Enhanced detection of vesicoureteric reflux with isotopic cystography

We compared the accuracy of isotope cystography (IC) and fluoroscopic cystourethrography (FC) in detecting vesicoureteric reflux (VUR) in children. FC and IC were performed in 124 children, 56 boys and 68 girls, aged 1 month to 9.2 years (mean 2.1 years), admitted consecutively for suspected VUR over a 10-month period. VUR was diagnosed by one or both studies in 51 of 124 (41%) patients. The two methods were concordant for the detection of VUR in 84% of kidney-ureter units and in 93% for the detection or exclusion of severe VUR. IC detected VUR more accurately than FC, both when all grades of VUR were considered together (P=0.00001) and when only severe reflux was considered (P=0.004). VUR was missed by FC in 23 of 51 (45%) subjects. Of those 23, 12 had severe VUR detected on one side at least by IC. VUR was missed by IC in 3 subjects. IC is significantly more accurate than FC in the initial diagnosis of VUR, even of severe grade. IC is the method of choice for the first diagnosis of VUR. Boys with VUR diagnosed by IC also need FC to investigate for posterior urethral valves. Received: 4 August 1999 / Revised: 22 November 1999 / Accepted: 23 November 1999     

Variation in the diagnosis of vesicoureteric reflux using micturating cystourethrography

  Variability in the interpretation of micturating cystourethrography by paediatric radiologists for the diagnosis of vesicoureteric reflux in children was evaluated. All 265 micturating cystourethrograms (MCUs) that were available from 304 consecutive children aged 0.5 – 61 months  –  who were investigated after their first urine infection between 1993 and 1995 as part of a prospective cohort study  –  were selected for interpretation. Three experienced paediatric radiologists from the same department independently interpreted the MCUs according to the grading system of the International Reflux Study in Children, from grades 0 to V, with the presence of intrarenal reflux also noted. Apart from being informed that urine infection was the indication for the MCU, no other clinical information was given to the radiologists. The indices of variability used were the percentage of agreement and the kappa statistic, expressed as a percentage. Both measures were weighted with integers representing the number of categories from perfect agreement. Disagreement was analysed for children and kidneys. For the diagnosis of vesicoureteric reflux in individual patients, including grade, the percentage of agreement was 96% – 97% (kappa 90% – 91%) and the weighted percentage of agreement was 96% – 98% (weighted kappa 93% – 94%). The same high level of agreement was present for individual kidneys, with a percentage of agreement of 97% – 98% (kappa 89% – 92%) and a weighted percentage of agreement of 98% – 99% (kappa 94% – 95%). There was near perfect agreement in the interpretation of radiological micturating cystourethrography among three experienced paediatric radiologists for the diagnosis and grade of vesicoureteric reflux. Any variations in the medical care of children suspected of having vesicoureteric reflux are not explained by differences in the reporting of this diagnostic test. Received June 19, 1996; received in revised form November 1, 1996; accepted December 6, 1996     

Cyclic voiding cystourethrography in the diagnosis of occult vesicoureteric reflux

Cyclic voiding cystourethrography (CVC) enhances the detection of vesicoureteric reflux (VUR). We investigated whether more-severe VUR may be overlooked, and whether older children are at risk of having their VUR missed with the conventional single-cycle study. Three hundred and seventy patients, 168 boys and 202 girls aged 1 month to 16 years, consecutively admitted over 1 year for suspicion of VUR, underwent two complete cycles of filling and voiding CVC. One hundred and four subjects, 33 boys and 71 girls, were older than 3 years (mean age 5.7 years, range 3.2–16 years).Sixty-six refluxing ureters from 51 patients were identified in the first cycle and 61 refluxing ureters from 45 patients were identified only with the second cycle. Four instances of grade IV VUR in 4 patients and three of grade V VUR in 3 patients were overlooked completely in the first cycle. Seven episodes of VUR ≤ grade III from 5 patients diagnosed in the first cycle were upgraded to ≥ grade IV at the second cycle. The presence of VUR was identified only in the second cycle in 35 of 74 subjects aged ≤ 3 years and in 10 of 22 aged >3 years (not significant). Of the 10 children aged >3 years, 2, who had diagnosis only at the second cycle, had ≥ grade IV VUR. More-severe VUR may be overlooked or down-graded in a single-cycle study. Two-cycle CVC is also useful in children older than 3 years. Received: 4 June 1998 / Revised: 11 January 1999 / Accepted: 22 January 1999     

Fetal vesicoureteric reflux

We present an analysis of 30 patients with fetal vesicoureteric reflux (VUR) from a series of 107 patients with prenatally diagnosed urinary tract anomalies. In 13 patients (Group 1) the fetal VUR was the only urinary tract abnormality. In 17 patients (Group 2) the fetal VUR was combined with other urinary tract problems. In 14 of 46 refluxing renal units there was no evidence of upper tract dilatation on a pre- and post-natal ultrasound examination. Any infant with postnatal urinary tract dilatation needs full urological investigations, including a micturating cystogram. A normal postnatal ultrasound examination does not exclude fetal VUR.     

The management of vesicoureteric reflux

An increasingly large volume of data is being accumulated regarding the effects of vesicoureteric reflux on the kidney, data that influence clinical management. Although concrete guidelines cannot be drawn that will apply to all patients, important considerations include the following: All children with documented urinary infections should have a voiding cystourethrogram. The voiding cystourethrogram may correlate with probability of spontaneous resolution of vesicoureteric reflux. Younger patients have a higher chance of spontaneous resolution of vesicoureteric reflux. There is a definite familial tendency to vesicoureteric reflux, and patients with significant vesicoureteric reflux and scarring are more likely to have affected siblings. DMSA renal scanning is highly sensitive in the detection of scarring. Cystoscopy may play a role in the evaluation of the refluxing ureterovesical junction, but does not have as much prognostic significance as the voiding cystourethrogram. Urodynamic investigation may be important in evaluating children with urinary infections, reflux, and symptoms of voiding dysfunction. High-grade vesicoureteric reflux is associated with an increased incidence of renal scarring, and the answer to optimal management is not yet available. Most scarring occurs in infancy or childhood. Nonoperative management, especially in moderate degrees of reflux, can achieve a high rate of success. Nonoperative management requires continuous antibiotic prophylaxis. Breakthrough infections or lack of compliance with nonsurgical management have a high complication rate and must be managed aggressively. Antireflux surgery can be performed with a minimal complication rate.(ABSTRACT TRUNCATED AT 250 WORDS)     

Gene discovery and vesicoureteric reflux

Vesicoureteric reflux (VUR) is a congenital urinary tract defect caused by abnormal insertion of the ureter within the bladder wall. This leads to a defective ureterovesical junction in which urine flows retrogradely from the bladder to the kidneys. Although VUR is associated with recurrent urinary tract infections, renal malformations, hypertension, and reflux nephropathy, its relationship to each of these clinical entities is poorly understood. Mutations in genes expressed by the developing kidney and urinary tract can cause VUR in mice, and some of these same genes have been identified in humans with VUR. By discovering the genes that are associated with VUR, new hypotheses will be generated such that, eventually, the relationship between VUR and its complications will be understood.     

Radionuclide cystography in the management of vesico-ureteric reflux

Direct radionuclide cystography in 100 patients has been shown to be a useful investigation in the diagnosis and management of reflux and a valuable complement to radiographic methods; it may well have a place in the detection of reflux in the infected patient. The advantages include low radiation exposure, an accurate measurement of residual urine volumes, simplicity of technique and the use of materials and equipment that have in recent years become increasingly available for routing investigation.     

Microproteinuria in children with vesicoureteric reflux

Microproteinuria was assessed by the measurement of albumin, retinol binding protein (RBP) and creatinine concentrations in random midstream urine samples using a single enzyme linked immunoassay (ELISA) in 36 children with vesicoureteric reflux (VUR) and 36 control patients. Infection was excluded by culture and microscopy of the specimens of urine. No patient was hypertensive. Albumin excretion increased in patients with increasing severity of VUR and with renal scarring. Similar findings were observed with RBP excretion. The results show that glomerular and tubular handling of proteins is altered in VUR. The degree of microproteinuria correlates well with the severity of the VUR and is evidence of tubular dysfunction. The effects of medical management and anti-reflux surgery on microproteinuria require further evaluation.     

Endoscopic correction of primary vesicoureteric reflux

One hundred and three children with primary vesicoureteric reflux treated by endoscopic injection of Polytef paste between March 1984 and February 1986 have been followed up for periods ranging from 3 to 23 months. Seventy-five per cent of refluxing ureters showed absence of reflux after one injection of Polytef paste; 14% of ureters required two to four sub-ureteric injections of Polytef paste for the correction of vesicoureteric reflux; 8% of ureters showed improvement in the grade of reflux after the initial injection of Polytef paste. Duplex systems were more difficult to correct and recurrence of reflux was much higher than in primary reflux. Follow-up intravenous urograms showed no evidence of ureteric obstruction in the treated ureters. The procedure is safe, simple and effective in correcting all grades of vesicoureteric reflux. To obtain best results, attention should be paid to minute details of the technique and the injection made with pinpoint accuracy.     

A model of sterile vesicoureteric reflux in the sheep

Eighteen Coopworth ewe lambs were divided into three groups based on the initial cystourethrogram and cystometry findings at 5 – 7 weeks of age: group 1, 6 lambs with spontaneous low-pressure bilateral vesicoureteric reflux (VUR) on bladder filling were used to study the natural history of reflux; group 2, 5 lambs with no VUR detected were used to establish an experimental model of bilateral VUR using an unroofing surgical procedure; group 3, 7 lambs with spontaneous VUR detected during micturition had the same surgical procedure to increase the degree of VUR. All three animal groups were followed for 4 – 10 months. Spontaneous VUR was demonstrated in 13 of 18 lambs (25/36 ureters). The presence and severity of spontaneously occurring reflux in group 1 lambs diminished with increasing age. VUR was created successfully in group 2 and increased in degree in group 3 animals. The only significant histological finding in all three animal groups with grades II and III VUR was distal renal tubular dilatation. The sheep is a useful and readily available animal for studying VUR. During 4 – 10 months of follow-up, sterile reflux without bladder outflow obstruction resulted in distal renal tubular dilatation, but no renal parenchymal damage. Received April 17, 1997; received in revised form August 5, 1997; accepted August 21, 1997     

Proteinuria and enzymuria in vesicoureteric reflux.

Vesicoureteric reflux is a common abnormality of the urinary tract leading to significant renal morbidity and premature mortality. No reliable non-invasive method exists for its diagnosis. This study investigated the presence of urinary proteins and enzymes in healthy children and those with reflux. A log normal distribution was found for all analyte/creatinine ratios. Significantly higher tubular protein/creatinine ratios were found in patients with reflux nephropathy. Three enzyme/creatinine ratios (n-acetyl-B-D-glucosaminidase, gamma-glutamyl transferase and lactate dehydrogenase) were higher in children with reflux who had no renal scarring, but the degree of overlap with the normal range was such that it is doubtful whether any will be of use as a urinary marker.     

Body growth in early diagnosed vesicoureteric reflux

Body growth was studied in 32 subjects with vesicoureteric reflux (VUR), diagnosed following the prenatal finding of urinary tract dilatation, who had normal renal filtration function and who received antibacterial prophylaxis by the first few days of life. They were followed for 1–5 years (mean 2.3 years). Most had persistent VUR during the 1st year of life. Body growth performance was compared with that of 94 subjects with VUR diagnosed and treated by us after the neonatal period. During the follow-up period, none of the patients with prenatally detected VUR had a height Z score below –2, nor a weight-for-height index below 90%, and 1 had variations in height Z score ≥1. The difference in the percentage of patients with prenatally detected VUR (1/32) and those with VUR diagnosed and treated after the neonatal period (20/94) who had variations in height Z score ≥1 was significant (P=0.035). Patients with prenatally detected VUR and normal renal filtration function, given antibacterial prophylaxis by the first few days of life, have normal body growth, although VUR still persists. Received: 19 March 1998 / Revised: 10 February 1999 / Accepted: 10 February 1999     

Megaprepuce associated with vesicoureteric reflux.

OBJECTIVE: To describe 4 patients in whom megaprepuce was associated with vesicoureteric reflux (VUR). PATIENTS AND METHODS: Four boys aged 6, 4, 5 and 7 months, respectively, presented with dribbling of urine, gross penile swelling and inability to void spontaneously. The first 3 patients had a history of documented urinary tract infection. Micturating cystourethrogram (MCUG) revealed grade III VUR on the right in the first patient, grade V on the left in the second patient, grade III on the right and grade IV in both moieties of left duplex system in the third patient and bilateral grade III in the fourth patient. All patients underwent circumcision. RESULTS: Follow-up MCUG demonstrated complete resolution of VUR in 2 patients after circumcision. One patient with bilateral VUR showed resolution of VUR on right side but persistence of VUR into the lower moiety of left duplex system after circumcision. Vesicoureteric reflux was downgraded from grade 5 to grade 3 after circumcision in one patient. CONCLUSION: These cases demonstrate for the first time the association of megaprepuce with VUR. VUR associated with megaprepuce is usually resolved after circumcision.     

Operative treatment of vesicoureteric reflux in duplicated ureters

Over a 10-year period 321 children underwent 490 antireflux operations. 21 duplicated vesicoureteric reflux was observed in 18 patients. The follow-up and the comparison with other authors results in 334 patients indicate that the submucosal inlay of the duplicated ureters is a particularly suitable operation. The Politano-Leadbetter and the Lich-Grégoir techniques yield good results.     

Congenital urethral cysts in boys with vesicoureteric reflux

Four cases of congenital urethral cysts are reported. Diagnosis wasmade by endoscopy. The coincidence of urethral cysts and vesicouretericrefluxes seemed incidental in three cases. Fetal infravesicalobstruction was provable in the fourth infant. Conclusion:Urethral cysts should be considered in boys with vesicoureteric reflux.For the vast majority of cases it seems improbable that urethral cystsplay a role in the pathogenesis of congenital vesicoureteric reflux.     

Reflux nephropathy secondary to intrauterine vesicoureteric reflux

In 107 infants with 182 antenatally diagnosed urinary tract anomalies, 24 had either unilateral (12) or bilateral (12) vesicoureteric reflux (VUR). The VUR was more common in boys (male to female ratio, 16:8) and usually severe (grades IV [16], III [10], II [4], and I [6]). Intravenous pyelography showed the changes of atrophic pyelonephritis in 10 refluxing units, and in another two with an associated pelviureteric junctional hydronephrosis. Lateral ectopia of the ureteric orifices was noted in six of these 10 refluxing renal units. Isotopic renography showed a reduction in function in nine of the 14 patients examined, ranging between 9% and 41%. (45% and above was considered within the normal range). Only two patients developed a urinary infection before intravenous pyelography or isotopic renography was performed, suggesting that renal changes noted were primary rather than secondary. Findings support the hypothesis that foetal VUR may be a contributing factor in the causation of atrophic pyelonephritis (foetal reflux nephropathy) observed in these patients.