Vesicoureteral Reflux

Fifth stage

Pediatric
Lec-8
د.اثل

17/11/2015

Vesicoureteral Reflux
VUR is the retrograde flow of urine from the bladder to the ureter or up to the kidney.

Classification of VUR

Various anatomic defects of the ureterovesical junction associated with VUR.

Grading of VUR (Very Important):



Grade I: into a nondilated ureter.
Grade II: into the pelvis and calyces without dilatation.
Grade III: mild to moderate dilatation of the ureter, renal pelvis, and calyces with minimal blunting of the fornices.
Grade IV: moderate ureteral tortuosity and dilatation of the pelvis and calyces.
Grade V: gross dilatation of the ureter, pelvis, and calyces; loss of papillary impressions; and ureteral tortuosity.

CLINICAL MANIFESTATIONS

VUR is most often identified during radiologic evaluation following a UTI.
The younger the patient with a UTI, the more likely VUR is present.
No clinical signs are reliable in differentiating children with UTI with and without VUR.

DIAGNOSTIC STUDIES

An imaging study can be performed after initiation treatment of UTI.
RUS
VCUG (radionuclide cystogram ): anatomical details
NCG (radionuclide cystogram ): less anatomical details but less radiation risk.


Indication of VSUG:
Recent AAP guidelines:
Infant with 1st UTI between 2-24 mo in whom RUS reveals hydronephrosis , scarring, other finding suggestive high grade VUR or obstructive uropathy.
Recurrent febrile UTI.
Atypical infection.
VSUG: showing
G 4 right VUR

TREATMENT

Controversy remains about whether long term prophylactic antibiotics is indicated in mild –moderate VUR.
Surgery: open or laproscopic.
Endoscopic repair of VUR involves injection of a bulking agent through a cystoscope just beneath the ureteral orifice, creating an artificial flap-valve. The FDA approved the use of a biodegradable material, dextranomer microspheres suspended in hyaluronic acid (Deflux), for subureteral injection.
Endoscopic correction of VUR. Through a cystoscope, a needle is inserted into the submucosal plane deep to the ureteral orifice and bulking agent is injected, creating a flap-valve to preventVUR.

A, Endoscopic view of right vesicoureteral refluxing ureter.

B, The same ureter after subureteral injection of dextranomer microspheres.

Complications

Hypertension
CKD