Surgical management of vesicoureteral reflux in children

Vesicoureteral reflux (VUR) is the most common uropathy affecting children. Compared to children without VUR, those with VUR have a higher rate of pyelonephritis and renal scarring following urinary tract infection (UTI). Options for treatment include observation with or without antibiotic prophylaxis and surgical repair. Surgical intervention may be necessary in patients with persistent reflux, renal scarring, and recurrent or breakthrough febrile UTI. Both open and endoscopic approaches to reflux correction are successful and reduce the occurrence of febrile UTI. Estimated success rates of open and endoscopic reflux correction are 98.1% (95% CI 95.1, 99.1) and 83.0% (95% CI 69.1, 91.4), respectively. Factors that affect the success of endoscopic injection include pre-operative reflux grade and presence of functional or anatomic bladder abnormalities including voiding dysfunction and duplicated collecting systems. Few studies have evaluated the long-term outcomes of endoscopic injection, and with variable results. In patients treated endoscopically, recurrent febrile UTI occurred in 0–21%, new renal damage in 9–12%, and recurrent reflux in 17–47.6% of treated ureters with at least 1 year follow-up. These studies highlight the need for standardized outcome reporting and longer follow-up after endoscopic treatment.     

EAU Guidelines on vesicoureteral reflux in children

Context

Primary vesicoureteral reflux (VUR) is a common congenital urinary tract abnormality in children. There is considerable controversy regarding its management. Preservation of kidney function is the main goal of treatment, which necessitates identification of patients requiring early intervention.

Objective

To present a management approach for VUR based on early risk assessment.

Evidence acquisition

A literature search was performed and the data reviewed. From selected papers, data were extracted and analyzed with a focus on risk stratification. The authors recognize that there are limited high-level data on which to base unequivocal recommendations, necessitating a revisiting of this topic in the years to come.

Evidence synthesis

There is no consensus on the optimal management of VUR or on its diagnostic procedures, treatment options, or most effective timing of treatment. By defining risk factors (family history, gender, laterality, age at presentation, presenting symptoms, VUR grade, duplication, and other voiding dysfunctions), early stratification should allow identification of patients at high potential risk of renal scarring and urinary tract infections (UTIs). Imaging is the basis for diagnosis and further management. Standard imaging tests comprise renal and bladder ultrasonography, voiding cystourethrography, and nuclear renal scanning. There is a well-documented link with lower urinary tract dysfunction (LUTD); patients with LUTD and febrile UTI are likely to present with VUR. Diagnosis can be confirmed through a video urodynamic study combined with a urodynamic investigation. Early screening of the siblings and offspring of reflux patients seems indicated.Conservative therapy includes watchful waiting, intermittent or continuous antibiotic prophylaxis, and bladder rehabilitation in patients with LUTD. The goal of the conservative approach is prevention of febrile UTI, since VUR will not damage the kidney when it is free of infection. Interventional therapies include injection of bulking agents and ureteral reimplantation. Reimplantation can be performed using a number of different surgical approaches, with a recent focus on minimally invasive techniques.

Conclusions

While it is important to avoid overtreatment, finding a balance between cases with clinically insignificant VUR and cases that require immediate intervention should be the guiding principle in the management of children presenting with VUR.     

Primärer vesikoureteraler Reflux

The never ending discussion about the diagnostics and treatment of vesicoureteral reflux (VUR) now includes arguments for diagnostic nihilism as well as invasive diagnostics and therapy, which is reminiscent of the debate on prostate cancer in adulthood. The common goal of all currently competing diagnostic strategies and approaches is the prevention of renal scars by the most effective and least burdensome approach. There is a difference between acquired pyelonephritic scars with VUR (acquired reflux nephropathy) and congenital reflux nephropathy (primary dysplasia) which cannot be influenced by any therapy. The VUR can be verified by conventional radiological voiding cystourethrography (VCUG), by urosonography, radionuclide cystography or even by magnetic resonance imaging (MRI). The guidelines of the European Association of Urology/European Society for Paediatric Urology (EAU/ESPU) recommend radiological screening for VUR after the first febrile urinary tract infection. Significant risk factors in patients with VUR are recurrent urinary tract infections (UTI) and parenchymal scarring and the patients should undergo patient and risk-adapted therapy. Infants with dilating reflux have a higher risk of renal scarring than those without dilatation of the renal pelvis. Bladder dysfunction or dysfunctional elimination syndrome represents a well-known but previously neglected risk factor in combination with VUR and should be treated prior to any surgical intervention as far as is possible. Certainly not every patient with VUR needs therapy. The current treatment strategies take into account age and gender, the presence of dysplastic or pyelonephritic renal scars, the clinical symptoms, bladder dysfunction and frequency and severity of recurrent UTI as criteria for the therapy decision. The use of an antibacterial prophylaxis as well as the duration is controversially discussed. Endoscopic therapy can be a good alternative to antibacterial prophylaxis or a surveillance strategy in patients with low grade VUR. In patients with dilating VUR and given indications for surgery, endoscopic treatment can be offered. However, parents should be completely informed about the significantly lower success rate of endoscopic therapy compared to open surgical procedures. The open surgical techniques guarantee the highest success rates and should be used in patients with a dilating VUR and high risk of renal damage.     

The role of endoscopic treatment in the management of grade v primary vesicoureteral reflux

OBJECTIVES: Although endoscopic treatment provides a high rate of success in children with grades II-IV vesicoureteral reflux (VUR), its role in the management of grade V reflux has been questioned. In this study we reviewed our 21-yr experience of endoscopic treatment in children with grade V primary VUR. METHODS: We retrospectively reviewed the medical records of 132 children who underwent endoscopic treatment for primary grade V reflux from 1984 to 2004. VUR was unilateral in 39 patients and bilateral in 34, and 59 patients had ipsilateral grade V reflux with a lower grade of VUR on the contralateral side. Endoscopic treatment was performed in a total of 166 grade V ureters; polytetrafluoroethylene was used from 1984 to 2000 and dextranomer/hyaluronic acid from 2001 to 2004. Median follow-up was 12.2 yr and mean follow-up was 13.4 yr. RESULTS: VUR was completely resolved after first injection in 88 (53%) ureters and downgraded to grade I or II in 26 (15.7%). VUR resolved after a second and third injection in 36 (21.7%) and 10 (6%) of ureters, respectively. Endoscopic treatment failed to correct VUR in 6 (3.6%) ureters, requiring ureteral reimplantation in 5 and nephrectomy in 1. Thirteen patients developed urinary tract infections during the follow-up period, and on investigation 9 ureters (5.4%) had recurrence of VUR. No injection or morbidity related to tissue-augmenting substances was noted in any patient. CONCLUSION: Endoscopic treatment should be the first-line of treatment in management of grade V vesicoureteral reflux.     

Obstructive ureterocele—an ongoing challenge

Ureterocele is a cystic dilatation of the intravesical ureter that is most commonly observed in females and children, and usually affects the upper moiety of a complete pyeloureteral duplication. According to their position, ureteroceles are divided into intravesical, when the ureterocele is completely contained inside the bladder, and extravesical when part of the cyst extends to the urethra or bladder neck. Most ureteroceles are diagnosed in utero or immediately after birth during an echographic screening of renal malformations. Severe, febrile urinary tract infection is the most common postnatal presentation of ureteroceles, but they may, rarely, prolapse and acutely obstruct the bladder outlet. Once an ureterocele is identified sonographically, a voiding cystourethrogram to detect vesicoureteral reflux (VUR) and a 99m-technetium dimercapto-succinic acid renal scan to evaluate the function of the different portions of the kidney are mandatory. VUR in the lower pole is observed in 50% of cases and in the contralateral kidney in 25%. Simple endoscopic puncture of the ureterocele has recently been advocated as an emergency therapy for infected or obstructing ureteroceles and as an elective therapy for intravesical ureteroceles. The rate of additional surgery after elective endoscopic puncture of an orthotopic ureterocele ranges from 7 to 23%. Treatment of ectopic ureteroceles is more challenging and both endoscopic puncture and upper pole partial nephrectomy frequently require additional surgery at the bladder level. The reoperation rate after endoscopic treatment varies from 48 to 100%. It is 15 to 20% after upper pole partial nephrectomy if VUR was absent before the operation, but is as high as 50–100% when VUR was present. Thus, endoscopic incision is appropriate as an emergency treatment or when dealing with a completely intravesical ureterocele. Upper pole partial nephrectomy is the elective treatment for an ectopic ureterocele without preoperative VUR. In an ectopic ureterocele with VUR, no matter which type of primary therapy has been chosen, a secondary procedure at the bladder level, involving ureterocele removal and reimplantation of the ureter(s), should be anticipated.     

Evidence-based medicine and vesicoureteral reflux

Vesicoureteral reflux (VUR) remains one of the most controversial subjects in paediatric urology. Much literature has been published on VUR, making the understanding of this anomaly and its treatments quite opaque. Evidence-Based Medicine (EBM) should be helpful to clarify the various VUR approaches contained in the 6224 titles found on Medline using the keywords "vesicoureteral reflux" and "vesicoureteric reflux". These articles were critically reviewed and graded according to EBM scorings, with regard to their methodological designs. This review of VUR literature suggests that most of our knowledge is based on publications with a low level of evidence, and that EBM lacks arguments to support recommendations for VUR diagnostic and treatment. It appears yet that antenatal dilatation of the urinary tract and symptomatic urinary tract infections (UTI) justify VUR screening. Surgery should be discussed in recurrent UTIs or deterioration of renal function. There is no consensus in case of persistent asymptomatic VUR regarding indication and duration of antibio-prophylaxis, and selection of radical treatment.     

A novel surgical technique for management of vesicoureteral reflux following kidney transplantation: prospective study of 12 cases

The incidence of vesicoureteral reflux (VUR) varies between 10% and 80% of transplanted kidneys. In cases of failure of endoscopic treatment or recurrent urinary tract infections, surgical correction is proposed by ureteral reimplantation or pyeloureteral anastomosis using the native ureter. The aim of this study was to assess the results of a technique that increases the submucosal length of the ureter without a ureterovesical reimplantation. We treated 12 patients with VUR in the transplanted kidney by open surgery. Retrograde cystography showed resolution of reflux in all the patients. Our technique has the advantage of avoiding ureteral dissection thereby avoiding its devascularization and no invasion of the bladder mucosa.     

Vesikoureteraler Reflux

Background

Vesico-ureteral reflux (VUR) is one of the most common urologic diseases in childhood. About every third child that presents with a urinary tract infection (UTI) has urinary reflux to the ureter or kidney. Demonstration of a backflow of urine into the ureters or kidneys proves vesicoureteral reflux. In unclear cases, a positioned instillation of contrast agent (PIC) cystogram might be performed and is able to prove vesico-ureteral reflux.

Objectives

Since low-grade VUR has a high probability of maturation and self-limitation, infants with VUR should be given prophylactic antibiotics during their first year of life, reevaluating the status of VUR after 12 months. The aim of any treatment is to prevent renal damage.

Therapy

The individual risk of renal scarring is decisive for the choice of adequate therapy. This risk is mainly dependent on reflux grade, age, and gender of the child as well as parental therapy adherence. In principle, therapeutic options include conservative as well as endoscopic or open surgical antireflux therapies.

Conclusion

Decisions on treatment should be made individually with parents taking into account all the findings available.

     

Treatment of vesico-ureteric reflux: a new algorithm based on parental preference

Authors from Rome evaluated parental preference for treatment in children with grade III VUR. Parents were provided with detailed information about the three treatment options: antibiotic treatment, open surgery, endoscopic treatment. Most parents chose endoscopic management; with this in mind, the authors proposed a new treatment algorithm for VUR. OBJECTIVE: To assess parental preference (acknowledged in treatment guidelines as important when choosing therapy) about treatments for vesico-ureteric reflux (VUR, commonly associated with urinary tract infection and which can cause long-term renal damage if left untreated), as at present there is no definitive treatment for VUR of moderate severity (grade III). SUBJECTS AND METHODS: The parents of 100 children with grade III reflux (38 boys and 62 girls, mean age 4 years, range 1-15) were provided with detailed information about the three treatment options available for treating VUR (antibiotic prophylaxis, open surgery and endoscopic treatment), including the mode of action, cure rate and possible complications, and the practical advantages and disadvantages. They were then presented with a questionnaire asking them to choose their preferred treatment. RESULTS: Most parents preferred endoscopic treatment (80%), rather than antibiotic prophylaxis (5%) or open surgery (2%); 13% could not decide among the three options and endoscopic treatment was recommended. CONCLUSION: Given the strong preference for endoscopic treatment we propose a new algorithm for treating VUR; endoscopic treatment would be considered as the first option for persistent VUR, except in severe cases where open surgery would still be recommended.     

Urodynamic Changes after Endoscopic Correction of Vesicoureteral Reflux

Massive bilateral vesicoureteral reflux (VUR) in a 7-year-old girl with spinal scoliosis was successfully treated by endoscopic correction. She was admitted due to a febrile urinary tract infection and urinary incontinence. A cystometrogram demonstrated normal detrusor function during storage. The endoscopic subureteric injection of polytetrafluoroethylene (Teflon^TM) was performed, resulting in the disappearance of the VUR. A postoperative cystometrogram demonstrated overactive detrusor function during storage, necessitating anticholinergic medication. She has been free of febrile urinary tract infections and incontinence for 2 years postoperatively, although self-catheterization is necessary. In a case of neurogenic vesical dysfunction with massive reflux, endoscopic subureteric injection is not only a therapeutic tool, but also a useful diagnostic option for detecting occult detrusor overactivity during storage prior to open surgery.     

Split renal function does not change after successful treatment in children with primary vesico-ureteric reflux

OBJECTIVE: To evaluate the renal growth pattern in patients with primary vesico-ureteric reflux (VUR) using long-term measurements of split renal function with 99mTc-dimercaptosuccinic acid (DMSA) scintigraphy. PATIENTS AND METHODS: In all, 712 children aged < 16 years (466 boys and 246 girls) with primary VUR were referred to our hospital from July 1991 to December 2000. VUR was diagnosed by voiding cysto-urethrography. The patients were treated either surgically (group 1) or conservatively (group 2) and followed with serial 99mTc-DMSA scintigraphy for up to 10 years. There were 942 examinations in 367 of 712 patients who had repeat scintigraphy. Patients with secondary VUR, VUR to a solitary or fused kidney, or upper urinary tract obstruction, were excluded. Five of 298 patients (1.7%) who had ureteric reimplantation had a febrile urinary tract infection (UTI) soon after surgery but none recurred (recurrence is an indication for surgery in children with VUR); there was no febrile UTI in the 69 patients in group 2. Planar scintigraphy with 99mTc-DMSA was used to assess the absolute uptake (AU) of each kidney, measured as a percentage of the injected dose, and the relative uptake (RU = AU of each kidney/AU of both kidneys) calculated. The initial examination was at least 4 weeks after any febrile UTI in most patients. Serial studies were conducted 1 year after surgery and then biannually in group 1. In group 2 the DMSA scan was repeated every 2-3 years. The change in split renal function was compared with the RU of the right kidney. RESULTS: The RU of the right kidney at the initial scan correlated closely with those on repeated scans in both groups. The correlation coefficients were 0.99 in group 1 and 0.94-0.97 in group 2 at every study. The change of RU remained within 0.05 in all patients after treatment. CONCLUSIONS: Under strict control of UTI, split renal function in children with primary VUR does not change. There may be no possibility of accelerated or compensatory growth of the kidney with reflux nephropathy, but no concern about deterioration and atrophy either.     

Langzeitergebnisse der endoskopischen Behandlung des vesikoureteralen Refluxes

For more than 10 years VUR has been treated by endoscopic injections with biocompatible substances. This study presents the results of this procedure with bovine collagen (Zyplast) in 42 children with 66 refluxing ureters. The follow-up period comprises an average time of 6.5 years (2-10 years). In 16 ureters a second and in 4 a third injection was given. In 5 kidneys scarring occurred during the years of follow up. Growth, kidney function and blood pressure remained normal in all children. 6 ureters were reimplanted because of recurrences, in 13 ureters (23%) the reflux improved and since no infection recurred no further management became necessary. In 36 (65.4%) ureters reflux was cured and in further 11 this was supposedly the case. However this was not proven by MCU, because parents refused this investigation. Earlier MCU have shown no reflux. We think that the endoscopic injection with collagen is a excellent option in management of VUR grade I-IV.     

Endoscopic management of vesicoureteral reflux: does it stand the test of time?

Endoscopic subureteral injection of tissue-augmenting substances, a 15-minute outpatient procedure has become an alternative to long-term antibiotic prophylaxis and surgical intervention in the treatment of vesicoureteral reflux (VUR) in children. This paper reviews the long-term results of endoscopic treatment of reflux using various tissue-augmenting substances presently available. In terms of effectiveness and long-term successful results, polytetrafluoroethylene is still the most reliable injectable material for the endoscopic treatment of VUR.     

Vesicoureteral reflux: why we can't agree on its management! An evidence based approach

Vesicoureteral reflux remains one of the most controversial subjects in paediatric urology. The flooding of publications on reflux makes the understanding of this anomaly and its treatments quite opaque. Evidence Based Medicine might be a helpful tool to clarify the various approaches of reflux reflected in 6.715 publications found on Medline with the key-words "vesicoureteral reflux" and "vesicoureteric reflux". These articles were critically reviewed and graded according to EBM scorings, with regard to their methodological designs. It appears clearly after this review of literature concerning VUR that most of our beliefs are based on low evidence publications and that EBM has not sufficient arguments to establish recommendations for diagnostic and treatment of VUR. It appears yet that antenatal dilatation of the urinary tract and symptomatic UTIs justify looking for VUR. Surgery should be discussed in recurrent UTIs or deterioration of renal function. There is no consensus in the case of persistent asymptomatic VUR, indication and duration of antibioprophylaxis, and choice of radical treatment.     

Use of collagen injections for vesicoureteral reflux in transplanted kidneys

Reports in the literature suggest the incidence of vesicoureteral reflux (VUR) in transplanted kidneys to range from 2-79%. Collagen injections have been used with reported success rates of up to 65% to prevent VUR into native orifices in children, but have not been studied in transplant neo-orifices. We evaluated the use of collagen injections in seven patients with transplant kidney neo-orifices who displayed grades II-IV VUR and seemed to be related to symptomatic urinary tract infections (UTIs). Postoperative VCUGs obtained at 2 months showed improvement in the grade of reflux in four of seven (57.1%) patients; one (14.3%), no change; and two (28.6%), worse reflux. All patients also redeveloped symptomatic UTIs after collagen injection. We conclude that the use of collagen injections in kidney transplant neo-orifices did not prevent VUR. Although prevention of VUR may have been achieved short term, VCUG examinations 2 months after initial injection revealed persistent reflux. Etiologies for failure to prevent VUR may be the readily absorbable nature of collagen, technical aspects of the procedure, the degree of reflux, and anatomic differences between native orifices (which lie on a well-supported trigone) and transplant neo-orifices (which lie on the posterior wall with less support).     

Relationship between febrile urinary tract infection and urodynamics in myelodysplastic children with vesicoureteral reflux

OBJECTIVE: We conducted a retrospective study in order to identify factors that may predict the incidence of febrile urinary tract infection (UTI) in myelodysplastic children with vesicoureteral reflux (VUR). METHODS: A total of 23 myelodysplastic children with persistent VUR who were managed by clean intermittent catheterization (CIC) were eligible for this study. Any factors, including urodynamic parameters and urinary tract abnormalities, that may have been associated with the incidence of febrile UTI were evaluated using both univariate analysis and multiple logistic regression analysis. RESULTS: Of 23 patients, 10 (43%) had had one or more episodes of febrile UTI. Both univariate and multivariate analyses showed a statistically significant relationship between low bladder compliance (<10 ml/cm H(2)O) and episodes of febrile UTI. CONCLUSION: These results demonstrated that the urodynamics linked to bladder function disorder in the filling phase appear to be correlated with the incidence of febrile UTI in myelodysplastic children with VUR who are managed by CIC.     

Successful treatment of vesicoureteric reflux by subureteric injection of silicone

Although the technique of subureteric injection has been widely accepted as an alternative to reimplantation in the treatment of vesicoureteric reflux (VUR), the choice of the material to be used is controversial. We report our experience with the endoscopic treatment of VUR by a submucosal injection of silicone. A 24-year-old man who had VUR (Grade II) and renal insufficiency was treated by endoscopic injection of silicone. Cystography after the treatment showed absence of reflux.     

Die Behandlung des vesikoureteralen Refluxes im Kindesalter

The pathophysiology, evaluation and therapy of vesicoureteral reflux (VUR) were newly illuminated over the past years through different clinical studies and basic research. Our understanding of vesicoureteral reflux and the therapeutic spectrum of its treatment should therefore consistently undergo critical revision. The Swedish Reflux Study set up three different therapy options for small children with dilated VUR: antibiotic prophylaxis, endoscopic reflux correction and surveillance were prospectively analysed in a randomized fashion. The results are discussed in this work and completed with a statement about open operative reflux therapy.     

The safety and efficacy of endoscopic incision of orthotopic ureterocele in adult

Endoscopic incision is a good management option for orthotopic ureterocele. But most of the literature has shown its efficacy only in children. We have done this retrospective study to evaluate the safety and efficacy of endoscopic incision of orthotopic ureterocele in adults. From March 2004 to January 2008, at our center, 26 adults underwent transurethral, transverse incision of an ureterocele. The perioperative data of these patients were retrospectively analyzed. The literature was reviewed to identify all the reported options for management of this relatively rare condition in adults. Unilateral ureterocele was present in 24 patients and two patients had bilateral ureterocele. One patient had associated upper tract stones. Three patients had associated stones in ureterocele. Transurethral, transverse incision of ureterocele was given in all patients. The mean postoperative hospital stay was 50.5 h. Twenty-three patients were available for follow-up at three, six and 12 months. All patients were symptom free. At three months ultrasound and intravenous urography revealed no residual ureterocele but four patients showed residual hydronephrosis, but with a decrease in the grade indicating decompression. Micturating cystourethrography revealed vesico-ureteral reflux (VUR) in two patients and the reflux persisted in one patient even at 6 months. We conclude that in adults, management with endoscopic incision of orthotopic ureterocele is safe and effective. VUR may occur in a few cases.     

Endoscopic Treatment for Post-Transplant Vesicoureteral Reflux

IntroductionVesicoureteral reflux (VUR) is one of the most common ureteric complications after kidney transplantation that might cause symptomatic infections which deteriorate graft function. Surgical reimplantation has been the standard treatment; recently, endoscopic injection has been an alternative approach. We report our endoscopic treatment results and analyze the long-term outcome, even in patients with less optimal graft function.Materials and methodsA total of 16 patients and 19 symptomatic VUR were diagnosed at mean time of 88.3 months after their transplantation. The distribution of VUR grade was 1, 2, 8, 6, and 2 for grade I to V, respectively, with a mean VUR grade of 3.26 according to their voiding cystourethrogram images. Endoscopic Deflux injections were performed by a single urologist via rigid cystoscope with a beveled needle system. They were followed monthly thereafter.ResultThe average number of admissions due to symptomatic urinary tract infection was 2.68/person, and the mean creatinine level before endoscopic treatment was 1.63 mg/dL. The amount of Deflux injection was 0.7 to 1.2 mL per affected ureter; the mean creatinine level after endoscopic treatment was 1.41 mg/dL. The eGFR remained stationary in both eGFR > 60 and eGFR < 60 mL/min groups with a clinical success rate of 75% in both groups.ConclusionEndoscopic dextranomer-hyaluronic acid injection is a safe and feasible treatment option for VUR after kidney transplantation. Our data showed its efficacy in recipients whose eGFR is less than 60 mL/min.