UrologySchool.com

Pediatrics: Vesicoureteral Reflux: Difference between revisions

← Older edit
Visual
 
(15 intermediate revisions by the same user not shown)
Line 1: Line 1:
'''See [[AUA: Vesicoureteral Reflux (2017)|2017 AUA Guidelines on Vesicoureteral Reflux]]'''
'''See [[AUA: Vesicoureteral Reflux (2017)|2017 AUA Guidelines on Vesicoureteral Reflux]]'''
See [https://www.youtube.com/watch?v=hdgES3qkzv0 Vesicoureteral Reflux Video Lecture] (Dr. Christina Ching, PedsUroFLO 2020)


== Embryology of the Ureterovesical Junction ==
== Embryology of the Ureterovesical Junction ==


* If the ureteric bud reaches the urogenital sinus too late (because of budding late), insufficient rotation occurs, resulting in an ectopic ureter
* '''Primary vesicoureteral reflux is due to early budding that results in a lateral and high insertion in the bladder'''
* '''A ureteral bud that is laterally (cranially) positioned from a normal takeoff at the trigone offers an embryologic explanation for primary reflux,''' whereas those inferiorly (caudally) positioned are often obstructed.
**'''A ureteral bud that is laterally (cranially) positioned from a normal takeoff at the trigone offers an embryologic explanation for primary reflux,''' whereas those inferiorly (caudally) positioned are often obstructed.
*'''Ectopic ureter is due to late budding''' (the ureteric bud reaches the urogenital sinus too late) that results in insufficient rotation and ectopic ureter


== Functional Anatomy of the Antireflux Mechanism ==
== Functional Anatomy of the Antireflux Mechanism ==
Line 45: Line 48:
* '''<span style="color:#ff0000">VUR due to fundamental deficiency of the longitudinal muscle of the intravesical ureter resulting in an inadequate valvular mechanism while the remaining factors (bladder and ureter) remain normal or relatively noncontributory'''
* '''<span style="color:#ff0000">VUR due to fundamental deficiency of the longitudinal muscle of the intravesical ureter resulting in an inadequate valvular mechanism while the remaining factors (bladder and ureter) remain normal or relatively noncontributory'''
** VUR may be a normal variant in the population but becomes clinically relevant only in some because of a predisposition to UTI. This is supported by the observation that VUR without infection is of questionable clinical significance
** VUR may be a normal variant in the population but becomes clinically relevant only in some because of a predisposition to UTI. This is supported by the observation that VUR without infection is of questionable clinical significance
* '''Genetics'''
* '''Risk Factors'''
** '''66% rate of reflux in the offspring'''
**'''Genetics'''
*** Tendency for an autosomal dominant pattern of inheritance; probably many genes are involved
*** Tendency for an '''autosomal dominant pattern of inheritance'''; probably many genes are involved
** '''Prevalence of VUR in siblings to be ≈32%'''
***'''Prevalence of VUR in'''
*** Because the renal consequences of VUR are at issue, rather than reflux itself, siblings may be better served by non-invasively (ultrasound) screening for cortical abnormalities first, and screening for VUR if history of compounding factors such as UTI or bowel and bladder dysfunction are manifested.
****'''Offspring: ≈65%'''
**** By taking into account the imaging of the kidneys first, as well as the patient’s age and history of UTI, a rational top-down approach to sibling reflux screening emerges.
**** '''Siblings: ≈30%'''
**** It cannot be assumed that all cortical abnormalities in siblings with VUR are acquired. The lack of prospective studies should temper the notion of mass screening of siblings
***** Screening in siblings
**** In any sibling, however, in whom reflux is diagnosed, the indications for treatment remain the same as for general reflux in the pediatric population.
******Because the renal consequences of VUR are at issue, rather than reflux itself, siblings may be better served by non-invasively (ultrasound) screening for cortical abnormalities first, and screening for VUR if history of compounding factors such as UTI or bowel and bladder dysfunction are manifested.
******* By taking into account the imaging of the kidneys first, as well as the patient’s age and history of UTI, a rational top-down approach to sibling reflux screening emerges.
******* It cannot be assumed that all cortical abnormalities in siblings with VUR are acquired. The lack of prospective studies should temper the notion of mass screening of siblings
******* In any sibling, however, in whom reflux is diagnosed, the indications for treatment remain the same as for general reflux in the pediatric population.


=== Secondary Reflux ===
=== Secondary Reflux ===
Line 69: Line 75:
#* Reflux is present in 48-70% of patients with PUV patients
#* Reflux is present in 48-70% of patients with PUV patients
# '''<span style="color:#ff0000">Neurogenic bladder'''
# '''<span style="color:#ff0000">Neurogenic bladder'''
#* '''Spina bifida, in particular, is at risk for VUR'''
#* '''<span style="color:#ff0000">Spina bifida, in particular, is at risk for VUR'''
#** '''Special attention for the potential for occult spinal dysraphism is warranted during evaluation of any child with UTI'''
#** '''Special attention for the potential for occult spinal dysraphism is warranted during evaluation of any child with UTI'''
#* '''Urodynamic risk factors for VUR:'''
#* '''Urodynamic risk factors for VUR:'''
Line 119: Line 125:
== Diagnosis and Evaluation ==
== Diagnosis and Evaluation ==


* '''UTI'''
=== Labs ===
** '''Confirmation of UTI''' is paramount in the appropriate management of the patient with VUR
 
* '''<span style="color:#ff0000">UTI'''
** '''<span style="color:#ff0000">Confirmation of UTI is paramount in the appropriate management of the patient with VUR'''
*** The method of urine collection and the presence of pyuria are of utmost importance in the diagnosis of UTI to avoid false-positive culture results
*** The method of urine collection and the presence of pyuria are of utmost importance in the diagnosis of UTI to avoid false-positive culture results
*** '''US of the kidneys and bladder can be considered a reasonable minimum evaluation in the infant or child after a UTI'''
*** '''<span style="color:#ff0000">US of the kidneys and bladder can be considered a reasonable minimum evaluation in the infant or child after a UTI'''
**** '''Older children who present with asymptomatic bacteriuria or UTIs that manifest solely with lower tract symptoms can be screened initially with US alone,''' reserving cystography for those with abnormal upper tracts or recalcitrant infections.
**** '''Older children who present with asymptomatic bacteriuria or UTIs that manifest solely with lower tract symptoms can be screened initially with US alone,''' reserving cystography for those with abnormal upper tracts or recalcitrant infections.
***** The presence of structural renal anomalies or significant asymmetry would support proceeding with a cystogram.
***** The presence of structural renal anomalies or significant asymmetry would support proceeding with a cystogram.
* '''Assessment of the Lower Urinary Tract'''
 
** '''Cystogram'''
=== Imaging ===
*** '''VCUG and radionuclide cystogram (RNC) are the two common forms of direct cystography and constitute the present-day gold standard approaches to detect VUR'''
 
**** '''Both VCUG and RNC require catheterization'''
==== Lower Urinary Tract ====
**** '''RNC'''
* '''<span style="color:#ff0000">Modality'''
***** '''Advantages (2):'''
**'''<span style="color:#ff0000">Voiding cystourethrogram (VCUG) and radionuclide cystogram (RNC)'''
*****# '''Reduced radiation requirements'''
***Two most common forms of direct cystography
*****#* RNC has historically been described as a technique that requires a significantly lower dose of radiation than a regular VCUG, but the advances with modern digital techniques have significantly narrowed the difference between these two imaging modalities.
***'''<span style="color:#ff0000">Present-day gold standard approaches to detect VUR'''
*****# '''Greater sensitivity for grade 2 to 5 VUR'''
***'''Both VCUG and RNC require catheterization'''
***** '''Disadvantage:'''
***'''Radionuclide Cystogram (RNC)'''
****** '''Provides much less anatomic detail than does a VCUG'''
**** '''Advantages (2):'''
**** More recently, to eliminate the need for ionizing radiation, some studies have demonstrated a growing interest in US detection of VUR using either color Doppler imaging
****# '''Reduced radiation requirements'''
*** Direct imaging of VUR is affected by several parameters which include''':'''
****#* RNC has historically been described as a technique that requires a significantly lower dose of radiation than a regular VCUG, but the advances with modern digital techniques have significantly narrowed the difference between these two imaging modalities.
***# Bladder contraction during voiding
****# '''Greater sensitivity for grade 2 to 5 VUR'''
***# Fluid volume instilled into the bladder
**** '''Disadvantage:'''
***# Presence of infection and therefore inflammation of the UVJ mucosa.
***** '''Provides much less anatomic detail than does a VCUG'''
**** '''Even during voiding, reflux may not be demonstrated on a single filling-voiding cycle'''. Several studies have demonstrated a roughly 12-20% '''greater detection rate for VUR if a cyclic study is performed'''
*** '''Voiding Cystourethrogram (VCUG)'''
*** '''Passive reflux (VUR during filling of the bladder) is generally considered a poor prognostic sign for reflux resolution and suggests the presence of a fixed decompensation of the UVJ.'''
****'''Technique'''
**** Filling assumes far lower intravesical pressure than that of voiding
*****Bladder contrast is instilled by gravity after urethral catheterization. Bladder capacity is recorded when contrast influx ceases. Static images record bladder contour, presence of diverticula or ureteroceles, grade of reflux, configuration and blunting of calyces, and intrarenal reflux. Passive or active reflux is demonstrated dynamically during fluoroscopy while filling and voiding, respectively. In addition, bladder neck anatomy, funneling or dilation, and urethral patency are parameters derived from the VCUG.
**** '''Passive reflux is common finding in patients with acquired or neurogenic voiding dysfunction'''
***** '''Delayed or postvoid films are crucial in documenting clearance of contrast from the upper tracts because retained contrast, particularly with dilated pelvicalyceal systems, could signify the presence of a concomitant UPJ obstruction (UPJO)'''
*** '''Cystogram during active infection'''
**Ultrasound
**** '''The general consensus has been to delay the voiding study for at least a week or longer to allow for adequate recovery from the acute infection episode.'''
***More recently, to eliminate the need for ionizing radiation, some studies have demonstrated a growing interest in US detection of VUR using either color Doppler imaging
***** Evoking reflux during an active cystitis, by definition, will transmit bacteria to the upper urinary tract and renal pelvis and risks iatrogenic pyelonephritis.
* '''Findings'''
**** '''Only if it is imperative to make the diagnosis of reflux in children with a history of recurrent pyelonephritis and repeatedly negative voiding studies in the intercurrent periods should cystography during UTI be considered.'''
**Parameters that effect direct imaging of VUR (3)''':'''
***** Some UVJs maintain only borderline antireflux mechanisms, which are competent in a sterile milieu but become incompetent from edema and inflammation associated with mucosal inflammation during cystitis. Such patients may have VCUG studies negative for reflux in the absence of infection but suffer from repeated pyelonephritic episodes. Cystograms in such patients may demonstrate reflux if obtained during clinically active infection, whereas cystogram obtained in the presence of positive urine cultures alone may not.
**# Bladder contraction during voiding
*** '''VCUG Technique'''
**# Fluid volume instilled into the bladder
**** Bladder contrast is instilled by gravity after urethral catheterization. Bladder capacity is recorded when contrast influx ceases. Static images record bladder contour, presence of diverticula or ureteroceles, grade of reflux, configuration and blunting of calyces, and intrarenal reflux. Passive or active reflux is demonstrated dynamically during fluoroscopy while filling and voiding, respectively. In addition, bladder neck anatomy, funneling or dilation, and urethral patency are parameters derived from the VCUG.
**# Presence of infection and therefore inflammation of the UVJ mucosa.
**** '''Delayed or postvoid films are crucial in documenting clearance of contrast from the upper tracts because retained contrast, particularly with dilated pelvicalyceal systems, could signify the presence of a concomitant UPJ obstruction (UPJO)'''
*** '''Even during voiding, reflux may not be demonstrated on a single filling-voiding cycle'''. Several studies have demonstrated a roughly 12-20% '''greater detection rate for VUR if a cyclic study is performed'''
** '''Diagnostic Controversies: Challenging the Assessment of VUR'''
** '''Passive reflux (VUR during filling of the bladder) is generally considered a poor prognostic sign for reflux resolution and suggests the presence of a fixed decompensation of the UVJ.'''
*** '''Uroflowmetry'''
*** Filling assumes far lower intravesical pressure than that of voiding
**** A valuable tool in the workup of a patient with vesicoureteral reflux
*** '''Passive reflux is common finding in patients with acquired or neurogenic voiding dysfunction'''
**** A minimal survey of bladder emptying characteristics can be obtained
* '''Cystogram during active infection'''
***** Lack of smoothness of the flow-velocity curve suggest incomplete relaxation of the bladder outlet during voiding.
** '''The general consensus has been to delay the voiding study for at least a week or longer to allow for adequate recovery from the acute infection episode.'''
****** This implies the existence or development of relatively higher pressures during voiding, which could delay the natural history of VUR resolution or even perpetuate VUR.
*** Evoking reflux during an active cystitis, by definition, will transmit bacteria to the upper urinary tract and renal pelvis and risks iatrogenic pyelonephritis.
***** Increased postvoid residual volume may be a risk factor for UTI.
** '''Only if it is imperative to make the diagnosis of reflux in children with a history of recurrent pyelonephritis and repeatedly negative voiding studies in the intercurrent periods should cystography during UTI be considered.'''
****** In the setting of passive VUR, carrying infected postvoid residual urine also can lead to ascending infection and pyelonephritis.
*** Some UVJs maintain only borderline antireflux mechanisms, which are competent in a sterile milieu but become incompetent from edema and inflammation associated with mucosal inflammation during cystitis. Such patients may have VCUG studies negative for reflux in the absence of infection but suffer from repeated pyelonephritic episodes. Cystograms in such patients may demonstrate reflux if obtained during clinically active infection, whereas cystogram obtained in the presence of positive urine cultures alone may not.
*** '''Top-Down Approach'''
* '''Diagnostic Controversies: Challenging the Assessment of VUR'''
**** '''Only a dimercaptosuccinic acid (DMSA) renal scan is obtained after a febrile UTI, with cystography reserved only for patients with abnormal scintigraphy findings.'''
** '''Uroflowmetry'''
***** '''Children with a normal DMSA scan undergo no further evaluation unless they develop recurrent UTI, in which case a VCUG should be obtained'''.
*** A valuable tool in the workup of a patient with vesicoureteral reflux
***** Photopenic areas may result from postinfection renal scarring and some renal dysplasia.
*** A minimal survey of bladder emptying characteristics can be obtained
***** Vesicoureteral reflux, particularly reflux of higher grades, may result in renal dysplasia, which often appears scintigraphically identical to postinfection pyelonephritic scars.
**** Lack of smoothness of the flow-velocity curve suggest incomplete relaxation of the bladder outlet during voiding.
***** During an episode of active pyelonephritis, the renal scan may show an area of photopenia that later, if it persists, represents renal scarring secondary to the infection.
***** This implies the existence or development of relatively higher pressures during voiding, which could delay the natural history of VUR resolution or even perpetuate VUR.
***** Neither renal scan nor ultrasonography can differentiate accurately between renal dysplasia and renal scarring
**** Increased postvoid residual volume may be a risk factor for UTI.
**** '''A critical assumption with this approach is that VUR in the absence of scintigraphic renal abnormality is unlikely to cause future renal damage'''
***** In the setting of passive VUR, carrying infected postvoid residual urine also can lead to ascending infection and pyelonephritis.
**** '''The top-down approach performs poorly at detecting high-grade VUR''' with a sensitivity and specificity of only 79% and 53%, respectively
** '''Top-Down Approach'''
** '''American Academy of Pediatrics Guidelines for Febrile UTI Diagnosis and Management in Young Children'''
*** '''Only a dimercaptosuccinic acid (DMSA) renal scan is obtained after a febrile UTI, with cystography reserved only for patients with abnormal scintigraphy findings.'''
*** '''VCUG should be obtained after second febrile UTI'''
**** '''Children with a normal DMSA scan undergo no further evaluation unless they develop recurrent UTI, in which case a VCUG should be obtained'''.
**** Previous recommendation was after the first febrile UTI
**** Photopenic areas may result from postinfection renal scarring and some renal dysplasia.
**** '''VCUG should be obtained after first febrile UTI if''':
**** Vesicoureteral reflux, particularly reflux of higher grades, may result in renal dysplasia, which often appears scintigraphically identical to postinfection pyelonephritic scars.
****# US shows hydronephrosis, possible renal scarring or dysmorphism
**** During an episode of active pyelonephritis, the renal scan may show an area of photopenia that later, if it persists, represents renal scarring secondary to the infection.
****# Other findings that suggest high-grade VUR
**** Neither renal scan nor ultrasonography can differentiate accurately between renal dysplasia and renal scarring
****# Obstructive uropathy are present
*** '''A critical assumption with this approach is that VUR in the absence of scintigraphic renal abnormality is unlikely to cause future renal damage'''
****# Any complex or clinically atypical scenario
*** '''The top-down approach performs poorly at detecting high-grade VUR''' with a sensitivity and specificity of only 79% and 53%, respectively
** '''Cystoscopy'''
* '''American Academy of Pediatrics Guidelines for Febrile UTI Diagnosis and Management in Young Children'''
*** '''Routine cystoscopy is contraindicated in reflux management'''
** '''VCUG should be obtained after second febrile UTI'''
**** The assessment of appearance and configuration of the ureteric orifices and intramural tunnel length provide little correlation with either the diagnosis or grade of reflux
*** Previous recommendation was after the first febrile UTI
**** '''The cystoscopic position of the refluxing ureteric orifice is permanent lateral displacement'''
*** '''VCUG should be obtained after first febrile UTI if''':
* '''Assessment of the Upper Urinary Tract'''
***# US shows hydronephrosis, possible renal scarring or dysmorphism
** '''Rationale for Serial Assessment of Upper Tracts'''
***# Other findings that suggest high-grade VUR
*** '''Pyelonephritis propagated by VUR causes:'''
***# Obstructive uropathy are present
***# '''Renal scarring'''
***# Any complex or clinically atypical scenario
***# '''Impedes attainment of full renal growth potential'''
 
***# '''Increases risk for renovascular hypertension'''
==== Upper Urinary Tract ====
*** '''Most parenchymal abnormalities are detected after the first episode of pyelonephritis'''
* '''Rationale for Serial Assessment of Upper Tracts'''
*** A fundamental goal in serial upper tract imaging with VUR is to ascertain whether abnormalities are due to ongoing or resolved reflux and differentiate them from intrinsic developmental disturbances, medical renal disease, or antegrade flow resistance.
** '''Pyelonephritis propagated by VUR causes:'''
*** Intensity of upper tract studies should be proportional to the propensity for renal damage
**# '''Renal scarring'''
*** The challenge in imaging is to differentiate congenital reflux–associated renal dysmorphism from scarring acquired after infection
**# '''Impedes attainment of full renal growth potential'''
**** VUR, particularly of higher grades, may result in renal maldevelopment that often appears scintigraphically or sonographically identical to postinfection pyelonephritic scars
**# '''Increases risk for renovascular hypertension'''
** '''Renal US'''
** '''Most parenchymal abnormalities are detected after the first episode of pyelonephritis'''
*** The mainstay of renal imaging in VUR management
** A fundamental goal in serial upper tract imaging with VUR is to ascertain whether abnormalities are due to ongoing or resolved reflux and differentiate them from intrinsic developmental disturbances, medical renal disease, or antegrade flow resistance.
*** '''The appearance of the kidneys on ultrasound does not correlate with the absence or presence of reflux, or with its grade'''
** Intensity of upper tract studies should be proportional to the propensity for renal damage
*** '''Renal resistive index measurements are significantly increased in higher grades of reflux'''
** The challenge in imaging is to differentiate congenital reflux–associated renal dysmorphism from scarring acquired after infection
** '''Renal Scintigraphy'''
*** VUR, particularly of higher grades, may result in renal maldevelopment that often appears scintigraphically or sonographically identical to postinfection pyelonephritic scars
*** '''The gold standard for imaging functioning renal parenchyma is scintigraphy using 99mTc-labeled DMSA.'''
* '''Renal US'''
**** The radiotracer is taken up only by functioning proximal tubular tissue mass, where it binds for several hours.
** The mainstay of renal imaging in VUR management
***** Because pyelonephritis impairs tubular uptake of radiotracer, these areas will fail to radioemit photons and appear as unexposed or underexposed regions in the resultant renal cortical images
** '''The appearance of the kidneys on ultrasound does not correlate with the absence or presence of reflux, or with its grade'''
***** DMSA scanning provides 98% sensitivity and 92% specificity for scar detection
** '''Renal resistive index measurements are significantly increased in higher grades of reflux'''
**** The uptake of DMSA provides a good proportional representation of glomerular filtration
* '''Renal Scintigraphy'''
**** No consensus exists on the precise use of DMSA scanning in reflux management.
** '''The gold standard for imaging functioning renal parenchyma is scintigraphy using 99mTc-labeled DMSA.'''
** DMSA and ultrasonography are often used complementarily, particularly when knowledge of relative renal function is desired since all DMSA defects are not necessarily scars.
*** The radiotracer is taken up only by functioning proximal tubular tissue mass, where it binds for several hours.
**** Because pyelonephritis impairs tubular uptake of radiotracer, these areas will fail to radioemit photons and appear as unexposed or underexposed regions in the resultant renal cortical images
**** DMSA scanning provides 98% sensitivity and 92% specificity for scar detection
*** The uptake of DMSA provides a good proportional representation of glomerular filtration
*** No consensus exists on the precise use of DMSA scanning in reflux management.
* DMSA and ultrasonography are often used complementarily, particularly when knowledge of relative renal function is desired since all DMSA defects are not necessarily scars.
 
=== Other ===
 
==== Cystoscopy ====
* '''Routine cystoscopy is contraindicated in reflux management'''
** The assessment of appearance and configuration of the ureteric orifices and intramural tunnel length provide little correlation with either the diagnosis or grade of reflux
** '''The cystoscopic position of the refluxing ureteric orifice is permanent lateral displacement'''


== Complications of Acquired Scarring ==
== Complications of Acquired Scarring ==
Line 278: Line 298:
== Natural History ==
== Natural History ==


* '''At birth, the probability of spontaneous resolution of primary VUR is inversely proportional to the initial grade'''
* '''<span style="color:#ff0000">At birth, the probability of spontaneous resolution of primary VUR is inversely proportional to the initial grade'''
** '''Most cases of low-grade reflux (grade 1 and 2) will resolve'''
** '''<span style="color:#ff0000">Most cases of low-grade reflux (grade 1 and 2) will resolve'''
** '''Grade 3 reflux will resolve in ≈50% of cases'''
** '''<span style="color:#ff0000">Grade 3 reflux will resolve in ≈50% of cases'''
** '''Very few cases of higher-grade reflux (grades 4 and 5, and bilateral grade 3) will resolve spontaneously'''
** '''<span style="color:#ff0000">Very few cases of higher-grade reflux (grades 4 and 5, and bilateral grade 3) will resolve spontaneously'''
*** Attempting to discriminate true differences in resolution rates for grades 3 and higher reflux may not be particularly clinically relevant.
*** Attempting to discriminate true differences in resolution rates for grades 3 and higher reflux may not be particularly clinically relevant.
* '''At a later age, spontaneous resolution will depend on:'''
* '''At a later age, spontaneous resolution will depend on:'''
Line 293: Line 313:
== Management ==
== Management ==


* '''See AUA VUR Guideline Notes'''
* '''See [[AUA: Vesicoureteral Reflux (2017)|2017 AUA Guidelines on Vesicoureteral Reflux]]'''
* '''Essential tenets of reflux management:'''
 
*# '''BBD is by far one of the most critical and modifiable variables that affect VUR management and attendant UTIs'''
=== Principles of Reflux Management ===
*#* '''Constipation must be recognized and eliminated as much as possible to establish optimal conditions for successful spontaneous or surgical resolution of reflux'''
# '''BBD is by far one of the most critical and modifiable variables that affect VUR management and attendant UTIs'''
*#* BBD lowers VUR resolution rates.
#* '''Constipation must be recognized and eliminated as much as possible to establish optimal conditions for successful spontaneous or surgical resolution of reflux'''
*# Parental perceptions of reflux management must be considered when treating a child with reflux
#* BBD lowers VUR resolution rates.
*# Spontaneous resolution of reflux is very common
# '''Parental perceptions of reflux management must be considered when treating a child with reflux'''
*#* ≈80% of low-grade and ≈50% of grade 3 reflux will resolve spontaneously.
# '''Spontaneous resolution of reflux is very common'''
*# High-grade reflux is less likely to resolve spontaneously
#* ≈80% of low-grade and ≈50% of grade 3 reflux will resolve spontaneously.
*# Sterile reflux is benign
# '''High-grade reflux is less likely to resolve spontaneously'''
*# "Extended use of prophylactic antibiotics is benign"
# '''Sterile reflux is benign'''
*# Success of (open) surgical correction is very high
# "Extended use of prophylactic antibiotics is benign"
*#* Ureteral reimplant is successful in correcting reflux in > 98% of cases
# Success of (open) surgical correction is very high
* '''Options:'''
#* Ureteral reimplant is successful in correcting reflux in > 98% of cases
** '''Includes management of any bowel-bladder dysfunction'''
 
** '''First-line (classic approach): watchful waiting''' '''with''' '''daily low-dose antibiotic prophylaxis'''
=== Options: ===
** '''Second-line: intervention'''
* '''Includes management of any bowel-bladder dysfunction'''
*** '''Options:'''
* '''First-line (classic approach): watchful waiting''' '''with''' '''daily low-dose antibiotic prophylaxis'''
**** '''Endoscopic'''
* '''Second-line: intervention'''
**** '''Open/laparoscopic ureteral reimplant'''
** '''Options:'''
*** '''Failure to address voiding abnormalities can adversely affect outcome of anti-reflux surgery'''
*** '''Endoscopic'''
*** '''Open/laparoscopic ureteral reimplant'''
** '''Failure to address voiding abnormalities can adversely affect outcome of anti-reflux surgery'''
 
=== Watchful waiting with daily low-dose antibiotic prophylaxis ===
* '''Underlying principle: every case of reflux should be offered time to resolve spontaneously, despite grade'''
* Maintaining urine sterility (through both prophylactic antibiotics and strict attention to bladder and bowel management) is the cornerstone of watchful waiting medical management
* '''Nighttime dosing allows for antibiotic concentration in the bladder urine over the longest period of expected physiologic retention, when infection is most likely to develop.'''
* '''For children age < 2 months, the most commonly used medications are trimethoprim and amoxicillin.'''
* '''In newborn patients, it is reasonable to wait until ≈5 years of age assuming no intercurrent breakthrough infections occur'''. Beyond this age, it is commonly believed that the kidneys become less prone to scarring after pyelonephritis. Thus, some withdraw prophylaxis as the child approaches the age of 5.
** '''After this age, boys with asymptomatic reflux will require little or no formal follow-up''' as long as lifelong attention to good bladder habits is reinforced, and they are counseled to seek prompt medical attention if a pyelonephritis were to occur in the future, as well as reassessment of their reflux status.
*** Uncircumcised male children older than 1 year do not appear to be at higher risk for development of recurrent UTI after discontinuation of CAP.
** '''Girls have traditionally undergone open surgical correction, even for asymptomatic reflux that fails to resolve by the age of 5, on the premise that it will reduce maternal and fetal morbidity during a future pregnancy'''
*** '''Women with a history of VUR have increased morbidity during pregnancy because of infection-related complications, whether the reflux has been corrected or not.'''
**** '''Addintional risk factors that may lead to increased morbidity in pregnant patients with VUR:'''
****# '''Hypertension'''
****# '''Renal insufficiency'''
****#* Associated with increased risk for fetal demise and accelerated maternal renal disease
****# '''Renal scarring'''
****#* Associated with an increased incidence of hypertension, increased risk for preeclampsia, increased risk of developing acute pyelonephritis, and a higher rate of obstetric interventions
****# '''History of prior infections'''
****#* Associated with increased risk of bacteriuria during pregnancy
**** '''Persistent VUR is associated with increased risk of developing acute pyelonephritis'''
**** VUR with normal kidneys is associated with an increased risk for hypertension during the last trimester
**** Impaired renal function is
**** '''Most clinicians recommend surgical correction for females with reflux that persists beyond puberty to minimize maternal and fetal morbidity'''
* '''In patients diagnosed after one or more episodes of pyelonephritis, the presence of scarring on renal scintigraphy may temper a decision for extended prophylaxis and observation''', particularly if:
** Scarring is extensive
** Reflux is high grade
** Renal function is already globally depressed
** Congenital dysmorphism of one or both kidneys is present
* '''Breakthrough febrile UTIs or pyelonephritis while on antibiotic prophylaxis are generally considered an indication for termination of watchful waiting and correcting the reflux.''' Anxiety related to ongoing reflux also warrants strong consideration for reflux correction
** '''BBD is associated with higher breakthrough infection rates.'''
* '''Adult patients who present with non-obstructive flank pain, febrile UTIs, or pyelonephritis and are found to have VUR have traditionally been offered antireflux surgery'''
* '''Cystoscopy'''
** '''Cystoscopy in the course of conservative management of VUR is indicated only to confirm or manage abnormalities found on other imaging modalities'''
* '''Landmark Studies'''
** '''International Reflux Study in Children'''
*** '''Population: 306 children aged < 11 years with high-grade reflux from North America and Europe'''
*** '''Randomized to watchful waiting with antibiotic prophylaxis vs. corrective open surgery'''
*** '''Primary end points: new renal scars and renal growth'''
*** '''Results:'''
**** '''No siginificant difference in risk of new renal scars'''
***** '''Antibiotic prophylaxis and surgery equally effective in reducing, but not eliminating, new scar formation'''
**** '''Surgery more effective than antibiotic prophylaxis in reducing, but not eliminating, the risk of pyelonephritis'''
**** '''Nosiginificant difference in risk of incident UTI (38%)'''
*** Jodal, Ulf, et al."Ten-year results of randomized treatment of children with severe vesicoureteral reflux. Final report of the International Reflux Study in Children." ''Pediatric Nephrology'' 21.6 (2006): 785.
** '''RIVUR'''
*** '''Population: 607 children with''' dilated and non-dilated '''VUR that was diagnosed after''' a first or second '''febrile or symptomatic UTI'''
**** Population was overwhelmingly female (91%)
**** Half of the study participants were < 11 months of age
*** '''Randomized to trimethoprim-sulfamethoxazole prophylaxis vs. placebo'''
*** '''Primary outcome: recurrence of UTI'''
*** '''Results:'''
**** '''45% significant decrease in UTI recurrence with antibiotic prophylaxis''' (RR: 0.55; 95% CI: 0.38-0.78)
***** When stratified into dilated and non-dilated groups, children with dilated VUR were more likely to have symptomatic recurrences than those with non-dilated VUR
***** Prophylaxis was particularly effective in children whose index infection was febrile and in those with baseline BBD.
**** '''No difference in the occurrence of renal scarring'''
**** '''Adverse reactions to antibiotics were reported in 2% of both the antibiotic prophylaxis and placebo groups.'''
*** '''Criticisms:'''
**** '''Population may not reflect typical patient in practice'''
***** '''Majority female and half under age 11 months'''
***** '''Trial does not address patients with VUR and no history of UTI'''
*** '''RIVUR Trial Investigators. Antimicrobial prophylaxis for children with vesicoureteral reflux. NEJM 2014; 370: 2367.''' <nowiki>https://www.nejm.org/doi/full/10.1056/NEJMoa1401811</nowiki>
* '''Antibiotic Controversies and Potential New Approaches'''
** There was a belief that the ''first'' febrile UTI, in the presence of reflux, will create the greater proportion of clinically significant post-infection scarring, This belief, in turn, spawned the now routine and widespread US follow-up of prenatal hydronephrosis for evidence of postnatal hydronephrosis, which, if present, then triggers the documentation of reflux by cystography to prevent the first febrile UTI by instituting immediate antibiotic prophylaxis if reflux is found.
** Antibiotic prophylaxis is destined to fail without adequate teaching and periodic review of perineal hygiene techniques, timely bladder emptying habits, and anticonstipation measures
** Prophylactic antibiotics are more likely to benefit patients with:
*** Higher grade reflux
*** Baseline bladder dysfunction
*** Bowel and bladder dysfunction
*** Febrile UTI
 
=== Endoscopic ===
* '''A reasonable alternative for children being considered for surgical correction'''
* '''Success rates vary across centers and that outcomes may not be durable.'''
** Higher success rates associated with:
**# Volume of Dx/HA used
**# Surgeon experience
**# Volcano-shaped mound with no hydrodistention
**# Utilization of the double hydrodistention-implantation technique
**# Accurate needle entry point during endoscopic injection, as well as the needle placement
*** Negative intraoperative cystogram is not associated with endoscopic success rates
* '''Untreated BBD is associated with decreased resolution rates of VUR at initial follow-up in children treated with endoscopic surgery'''
* The learning curve for endoscopic injection is believed to be different from that of open surgical reimplantation, but studies have compared these two approaches
* Indications for treatment are the same as that of open surgical reimplantation
* '''Materials used for endoscopic correction of reflux'''
** Characteristics of an ideal injectable biomaterial (4):
**# Non-toxic and stable without migration to vital organs
**# Cause minimal local inflammation, while at the same time be well encapsulated by normal fibrous tissue and fibrocytes
**# Easy to inject through a long needle that passes easily through most standard endoscopic instruments
**# Viscous enough to prevent leakage from the puncture site and maintain its injected volume and the mound shape after the normal process of exchange and excretion of any carrier molecules.
** '''Classified as particulate vs. degradable and autologous vs. non-autologous'''
*** '''Disadvantage of particulate agents is risk of migration'''
*** '''Disadvantage of degradable agents is less durability'''
**** '''Deflux is biodegradable, the carrier gel is reabsorbed''', and the dextranomer microspheres become capsulated by fibroblast migration and collagen ingrowth
**** '''DX/HA loses ≈23% of its volume beyond 3 months of follow-up'''
*** '''Autologous Materials'''
**** '''Fat, collagen, muscle, and chondrocytes have been evaluated as bulking agents'''
* '''Follow-Up after Endoscopic Treatment'''
** '''The child is maintained on antibiotics for 3 months.'''
** '''US and VCUG are obtained at 3 months.'''
*** '''If reflux is persistent, a repeat injection can be considered 6 months after the initial injection'''
*** '''If there is still no resolution, open surgery is recommended.'''
**** '''Most reports to date have not indicated any additional difficulty with open surgery after endoscopic correction using Deflux'''


* '''Watchful waiting with''' '''daily low-dose antibiotic prophylaxis'''
=== Ureteral reimplant ===
** '''Underlying principle: every case of reflux should be offered time to resolve spontaneously, despite grade'''
* '''The principles of ureteral reimiplant for reflux include the following:'''
** Maintaining urine sterility (through both prophylactic antibiotics and strict attention to bladder and bowel management) is the cornerstone of watchful waiting medical management
*# '''Exclusion of causes of secondary VUR'''
** '''Nighttime dosing allows for antibiotic concentration in the bladder urine over the longest period of expected physiologic retention, when infection is most likely to develop.'''
*# Adequate mobilization of the distal ureter without tension or damage to its delicate blood supply
** '''For children age < 2 months, the most commonly used medications are trimethoprim and amoxicillin.'''
*# '''Creation of a submucosal tunnel that is generous in caliber and satisfies the 5:1 ratio of length to width'''
** '''In newborn patients, it is reasonable to wait until ≈5 years of age assuming no intercurrent breakthrough infections occur'''. Beyond this age, it is commonly believed that the kidneys become less prone to scarring after pyelonephritis. Thus, some withdraw prophylaxis as the child approaches the age of 5.
*# Attention to the entry point of the ureter into the bladder (hiatus), the direction of the submucosal tunnel, and the ureteromucosal anastomosis to prevent stenosis, angulation, or twisting of the ureter
*** '''After this age, boys with asymptomatic reflux will require little or no formal follow-up''' as long as lifelong attention to good bladder habits is reinforced, and they are counseled to seek prompt medical attention if a pyelonephritis were to occur in the future, as well as reassessment of their reflux status.
*# '''Attention to the muscular backing of the ureter to achieve an effective anti-reflux mechanism'''
**** Uncircumcised male children older than 1 year do not appear to be at higher risk for development of recurrent UTI after discontinuation of CAP.
*# Gentle handling of the bladder to reduce postoperative hematuria and bladder spasms
*** '''Girls have traditionally undergone open surgical correction, even for asymptomatic reflux that fails to resolve by the age of 5, on the premise that it will reduce maternal and fetal morbidity during a future pregnancy'''
** '''Common to each type of open surgical repair for reflux is the creation of a valvular mechanism that enables ureteral compression with bladder filling and contraction, thus reenacting normal anatomy and function.'''
**** '''Women with a history of VUR have increased morbidity during pregnancy because of infection-related complications, whether the reflux has been corrected or not.'''
* '''Ureteral duplication'''
***** '''Addintional risk factors that may lead to increased morbidity in pregnant patients with VUR:'''
** Approximately 10% of children undergoing antireflux surgery have an element of ureteral duplication. The most common configuration is a complete duplication that results in two separate orifices. This is best managed by preserving a cuff of bladder mucosa that encompasses both orifices. Because the pair typically share blood supply along their adjoining wall, mobilization as one unit with a “common sheath” preserves vascularity and minimizes trauma.
*****# '''Hypertension'''
* '''Success rate for ureteroneocystostomy in patients with low-grade primary VUR approaches 100%'''
*****# '''Renal insufficiency'''
** '''BBD does not alter surgical resolution rates in children treated with open surgery'''
*****#* Associated with increased risk for fetal demise and accelerated maternal renal disease
** '''BBD is associated with increased incidence of UTI after surgery.'''
*****# '''Renal scarring'''
* '''Follow-Up after Ureteral Reimplant'''
*****#* Associated with an increased incidence of hypertension, increased risk for preeclampsia, increased risk of developing acute pyelonephritis, and a higher rate of obstetric interventions
** '''An US is necessary at 6-12 weeks postoperatively'''
*****# '''History of prior infections'''
*** Ureteral obstruction can be clinically silent, and therefore, the absence of ureteral obstruction must be documented.
*****#* Associated with increased risk of bacteriuria during pregnancy
*** '''Minimal ureteral dilation and low-grade hydronephrosis on early post-operative ultrasonography is not unusual'''
***** '''Persistent VUR is associated with increased risk of developing acute pyelonephritis'''
**** '''Persistence of this dilation > 3 months or its progression should be further investigated'''
***** VUR with normal kidneys is associated with an increased risk for hypertension during the last trimester
** '''Postoperative VCUG can be avoided in patients with:'''
***** Impaired renal function is
**# '''Low-grade primary reflux initially'''
***** '''Most clinicians recommend surgical correction for females with reflux that persists beyond puberty to minimize maternal and fetal morbidity'''
**# '''Normal preoperative and post-operative US examinations'''
** '''In patients diagnosed after one or more episodes of pyelonephritis, the presence of scarring on renal scintigraphy may temper a decision for extended prophylaxis and observation''', particularly if:
*** Recall that follow-up after endoscopic management includes post-operative antbiotics for 3 months and imaging with US and VCUG
*** Scarring is extensive
** Children with renal scarring should have their blood pressure measured at every visit with their family physician
*** Reflux is high grade
* '''Complications of Ureteral Reimplantation'''
*** Renal function is already globally depressed
** '''Early Complications'''
*** Congenital dysmorphism of one or both kidneys is present
*** '''Persistent Reflux'''
** '''Breakthrough febrile UTIs or pyelonephritis while on antibiotic prophylaxis are generally considered an indication for termination of watchful waiting and correcting the reflux.''' Anxiety related to ongoing reflux also warrants strong consideration for reflux correction
**** '''Early reflux after ureteroneocystostomy usually is not a significant clinical problem and commonly resolves by 1 year on repeat cystography'''
*** '''BBD is associated with higher breakthrough infection rates.'''
*** '''De novo contralateral Reflux'''
** '''Adult patients who present with non-obstructive flank pain, febrile UTIs, or pyelonephritis and are found to have VUR have traditionally been offered antireflux surgery'''
**** '''Prophylactic bilateral reimplantation for unilateral reflux, to avoid contralateral reflux, is not warranted on the basis of the high spontaneous resolution rates'''
** '''Cystoscopy'''
*** '''Obstruction at the anastamosis'''
*** '''Cystoscopy in the course of conservative management of VUR is indicated only to confirm or manage abnormalities found on other imaging modalities'''
**** Early after surgery, various degrees of obstruction can be expected of the reimplanted ureter. Edema, subtrigonal bleeding, and bladder spasms all possibly contribute. Mucus plugs and blood clots are other causes.
** '''Landmark Studies'''
**** '''Most postoperative obstructions are mild and asymptomatic and resolve spontaneously without requiring additional surgery.''' More significant obstructions are usually symptomatic.
*** '''International Reflux Study in Children'''
***** Affected children typically present 1 to 2 weeks after surgery with acute abdominal pain, nausea, and vomiting
**** '''Population: 306 children aged < 11 years with high-grade reflux from North America and Europe'''
***** '''In the more significant cases, drainage of the system either by retrograde insertion of a double-J stent or a percutaneous nephrostomy tube may be necessary'''
**** '''Randomized to watchful waiting with antibiotic prophylaxis vs. corrective open surgery'''
**** '''Many of these cases resolve without requiring additional surgery'''
**** '''Primary end points: new renal scars and renal growth'''
** '''Late complications'''
**** '''Results:'''
*** '''Obstruction at the anastamosis'''
***** '''No siginificant difference in risk of new renal scars'''
*** '''Recurrent or Persistent Reflux'''
****** '''Antibiotic prophylaxis and surgery equally effective in reducing, but not eliminating, new scar formation'''
**** '''Causes (4):'''
***** '''Surgery more effective than antibiotic prophylaxis in reducing, but not eliminating, the risk of pyelonephritis'''
****# '''High-grade reflux'''
***** '''Nosiginificant difference in risk of incident UTI (38%)'''
****# '''Inadequate ratio of tunnel length to ureteral diameter'''
**** Jodal, Ulf, et al."Ten-year results of randomized treatment of children with severe vesicoureteral reflux. Final report of the International Reflux Study in Children." ''Pediatric Nephrology'' 21.6 (2006): 785.
****#* Development of a short tunnel and failure to taper the excessively wide ureter are important factors
*** '''RIVUR'''
****# '''Failure to recognize secondary reflux''', especially associated with neurogenic bladders and PUV bladders.
**** '''Population: 607 children with''' dilated and non-dilated '''VUR that was diagnosed after''' a first or second '''febrile or symptomatic UTI'''
****# '''Bladder and bowel function''' preoperatively, as well as in all cases of persistent or recurrent reflux.
***** Population was overwhelmingly female (91%)
* '''Laparoscopic approach'''
***** Half of the study participants were < 11 months of age
** Should theoretically provide the success rate and durability of open surgery while avoiding its morbidity.
**** '''Randomized to trimethoprim-sulfamethoxazole prophylaxis vs. placebo'''
** Procedures have been attempted laparoscopically (3)
**** '''Primary outcome: recurrence of UTI'''
**# Extravesical reimplant
**** '''Results:'''
**# Gil-Vernet procedure
***** '''45% significant decrease in UTI recurrence with antibiotic prophylaxis''' (RR: 0.55; 95% CI: 0.38-0.78)
**# Cohen cross-trigonal reimplant.
****** When stratified into dilated and non-dilated groups, children with dilated VUR were more likely to have symptomatic recurrences than those with non-dilated VUR
****** Prophylaxis was particularly effective in children whose index infection was febrile and in those with baseline BBD.
***** '''No difference in the occurrence of renal scarring'''
***** '''Adverse reactions to antibiotics were reported in 2% of both the antibiotic prophylaxis and placebo groups.'''
**** '''Criticisms:'''
***** '''Population may not reflect typical patient in practice'''
****** '''Majority female and half under age 11 months'''
****** '''Trial does not address patients with VUR and no history of UTI'''
**** '''RIVUR Trial Investigators. Antimicrobial prophylaxis for children with vesicoureteral reflux. NEJM 2014; 370: 2367.''' <nowiki>https://www.nejm.org/doi/full/10.1056/NEJMoa1401811</nowiki>
** '''Antibiotic Controversies and Potential New Approaches'''
*** There was a belief that the ''first'' febrile UTI, in the presence of reflux, will create the greater proportion of clinically significant post-infection scarring, This belief, in turn, spawned the now routine and widespread US follow-up of prenatal hydronephrosis for evidence of postnatal hydronephrosis, which, if present, then triggers the documentation of reflux by cystography to prevent the first febrile UTI by instituting immediate antibiotic prophylaxis if reflux is found.
*** Antibiotic prophylaxis is destined to fail without adequate teaching and periodic review of perineal hygiene techniques, timely bladder emptying habits, and anticonstipation measures
*** Prophylactic antibiotics are more likely to benefit patients with:
**** Higher grade reflux
**** Baseline bladder dysfunction
**** Bowel and bladder dysfunction
**** Febrile UTI
* '''Endoscopic'''
** '''A reasonable alternative for children being considered for surgical correction'''
** '''Success rates vary across centers and that outcomes may not be durable.'''
*** Higher success rates associated with:
***# Volume of Dx/HA used
***# Surgeon experience
***# Volcano-shaped mound with no hydrodistention
***# Utilization of the double hydrodistention-implantation technique
***# Accurate needle entry point during endoscopic injection, as well as the needle placement
**** Negative intraoperative cystogram is not associated with endoscopic success rates
** '''Untreated BBD is associated with decreased resolution rates of VUR at initial follow-up in children treated with endoscopic surgery'''
** The learning curve for endoscopic injection is believed to be different from that of open surgical reimplantation, but studies have compared these two approaches
** Indications for treatment are the same as that of open surgical reimplantation
** '''Materials used for endoscopic correction of reflux'''
*** Characteristics of an ideal injectable biomaterial (4):
***# Non-toxic and stable without migration to vital organs
***# Cause minimal local inflammation, while at the same time be well encapsulated by normal fibrous tissue and fibrocytes
***# Easy to inject through a long needle that passes easily through most standard endoscopic instruments
***# Viscous enough to prevent leakage from the puncture site and maintain its injected volume and the mound shape after the normal process of exchange and excretion of any carrier molecules.
*** '''Classified as particulate vs. degradable and autologous vs. non-autologous'''
**** '''Disadvantage of particulate agents is risk of migration'''
**** '''Disadvantage of degradable agents is less durability'''
***** '''Deflux is biodegradable, the carrier gel is reabsorbed''', and the dextranomer microspheres become capsulated by fibroblast migration and collagen ingrowth
***** '''DX/HA loses ≈23% of its volume beyond 3 months of follow-up'''
**** '''Autologous Materials'''
***** '''Fat, collagen, muscle, and chondrocytes have been evaluated as bulking agents'''
** '''Follow-Up after Endoscopic Treatment'''
*** '''The child is maintained on antibiotics for 3 months.'''
*** '''US and VCUG are obtained at 3 months.'''
**** '''If reflux is persistent, a repeat injection can be considered 6 months after the initial injection'''
**** '''If there is still no resolution, open surgery is recommended.'''
***** '''Most reports to date have not indicated any additional difficulty with open surgery after endoscopic correction using Deflux'''
* '''Ureteral reimplant'''
** '''The principles of ureteral reimiplant for reflux include the following:'''
**# '''Exclusion of causes of secondary VUR'''
**# Adequate mobilization of the distal ureter without tension or damage to its delicate blood supply
**# '''Creation of a submucosal tunnel that is generous in caliber and satisfies the 5:1 ratio of length to width'''
**# Attention to the entry point of the ureter into the bladder (hiatus), the direction of the submucosal tunnel, and the ureteromucosal anastomosis to prevent stenosis, angulation, or twisting of the ureter
**# '''Attention to the muscular backing of the ureter to achieve an effective anti-reflux mechanism'''
**# Gentle handling of the bladder to reduce postoperative hematuria and bladder spasms
*** '''Common to each type of open surgical repair for reflux is the creation of a valvular mechanism that enables ureteral compression with bladder filling and contraction, thus reenacting normal anatomy and function.'''
** '''Ureteral duplication'''
*** Approximately 10% of children undergoing antireflux surgery have an element of ureteral duplication. The most common configuration is a complete duplication that results in two separate orifices. This is best managed by preserving a cuff of bladder mucosa that encompasses both orifices. Because the pair typically share blood supply along their adjoining wall, mobilization as one unit with a “common sheath” preserves vascularity and minimizes trauma.
** '''Success rate for ureteroneocystostomy in patients with low-grade primary VUR approaches 100%'''
*** '''BBD does not alter surgical resolution rates in children treated with open surgery'''
*** '''BBD is associated with increased incidence of UTI after surgery.'''
** '''Follow-Up after Ureteral Reimplant'''
*** '''An US is necessary at 6-12 weeks postoperatively'''
**** Ureteral obstruction can be clinically silent, and therefore, the absence of ureteral obstruction must be documented.
**** '''Minimal ureteral dilation and low-grade hydronephrosis on early post-operative ultrasonography is not unusual'''
***** '''Persistence of this dilation > 3 months or its progression should be further investigated'''
*** '''Postoperative VCUG can be avoided in patients with:'''
***# '''Low-grade primary reflux initially'''
***# '''Normal preoperative and post-operative US examinations'''
**** Recall that follow-up after endoscopic management includes post-operative antbiotics for 3 months and imaging with US and VCUG
*** Children with renal scarring should have their blood pressure measured at every visit with their family physician
** '''Complications of Ureteral Reimplantation'''
*** '''Early Complications'''
**** '''Persistent Reflux'''
***** '''Early reflux after ureteroneocystostomy usually is not a significant clinical problem and commonly resolves by 1 year on repeat cystography'''
**** '''De novo contralateral Reflux'''
***** '''Prophylactic bilateral reimplantation for unilateral reflux, to avoid contralateral reflux, is not warranted on the basis of the high spontaneous resolution rates'''
**** '''Obstruction at the anastamosis'''
***** Early after surgery, various degrees of obstruction can be expected of the reimplanted ureter. Edema, subtrigonal bleeding, and bladder spasms all possibly contribute. Mucus plugs and blood clots are other causes.
***** '''Most postoperative obstructions are mild and asymptomatic and resolve spontaneously without requiring additional surgery.''' More significant obstructions are usually symptomatic.
****** Affected children typically present 1 to 2 weeks after surgery with acute abdominal pain, nausea, and vomiting
****** '''In the more significant cases, drainage of the system either by retrograde insertion of a double-J stent or a percutaneous nephrostomy tube may be necessary'''
***** '''Many of these cases resolve without requiring additional surgery'''
*** '''Late complications'''
**** '''Obstruction at the anastamosis'''
**** '''Recurrent or Persistent Reflux'''
***** '''Causes (4):'''
*****# '''High-grade reflux'''
*****# '''Inadequate ratio of tunnel length to ureteral diameter'''
*****#* Development of a short tunnel and failure to taper the excessively wide ureter are important factors
*****# '''Failure to recognize secondary reflux''', especially associated with neurogenic bladders and PUV bladders.
*****# '''Bladder and bowel function''' preoperatively, as well as in all cases of persistent or recurrent reflux.
** '''Laparoscopic approach'''
*** Should theoretically provide the success rate and durability of open surgery while avoiding its morbidity.
*** Procedures have been attempted laparoscopically (3)
***# Extravesical reimplant
***# Gil-Vernet procedure
***# Cohen cross-trigonal reimplant.


== Questions ==
== Questions ==
Retrieved from "https://urologyschool.com/wikiuro/index.php/Pediatrics:_Vesicoureteral_Reflux"