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== 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'''
*#* '''Constipation must be recognized and eliminated as much as possible to establish optimal conditions for successful spontaneous or surgical resolution of reflux'''
*#* BBD lowers VUR resolution rates.
*# Parental perceptions of reflux management must be considered when treating a child with reflux
*# Spontaneous resolution of reflux is very common
*#* ≈80% of low-grade and ≈50% of grade 3 reflux will resolve spontaneously.
*# High-grade reflux is less likely to resolve spontaneously
*# Sterile reflux is benign
*# "Extended use of prophylactic antibiotics is benign"
*# Success of (open) surgical correction is very high
*#* Ureteral reimplant is successful in correcting reflux in > 98% of cases
* '''Options:'''
** '''Includes management of any bowel-bladder dysfunction'''
** '''First-line (classic approach): watchful waiting''' '''with''' '''daily low-dose antibiotic prophylaxis'''
** '''Second-line: intervention'''
*** '''Options:'''
**** '''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'''
=== '''Essential tenets of reflux management''' ===
** '''Underlying principle: every case of reflux should be offered time to resolve spontaneously, despite grade'''
# '''BBD is by far one of the most critical and modifiable variables that affect VUR management and attendant UTIs'''
** Maintaining urine sterility (through both prophylactic antibiotics and strict attention to bladder and bowel management) is the cornerstone of watchful waiting medical management
#* '''Constipation must be recognized and eliminated as much as possible to establish optimal conditions for successful spontaneous or surgical resolution of reflux'''
** '''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.'''
#* BBD lowers VUR resolution rates.
** '''For children age < 2 months, the most commonly used medications are trimethoprim and amoxicillin.'''
# Parental perceptions of reflux management must be considered when treating a child with reflux
** '''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.
# Spontaneous resolution of reflux is very common
*** '''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.
#* ≈80% of low-grade and ≈50% of grade 3 reflux will resolve spontaneously.
**** Uncircumcised male children older than 1 year do not appear to be at higher risk for development of recurrent UTI after discontinuation of CAP.
# High-grade reflux is less likely to resolve spontaneously
*** '''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'''
# Sterile reflux is benign
**** '''Women with a history of VUR have increased morbidity during pregnancy because of infection-related complications, whether the reflux has been corrected or not.'''
# "Extended use of prophylactic antibiotics is benign"
***** '''Addintional risk factors that may lead to increased morbidity in pregnant patients with VUR:'''
# Success of (open) surgical correction is very high
*****# '''Hypertension'''
#* Ureteral reimplant is successful in correcting reflux in > 98% of cases
*****# '''Renal insufficiency'''
 
*****#* Associated with increased risk for fetal demise and accelerated maternal renal disease
=== '''Options:''' ===
*****# '''Renal scarring'''
* '''Includes management of any bowel-bladder dysfunction'''
*****#* Associated with an increased incidence of hypertension, increased risk for preeclampsia, increased risk of developing acute pyelonephritis, and a higher rate of obstetric interventions
* '''First-line (classic approach): watchful waiting''' '''with''' '''daily low-dose antibiotic prophylaxis'''
*****# '''History of prior infections'''
* '''Second-line: intervention'''
*****#* Associated with increased risk of bacteriuria during pregnancy
** '''Options:'''
***** '''Persistent VUR is associated with increased risk of developing acute pyelonephritis'''
*** '''Endoscopic'''
***** VUR with normal kidneys is associated with an increased risk for hypertension during the last trimester
*** '''Open/laparoscopic ureteral reimplant'''
***** Impaired renal function is
** '''Failure to address voiding abnormalities can adversely affect outcome of anti-reflux surgery'''
***** '''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:
=== '''Watchful waiting with''' '''daily low-dose antibiotic prophylaxis''' ===
*** Scarring is extensive
* '''Underlying principle: every case of reflux should be offered time to resolve spontaneously, despite grade'''
*** Reflux is high grade
* Maintaining urine sterility (through both prophylactic antibiotics and strict attention to bladder and bowel management) is the cornerstone of watchful waiting medical management
*** Renal function is already globally depressed
* '''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.'''
*** Congenital dysmorphism of one or both kidneys is present
* '''For children age < 2 months, the most commonly used medications are trimethoprim and amoxicillin.'''
** '''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
* '''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.
*** '''BBD is associated with higher breakthrough infection rates.'''
** '''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.
** '''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'''
*** Uncircumcised male children older than 1 year do not appear to be at higher risk for development of recurrent UTI after discontinuation of CAP.
** '''Cystoscopy'''
** '''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'''
*** '''Cystoscopy in the course of conservative management of VUR is indicated only to confirm or manage abnormalities found on other imaging modalities'''
*** '''Women with a history of VUR have increased morbidity during pregnancy because of infection-related complications, whether the reflux has been corrected or not.'''
** '''Landmark Studies'''
**** '''Addintional risk factors that may lead to increased morbidity in pregnant patients with VUR:'''
*** '''International Reflux Study in Children'''
****# '''Hypertension'''
**** '''Population: 306 children aged < 11 years with high-grade reflux from North America and Europe'''
****# '''Renal insufficiency'''
**** '''Randomized to watchful waiting with antibiotic prophylaxis vs. corrective open surgery'''
****#* Associated with increased risk for fetal demise and accelerated maternal renal disease
**** '''Primary end points: new renal scars and renal growth'''
****# '''Renal scarring'''
**** '''Results:'''
****#* Associated with an increased incidence of hypertension, increased risk for preeclampsia, increased risk of developing acute pyelonephritis, and a higher rate of obstetric interventions
***** '''No siginificant difference in risk of new renal scars'''
****# '''History of prior infections'''
****** '''Antibiotic prophylaxis and surgery equally effective in reducing, but not eliminating, new scar formation'''
****#* Associated with increased risk of bacteriuria during pregnancy
***** '''Surgery more effective than antibiotic prophylaxis in reducing, but not eliminating, the risk of pyelonephritis'''
**** '''Persistent VUR is associated with increased risk of developing acute pyelonephritis'''
***** '''Nosiginificant difference in risk of incident UTI (38%)'''
**** VUR with normal kidneys is associated with an increased risk for hypertension during the last trimester
**** 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.
**** Impaired renal function is
*** '''RIVUR'''
**** '''Most clinicians recommend surgical correction for females with reflux that persists beyond puberty to minimize maternal and fetal morbidity'''
**** '''Population: 607 children with''' dilated and non-dilated '''VUR that was diagnosed after''' a first or second '''febrile or symptomatic UTI'''
* '''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:
***** Population was overwhelmingly female (91%)
** Scarring is extensive
***** Half of the study participants were < 11 months of age
** Reflux is high grade
**** '''Randomized to trimethoprim-sulfamethoxazole prophylaxis vs. placebo'''
** Renal function is already globally depressed
**** '''Primary outcome: recurrence of UTI'''
** Congenital dysmorphism of one or both kidneys is present
**** '''Results:'''
* '''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
***** '''45% significant decrease in UTI recurrence with antibiotic prophylaxis''' (RR: 0.55; 95% CI: 0.38-0.78)
** '''BBD is associated with higher breakthrough infection rates.'''
****** 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
* '''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'''
****** Prophylaxis was particularly effective in children whose index infection was febrile and in those with baseline BBD.
* '''Cystoscopy'''
***** '''No difference in the occurrence of renal scarring'''
** '''Cystoscopy in the course of conservative management of VUR is indicated only to confirm or manage abnormalities found on other imaging modalities'''
***** '''Adverse reactions to antibiotics were reported in 2% of both the antibiotic prophylaxis and placebo groups.'''
* '''Landmark Studies'''
**** '''Criticisms:'''
** '''International Reflux Study in Children'''
***** '''Population may not reflect typical patient in practice'''
*** '''Population: 306 children aged < 11 years with high-grade reflux from North America and Europe'''
****** '''Majority female and half under age 11 months'''
*** '''Randomized to watchful waiting with antibiotic prophylaxis vs. corrective open surgery'''
****** '''Trial does not address patients with VUR and no history of UTI'''
*** '''Primary end points: new renal scars and renal growth'''
**** '''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>
*** '''Results:'''
** '''Antibiotic Controversies and Potential New Approaches'''
**** '''No siginificant difference in risk of new renal scars'''
*** 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 and surgery equally effective in reducing, but not eliminating, new scar formation'''
*** Antibiotic prophylaxis is destined to fail without adequate teaching and periodic review of perineal hygiene techniques, timely bladder emptying habits, and anticonstipation measures
**** '''Surgery more effective than antibiotic prophylaxis in reducing, but not eliminating, the risk of pyelonephritis'''
*** Prophylactic antibiotics are more likely to benefit patients with:
**** '''Nosiginificant difference in risk of incident UTI (38%)'''
**** Higher grade reflux
*** 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.
**** Baseline bladder dysfunction
** '''RIVUR'''
**** Bowel and bladder dysfunction
*** '''Population: 607 children with''' dilated and non-dilated '''VUR that was diagnosed after''' a first or second '''febrile or symptomatic UTI'''
**** Febrile UTI
**** Population was overwhelmingly female (91%)
* '''Endoscopic'''
**** Half of the study participants were < 11 months of age
** '''A reasonable alternative for children being considered for surgical correction'''
*** '''Randomized to trimethoprim-sulfamethoxazole prophylaxis vs. placebo'''
** '''Success rates vary across centers and that outcomes may not be durable.'''
*** '''Primary outcome: recurrence of UTI'''
*** Higher success rates associated with:
*** '''Results:'''
***# Volume of Dx/HA used
**** '''45% significant decrease in UTI recurrence with antibiotic prophylaxis''' (RR: 0.55; 95% CI: 0.38-0.78)
***# Surgeon experience
***** 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
***# Volcano-shaped mound with no hydrodistention
***** Prophylaxis was particularly effective in children whose index infection was febrile and in those with baseline BBD.
***# Utilization of the double hydrodistention-implantation technique
**** '''No difference in the occurrence of renal scarring'''
***# Accurate needle entry point during endoscopic injection, as well as the needle placement
**** '''Adverse reactions to antibiotics were reported in 2% of both the antibiotic prophylaxis and placebo groups.'''
**** Negative intraoperative cystogram is not associated with endoscopic success rates
*** '''Criticisms:'''
** '''Untreated BBD is associated with decreased resolution rates of VUR at initial follow-up in children treated with endoscopic surgery'''
**** '''Population may not reflect typical patient in practice'''
** The learning curve for endoscopic injection is believed to be different from that of open surgical reimplantation, but studies have compared these two approaches
***** '''Majority female and half under age 11 months'''
** Indications for treatment are the same as that of open surgical reimplantation
***** '''Trial does not address patients with VUR and no history of UTI'''
** '''Materials used for endoscopic correction of reflux'''
*** '''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>
*** Characteristics of an ideal injectable biomaterial (4):
* '''Antibiotic Controversies and Potential New Approaches'''
***# Non-toxic and stable without migration to vital organs
** 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.
***# Cause minimal local inflammation, while at the same time be well encapsulated by normal fibrous tissue and fibrocytes
** Antibiotic prophylaxis is destined to fail without adequate teaching and periodic review of perineal hygiene techniques, timely bladder emptying habits, and anticonstipation measures
***# Easy to inject through a long needle that passes easily through most standard endoscopic instruments
** Prophylactic antibiotics are more likely to benefit patients with:
***# 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.
*** Higher grade reflux
*** '''Classified as particulate vs. degradable and autologous vs. non-autologous'''
*** Baseline bladder dysfunction
**** '''Disadvantage of particulate agents is risk of migration'''
*** Bowel and bladder dysfunction
**** '''Disadvantage of degradable agents is less durability'''
*** Febrile UTI
***** '''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'''
=== Endoscopic ===
**** '''Autologous Materials'''
* '''A reasonable alternative for children being considered for surgical correction'''
***** '''Fat, collagen, muscle, and chondrocytes have been evaluated as bulking agents'''
* '''Success rates vary across centers and that outcomes may not be durable.'''
** '''Follow-Up after Endoscopic Treatment'''
** Higher success rates associated with:
*** '''The child is maintained on antibiotics for 3 months.'''
**# Volume of Dx/HA used
*** '''US and VCUG are obtained at 3 months.'''
**# Surgeon experience
**** '''If reflux is persistent, a repeat injection can be considered 6 months after the initial injection'''
**# Volcano-shaped mound with no hydrodistention
**** '''If there is still no resolution, open surgery is recommended.'''
**# Utilization of the double hydrodistention-implantation technique
***** '''Most reports to date have not indicated any additional difficulty with open surgery after endoscopic correction using Deflux'''
**# Accurate needle entry point during endoscopic injection, as well as the needle placement
* '''Ureteral reimplant'''
*** Negative intraoperative cystogram is not associated with endoscopic success rates
** '''The principles of ureteral reimiplant for reflux include the following:'''
* '''Untreated BBD is associated with decreased resolution rates of VUR at initial follow-up in children treated with endoscopic surgery'''
**# '''Exclusion of causes of secondary VUR'''
* The learning curve for endoscopic injection is believed to be different from that of open surgical reimplantation, but studies have compared these two approaches
**# Adequate mobilization of the distal ureter without tension or damage to its delicate blood supply
* Indications for treatment are the same as that of open surgical reimplantation
**# '''Creation of a submucosal tunnel that is generous in caliber and satisfies the 5:1 ratio of length to width'''
* '''Materials used for endoscopic correction of reflux'''
**# 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
** Characteristics of an ideal injectable biomaterial (4):
**# '''Attention to the muscular backing of the ureter to achieve an effective anti-reflux mechanism'''
**# Non-toxic and stable without migration to vital organs
**# Gentle handling of the bladder to reduce postoperative hematuria and bladder spasms
**# Cause minimal local inflammation, while at the same time be well encapsulated by normal fibrous tissue and fibrocytes
*** '''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.'''
**# Easy to inject through a long needle that passes easily through most standard endoscopic instruments
** '''Ureteral duplication'''
**# 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.
*** 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.
** '''Classified as particulate vs. degradable and autologous vs. non-autologous'''
** '''Success rate for ureteroneocystostomy in patients with low-grade primary VUR approaches 100%'''
*** '''Disadvantage of particulate agents is risk of migration'''
*** '''BBD does not alter surgical resolution rates in children treated with open surgery'''
*** '''Disadvantage of degradable agents is less durability'''
*** '''BBD is associated with increased incidence of UTI after surgery.'''
**** '''Deflux is biodegradable, the carrier gel is reabsorbed''', and the dextranomer microspheres become capsulated by fibroblast migration and collagen ingrowth
** '''Follow-Up after Ureteral Reimplant'''
**** '''DX/HA loses ≈23% of its volume beyond 3 months of follow-up'''
*** '''An US is necessary at 6-12 weeks postoperatively'''
*** '''Autologous Materials'''
**** Ureteral obstruction can be clinically silent, and therefore, the absence of ureteral obstruction must be documented.
**** '''Fat, collagen, muscle, and chondrocytes have been evaluated as bulking agents'''
**** '''Minimal ureteral dilation and low-grade hydronephrosis on early post-operative ultrasonography is not unusual'''
* '''Follow-Up after Endoscopic Treatment'''
***** '''Persistence of this dilation > 3 months or its progression should be further investigated'''
** '''The child is maintained on antibiotics for 3 months.'''
*** '''Postoperative VCUG can be avoided in patients with:'''
** '''US and VCUG are obtained at 3 months.'''
***# '''Low-grade primary reflux initially'''
*** '''If reflux is persistent, a repeat injection can be considered 6 months after the initial injection'''
***# '''Normal preoperative and post-operative US examinations'''
*** '''If there is still no resolution, open surgery is recommended.'''
**** Recall that follow-up after endoscopic management includes post-operative antbiotics for 3 months and imaging with US and VCUG
**** '''Most reports to date have not indicated any additional difficulty with open surgery after endoscopic correction using Deflux'''
*** Children with renal scarring should have their blood pressure measured at every visit with their family physician
 
** '''Complications of Ureteral Reimplantation'''
=== Ureteral reimplant ===
*** '''Early Complications'''
* '''The principles of ureteral reimiplant for reflux include the following:'''
**** '''Persistent Reflux'''
*# '''Exclusion of causes of secondary VUR'''
***** '''Early reflux after ureteroneocystostomy usually is not a significant clinical problem and commonly resolves by 1 year on repeat cystography'''
*# Adequate mobilization of the distal ureter without tension or damage to its delicate blood supply
**** '''De novo contralateral Reflux'''
*# '''Creation of a submucosal tunnel that is generous in caliber and satisfies the 5:1 ratio of length to width'''
***** '''Prophylactic bilateral reimplantation for unilateral reflux, to avoid contralateral reflux, is not warranted on the basis of the high spontaneous resolution rates'''
*# 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
**** '''Obstruction at the anastamosis'''
*# '''Attention to the muscular backing of the ureter to achieve an effective anti-reflux mechanism'''
***** 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.
*# Gentle handling of the bladder to reduce postoperative hematuria and bladder spasms
***** '''Most postoperative obstructions are mild and asymptomatic and resolve spontaneously without requiring additional surgery.''' More significant obstructions are usually symptomatic.
** '''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.'''
****** Affected children typically present 1 to 2 weeks after surgery with acute abdominal pain, nausea, and vomiting
* '''Ureteral duplication'''
****** '''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'''
** 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.
***** '''Many of these cases resolve without requiring additional surgery'''
* '''Success rate for ureteroneocystostomy in patients with low-grade primary VUR approaches 100%'''
*** '''Late complications'''
** '''BBD does not alter surgical resolution rates in children treated with open surgery'''
**** '''Obstruction at the anastamosis'''
** '''BBD is associated with increased incidence of UTI after surgery.'''
**** '''Recurrent or Persistent Reflux'''
* '''Follow-Up after Ureteral Reimplant'''
***** '''Causes (4):'''
** '''An US is necessary at 6-12 weeks postoperatively'''
*****# '''High-grade reflux'''
*** Ureteral obstruction can be clinically silent, and therefore, the absence of ureteral obstruction must be documented.
*****# '''Inadequate ratio of tunnel length to ureteral diameter'''
*** '''Minimal ureteral dilation and low-grade hydronephrosis on early post-operative ultrasonography is not unusual'''
*****#* Development of a short tunnel and failure to taper the excessively wide ureter are important factors
**** '''Persistence of this dilation > 3 months or its progression should be further investigated'''
*****# '''Failure to recognize secondary reflux''', especially associated with neurogenic bladders and PUV bladders.
** '''Postoperative VCUG can be avoided in patients with:'''
*****# '''Bladder and bowel function''' preoperatively, as well as in all cases of persistent or recurrent reflux.
**# '''Low-grade primary reflux initially'''
** '''Laparoscopic approach'''
**# '''Normal preoperative and post-operative US examinations'''
*** Should theoretically provide the success rate and durability of open surgery while avoiding its morbidity.
*** Recall that follow-up after endoscopic management includes post-operative antbiotics for 3 months and imaging with US and VCUG
*** Procedures have been attempted laparoscopically (3)
** Children with renal scarring should have their blood pressure measured at every visit with their family physician
***# Extravesical reimplant
* '''Complications of Ureteral Reimplantation'''
***# Gil-Vernet procedure
** '''Early Complications'''
***# Cohen cross-trigonal reimplant.
*** '''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 ==
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