea nitrogen (BUN) was also decreased significantly (p < 0.05). VUR was present in 63.3% cases. Non-VUR was found in 60% cases on right side and 50% cases on left side. On the third follow-up after 3 months it became 73.3% on right side and 63.3% on left side. Positive correlation found in Pearson correlation test about the changes of reflux grades before and after fulguration was significant (p < 0.001). It was significant on both left and right kidneys. Positive correlation found in Pearson correlation test about the changes of GFR before and after fulguration was also significant (p < 0.001). Collected data was cleaned, edited, and analyzed with the help of software SPSS window version 15.0. Conclusion: VUR disappeared in some cases and decreased in majority of the cases by 3 months after adequate restoration of urethral patency. Renal function came to normal range in two thirds of the cases.

Vesicoureteral reflux: A new treatment algorithm (original) (raw)

Related papers