Pediatric urology : Vesicoureteric reflux(vur)- overview

Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai
1

Professors:
 Prof. Dr. G. Sivasankar, M.S., M.Ch.,
 Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
 Dr. J. Sivabalan, M.S., M.Ch.,
 Dr. R. Bhargavi, M.S., M.Ch.,
 Dr. S. Raju, M.S., M.Ch.,
 Dr. K. Muthurathinam, M.S., M.Ch.,
 Dr. D. Tamilselvan, M.S., M.Ch.,
 Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH and KMC,
Chennai. 2

 Spirally oriented mural
smooth muscle of
ureter becomes
longitudinal as it
approaches bladder
 Fibromuscular
sheath(waldeyer)
extends longitudinally
over the ureter from 2-
3 cm from the bladder
upto trigone
3
Chennai.

 Ureter pierces the wall obliquely , travels 1 to
1.5 cm and terminates at UO
 The ureter is compressed as it passes thro
the hiatus in the detrusor
4
Chennai.

 JUXTA VESICAL / INTRAVESICAL
 JUXTA VESICAL
Conversion of spiral layer into
longitudinal layer
Formation of Waldeyer’s sheath
5
Chennai.

 Ureter enters posterolateraly
 Oblique course
 Length 1 – 1.5 cm
 Neonates 5 mm
 Adult size by 12 years
6
Chennai.

 Intra mural
 Submucosal
 Ureteric orifice
7
Chennai.

 INTRAMURAL
Narrowest portion
4 – 5 mm in length
3 – 3.7 mm in dia.
SUBMUCOSAL
9-10.5 mm length
only longitudinal layer
more pliable/ flap valve
8
Chennai.

 Intravesical portion of the
ureter lies immediately
beneath the urothelium and
backed by a strong detrusor
 With bladder filling this
arrangement causes passive
occlusion of the ureter like a
flap valve
 Vesico ureteric reflux results
from insufficient
submucosal ureteral length
and poor detrusor backing
9
Chennai.

 It’s a retrograde flow
of urine from bladder
to the upper urinary
tract
 Usually asymptomatic
and may lead to
pyelonephritic scarring
10
Chennai.

 Galen and Davinci – UVJ as the mediator for
unidirectional flow of urine
 sampson(1907) - Oblique course of ureter created a
locking mech at the UVJ
 Hutch(1952) and Hodson(1959) –Relationship between
VUR and chronic
pyelonephritis
 Ransley and Risdon(1979) – Defined the
pathophysiology of reflux
nephropathy
11
Chennai.

 Reflux may be present in 70% of infants with UTI
 Reflux may be present in 30% of children with UTI
and 17% without UTI
 Relatively uncommon in adult males
12
Chennai.

AGE(year) INCIDENCE
<I - 70%
4 - 25%
12 - 15%
Adults - 5.2%
 As natural history of reflux involves spontaneous
resolution over time, less primary reflux would be
prevalent in older children
13
Chennai.

 Embryonic ureter buds from
the mesonephric or wolffian
duct to define the
metanephric duct or the
early fetal ureter
 Wolffian duct (early vas
deferens) and early ureter
forms two upper arms of
the Y and the distal
mesonephric duct forms the
stem of Y
14
Chennai.

 While budding is occuring
the distal mesonephric duct
is drawn and incorporated
into the region of
urogenital sinus(which later
becomes bladder)
 Incorporation continues
until the entire stem is
absorbed, leaving the two
arms of the Y to enter the
bladder separately-
one as the ureter and the
other as the vas and
ejaculatory duct in male
prostatic urethra
15
Chennai.

 Two arms of the Y also rotate relative to each other as the
reach the urogenital sinus(UGS) resulting in the UO being
proximal to the ejaculatory duct orifice
 If the ureteral bud reaches UGS too soon- over rotation draws
it high and lateral –inadequate incorporation and insufficient
intramural length – REFLUX
 If it reaches UGS too late- insufficient rotation occurs-
ectopic ureter that is drawn distally and medially often
obstructing the bladder neck
16
Chennai.

Depends on
The functional integrity of the ureter
 Anatomic composition of UVJ
And the functional dynamics of the
bladder
17
Chennai.

 Ureter is a dynamic
conduit which propels
the urine in a bolus
fashion, antegrade by
peristaltic activity
 By doing so reflux is
actively opposed
 Even if reflux occur this
will prevent the refluxing
urine from reaching the
renal pelvis
18
Chennai.

 The intramural ureter remains passively
compressed by the bladder wall during filling,
preventing urine from entering the ureter
 Adequate intramural length and fixation of ureter
between the intra and extravesical points is
required to create this antirefluxing compression
valve
 Tunnel length : ureteral diameter in nonrefluxing
VUJ is 5:1 where as in refluxing VUJ is
1.4:1(described by paquin 1959)
19
Chennai.

 Refluxing UVJ has the
same anatomic features
as a non refluxing VUJ
except for inadequate
length of submucosal
ureter
20
Chennai.

OPENING OF VUJ
 Active contraction of longitudinal muscles bring the
extra and intra vesical points of intra mural ureter
together – shortening & widening of tunnel- passage of
urine
CLOSURE OF VUJ
 Results from both compression of the intramural ureter
and a return to its full length as the ureteral muscles
relaxes
Thus active and passive mechanisms dynamically
reconfigure the tunnel as needed to allow antegrade
passage of urine while preventing retrograde flow
21
Chennai.

 VUR represents a balance of several factors
 Reflux is considered primary or secondary
depends on which factor contribute to the
pathology predominantly
22
Chennai.

 Due to congenital defect in the structure &
therefore the function of VUJ
 Reflux occur despite a low pressure in the
bladder
 Length –to- diameter ratio of the tunnel is
almost always less than that described by
Paquin
23
Chennai.

 Occurs when anything which increases the
intravesical pressure that eventually
overwhelm a normal antirefluxing mechanism
 Such abnormalities may be anatomical or
functional
24
Chennai.

Peadiatric population- Post urethal valve(PUV)
It is the MC anatomic obstruction of bladder in
peadiatric age
Reflux is present in 48-70% of PUV patients
Relief of PUV leads to resolution of reflux in 1/3rd of
patients
Older age
Prostatomegaly and its relief are associated with
VUR and its resolution respectively
25
Chennai.

Female
Anatomic bladder obstruction is rare
MC structural obstruction is ureterocele which
prolapse into the bladder neck
Reflux in contralateral ureter occurs due to outlet
obstruction- Resolves with the decompression of
ureterocele
In general if relief to obstruction results in rapid
reflux resolution , the reflux was likely secondary
26
Chennai.

 Neurogenic bladder associated with spina bifida-
should be borne in mind during evaluation of child
with UTI
 Overactive bladder predispose to VUR
 In infants increased voiding pressures(inadequate
sphincter relaxation) leads to reflux- resolves as
the infant grows
 In older children dysfunctional voiding is assc with
reflux
27
Chennai.

 Based on the appearance of ureter, pelvis and
calices in voiding cystourethrogram
 Grading standardizes the description of the
degree of reflux for clinical management
 Description of initial grade in primary reflux
is the most significant parameter for the
prediction of reflux resolution
28
Chennai.

 Grade 1- In to non dilated
ureter
 Grade 2 – in to nondilated
pelvis and calyces
 Grade 3 – mild to
moderate dilatation of
ureter, pelvis and calyces
with minimal blunting of
fornices
 Grade 4 -Moderate
ureteral tortuosity and
dilatation of pelvis and
calyces
 Grade 5 – Gross dilatation
of ureter, pelvis and
calyces, ureteral
tortuosity and loss of
papillary impressions
29
Chennai.

 Expected concordance between ureter and calyceal
dilatation does not always occur
 Grading system does not include
 the degree of bladder filling,
 the voiding cycle,
 whether the reflux occur during voiding or filling
30
Chennai.

 USG
 IVU
 MCUG
 RADIO NUCLIDE CYSTOGRAM
 RENAL SCINTIGRAPHY
 CYSTOSCOPY/UDE
31
Chennai.

 Mainstay of lower tract assessment
 Goal: To demonstrate retrograde passage of
contrast from bladder in to ureter and renal
pelvicalyceal system
 Two approaches
◦ Indirect cystogram
◦ Direct cystogram
32
Chennai.

 Contrast enters the bladder indirectly
following excretory urography
 Advantage :
◦ Avoids the invasive nature of urethral
catheterisation
◦ Additional information on anatomy
 Disadvantage :
◦ Obvious false positive interpretation, due to
contrast remaining in the ureter
33
Chennai.

 “Gold standard” for detection of VUR
 Two types
◦ VCUG (Voiding Cysto Urethrography)
◦ RNC (Radionuclide Cystogram)
 Factors that affect the study
◦ Bladder contraction during voiding
◦ Volume of fluid instilled
◦ Presence of coexistent infection and inflammation
of the UVJ, bladder mucosa
◦ Postvoid films necessary after VCUG to rule out
associated PUJO
34
Chennai.

35
Chennai.

 Technetium Tc99 pertechnetate,itself is the radiation
source
 Reflux is detected on scintigraphic gamma camera
images.
 Provides little anatomic detail
 Ideal for
◦ Screening purpose
◦ Monitoring the natural history of the disease
◦ Surgical follow-up of reflux
 Greater sensitivity for reflux Grade II - V
 Less sensitive for Grade I reflux
36
Chennai.

37
Chennai.

“Assessment of reflux should take into
account the functional status of the bladder”
 Any case of reflux, the status of the bladder
oultlet should be established
 Increase outlet resistence predispose high
pressure voiding
 High post void residue perpetuate infection
 High bladder outlet resistence
◦ Alter the natural history
◦ Determine the outcome of treatment
◦ Might cause worsening of disease
38
Chennai.

 Renal Sonography
 Renal Scintigraphy
39
Chennai.

 Mainstay of renal imaging in VUR
 Advantages :
◦ Nonionizing, noninvasive
◦ Possible to assess renal vasculature
◦ Provides quantitative assessment of renal
dimensions
◦ Images the degree of corticomedullary
differentiation (functional aspect of the kidney)
◦ Increase in the echogenicity of kidney
◦ Using color Doppler ultrasound, renal resistive
index could be measured (High in VUR,
Pyelonephritis)
40
Chennai.

41
Chennai.

 The “Gold Standard” imaging- functioning
renal parenchyma
 Radiotracer taken up by functioning
proximal tubular tissue
 DMSA uptake is a good representation of
glomerular filtration
 Unexposed or Underexposed regions imply
possible pyelonephritis (or scarring if it
persists)
 98% sensitivity and 92% specificity for scar
detection
42
Chennai.

Normal left kidney Right kidney with
Multiple cortical defects 43
Chennai.

DMSA isotope scan showing reduced
function and
focal scarring on the left.
44
Chennai.

 Recent concept
 Principle:
“Only clinically relevant reflux with potential to
cause renal injury is worthy of uncovering”
 Method
◦ DMSA scan for patients following a febrile UTI
◦ VCUG if DMSA shows abnormality or if febrile
episode recur when observed
45
Chennai.

DMSA
Abnormalit
y detected
No
abnormalit
y
VCUG
VUR
confirmed
Febrile
episode
No
abnormalit
y
Observe
Observe
Treatment
v
After
febrile
UTI
46
Chennai.

 Strength:
◦ Detects only those children with significant VUR & at
risk for renal scarring
◦ Avoids invasive evaluation and unnecessary treatment
in the rest of the group
◦ Takes advantage of the fact that VUR could resolve
spontaneously
 Flaws :
◦ 34% of cases could be initially missed
◦ This approach is based on a trial
47
Chennai.

48
Chennai.

 Scar – fibrous tissue, photopenic area, hyperechoic
area
 Scarring – sequelae of pyelonephritis
 Reflux perpeuates ascent of infection
 Scarring proportional to grade of reflux
 VUR, particularly of higher grades, may result in
renal maldevelopment that often appears
scintigraphically or sonographically identical to
postinfection pyelonephritic scars
49
Chennai.

 Reflux asso renal dysmorphism
smaller
poor function
poor uptake
51
Chennai.

Propensity to scarring inversely proportional
to age
 Greatest risk in infants
Polar scarring
 Papillae with convex borders, obliquely
angulated ducts – less chance of reflux
 Papillae with concave borders – right
angled opening of ducts – high chance for
reflux
52
Chennai.

A convex papilla (right) does not reflux because the
crescentic or slitlike openings of its collecting ducts open
obliquely onto the papilla.
In contrast,
a concave (left) or flat papilla refluxes because its collecting
ducts open at right angles onto a flat papilla.
53
Chennai.

 Host susceptibility and bacterial virulence
have bearing on the incidence of
pyelonephitis
Hypertension
 Primary cause of significant hypertension in
children
 Deranged renal microvascular mechanisms
associated with parenchymal defects
 Successful correction of reflux alone is
unlikely to ameliorate HT
54
Chennai.

 Correction of reflux will restore retarded renal
growth
 Somatic growth also affected
55
Chennai.

 Development of both VUJ and the kidney are
linked so-existance of reflux may also have
anomaly of renal form or number
 The incidence of VUR associated with UPJO
ranges from 9% to 18%
 When the two conditions were primarily present,
had reflux low grade, and resolved
spontaneously with time
 minimal degree of ureteral dilation and the
significantly dilated renal pelvis
56
Chennai.

 The incidence of UPJO in patients with reflux ranges from
0.75% to 3.6%
 high-grade reflux being five times more likely to be
associated with UPJO than lower grades of reflux
 Three radiology signs of UPJO in the setting of reflux.
 1. if the pelvis shows little or no filling, while the ureter is
dilated by contrast, this may indicate a point of kinking
secondary to reflux or from a primary UPJO .
 2.contrast that does enter the pelvis poorly visualized
because of dilution in a large pelvic volume and exhibits a
markedly reduced radiodensity compared with the ureter or
bladder
 3.Large pelvis that fails to exhibit prompt drainage but
retains contrast is also suggestive of UPJO
57
Chennai.

58
Chennai.

 Ureteric duplication
 VUR is the most common abnormality
associated with complete ureteral duplications.
 The embryologic origin of the duplicated ureter
supports the observation that reflux occurs
most commonly into the lower pole
 High-grade reflux into lower pole ureters in
females more prone to breakthrough infection
and scarring and aggressive management
59
Chennai.

 Bladder diverticulae
 UVJ is distorted by paraureteral diverticulum,
which shares an anatomic point of origin at or near
the UVJ, - the diverticulum could compromise the
antireflux configuration of the UVJ to cause reflux
 Thus reflux associated with paraureteral diverticula
resolves at rates similar to that of primary reflux
 should be managed according to the prevailing
indications for the reflux itself, irrespective of the
diverticulum
60
Chennai.

 MCKD, Renal agenesis
 Megacystis, megaureter syndrome
 Massive bilateral VUR can cause a gradual
remodeling of the entire upper urinary
tract
 marked ureteral dilation, leading to the
radiographic appearance of massive
hydroureter and a thin-walled enlarged
bladder
61
Chennai.

 Pregnancy and reflux
 Bladder tone decreases because of edema and
hyperemia, that predispose to bacteriuria.
 during pregnancy the presence of VUR in a system
already prone to bacteriuria would lead to
increased morbidity
 uncorrected reflux appear to be particularly
at risk and should have their reflux corrected
before pregnancy to minimize maternal and fetal
morbidity.
62
Chennai.

 Reflux will disappear spontaneosly in many
children
 Spontaeous resolution depends on
Age at diagnosis
Initial grade of reflux
Laterality
 Resolution usually occurs within few years
of initial diagnosis of reflux
 Onset of puberty-spontaneous resolution
nil
63
Chennai.

 Resolution rates for low-grade reflux is
◦ 63% of grade II ( Duckett, 1983 )
◦ 80% of grade II ( Arant, 1992 )
 Grade III reflux will resolve in approximately
50% of cases .
 Very few cases of higher-grade reflux (grades
IV & V and bilateral grade III) will resolve
spontaneously
64
Chennai.

 Daily low dose antibiotic prophylaxis as the first
line of treatment to offer time for reflux to
resolve spontaneously
 Factors to be considered
 Age
 Grade
 H/O Pyelonephritis
 Scarring
 Renal function
65
Chennai.

 Rationale :
◦ It is not reflux alone that causes renal damage but it
is the coexistent infection
◦ Keeping urine sterile prevents renal damage
 Low dose prophylactic antibiotics until reflux
resolves
 Medication preferably given as oral suspension
 Once daily dose at night time
◦ To allow antibiotic to concentrate in the bladder over
the night
 Personal hygiene
66
Chennai.

 International Reflux study In Children (1992)
Surgery reduces incidence of pyelonephritis,
but incidence of UTI not reduced
 Birmingham Reflux Study
Incidence of new scars similar in both groups
67
Chennai.

 Regular bladder emptying (every 3 h),
adequate hydration, constipation prevention
 Treat voiding disturbances and overactive
bladder
69
Chennai.

 Broad spectrum activity against most Gram
negative pathogens
 High urinary concentration
 Least risk to patient with minimal side
effects
 Minimally alters bowel & vaginal flora
 Well tolerable in liquid form
 Available at minimum cost to the patient
70
Chennai.

 Amoxicillin or Ampicillin in children upto 6
weeks of age.
 After 6 weeks of age Cotrimoxazole is the
antibiotic of choice.
 Other alternatives
Nitrofurantoin
Nalidixic acid
Cephalexin
71
Chennai.

 Children with renal scarring at diagnosis
<1 y, grades I-V reflux
1-5 years, bilateral grades I-IV reflux or
unilateral grades III-V reflux
6-10 years, bilateral grades I-II reflux and
unilateral grades III-IV.
72
Chennai.

 Urinalysis & culture every 3 months.
 Renal parameters every 6 months.
 Radiological studies yearly in the form of
USG & Cystography.
 Prophylaxis discontinued whenever
cystography demonstrates cessation of
reflux
 If reflux persist after puberty
Boys- can be observed
Girls- surgery
73
Chennai.

74
Chennai.

1) Exclusion of causes of secondary VUR
2) Adequate mobilization of the distal ureter
 Without tension
 Without damage to its delicate blood supply
3) Creation of a submucosal tunnel
 Generous in caliber
 Has the 5 : 1 ratio of length to width (Paquin
1959)
75
Chennai.

4) Attention to
 The entry point of ureter into bladder
 The direction of the submucosal tunnel
 The ureteromucosal anastamosis
To prevent stenosis, angulation or twisting of ureter
5) Attention to the muscular backing of the ureter to
achieve an effective antireflux mechanism
6) Gentle handling of the bladder
 to reduce postoperative hematuria
 to reduce bladder spasms
76
Chennai.

 Open Ureteroneocystostomy is the gold
standard for VUR
 This can be
Intravesical
Extravescical
Combined approach
 Intravesical approach may be
Suprahiatal
Infrahiatal repairs
 Common denominator- creation of
submucosal tunnel of sufficient length with
adequate muscular backing
77
Chennai.

 After induction of anaesthesia
 To detect subtle anomalies not detected on
pre op imaging, particularly if an extravesical
technique is employed
78
Chennai.

 Supine
 Rolled towel placed at the level of upper
sacrum or a slight break in the table is used
to raise the lower pelvis & hips
 All pressure points appropriately padded
79
Chennai.

80
Chennai.

Principle:
“To bring the ureter through a new hiatus
superior to the original insertion”
– A submucosal tunnel created in the direction of the
trigone, medial to the original orifice
• Advantages
– Long tunnel could be created, which is valuable in
the higher grades of reflux.
• Disadvantage
– Post-op ureteric obstruction is common
81
Chennai.

-Transverse, lower abdominal
incision
-Made along a skin crease
-One or two fingerbreadths above
the symphysis pubis
-Ant rectus fascia is opened in a
transverse fashion
-The recti are the opened in the
midline exposing the bladder
82
Chennai.

-Peritoneum is swept off
the dome of the bladder
--Bladder is opened in the
midline
-Fine sutures are placed
above and below the
ureteral orifice for
handling. A feeding tube
in the ureter aids in initial
dissection
83
Chennai.

-Inject epinephrine
submucosally
-Circumferential
incision around the orifice
84
Chennai.

Dissection of the ureter
85
Chennai.

 After sweeping the
peritoneum away, a
blunt rt angle
clamp indents the
bladder from
behind at a new
hiatus approx
2.5cm superior &
somewhat medial
to the original
hiatus
86
Chennai.

 The clamp is
incised on from
within & generously
spread to make
certain that the new
hiatus is wide
enough
87
Chennai.

 A second right
angle clamp follows
the first from within
the bladder to the
original hiatus
88
Chennai.

 The right angle
clamp grasps the
stay suture and the
ureter is pulled
through the new
hiatus
89
Chennai.

 The inferior lip of
muscle at the new
hiatus is divided for
a few millimeters to
eliminate any
ureteral angulation
at its entrance to
the submucosal
tunnel that is
created with
scissors
90
Chennai.

 The ureter is
brought through
the new tunnel to
the original hiatus
91
Chennai.

 The ureter is spatulated
ventrally (6 o’clock)
 Three interrupted sutures
of 5-0 polyglactin anchor
the ureter to the trigone by
suturing it to the bladder
mucosa & muscle
 Interrupted sutures at 3, 9,
12 o’ clock position
 The mucosa overlying the
new hiatus is closed with 5-
0 polyglactin suture
 The bladder is closed in two
layers using 3-0 polyglactin
 Foley’s is placed for 48 hrs
92
Chennai.

93
Chennai.

Advancing the ureter distally toward the bladder
neck
 Advantage
 Avoids kinking of ureter (unlike Politano-Leadbetter)
 Disadvantage
 Since the advancement is towards the bladder neck,
the anastomosis of ureter at this level is difficult
technically
94
Chennai.

95
Chennai.

• The most commonly employed intravesical reimplant
• Advantages
– Simple and reliable
– Overcomes the limitation of the tunnel length(unlike
Glenn-Anderson)
– Overcomes the difficulty with the distal
anastomosis(unlike Glenn-Anderson)
– Suitable for small thick-walled bladders
(eg:neuropathic bladder)
– Suitable to carry out conjunct bladder neck
reconstructive procedure
• Disadvantage
– Subsequent RGC very difficult
96
Chennai.

Unilateral
Reimplantation
- After the ureter
is freed a
submucosal
tunnel is made,
with the new
mucosal hiatus
just above the
contralateral
ureteral orifice
97
Chennai.

Bilateral
Reimplantation
-The tunnel for the more
laterally displaced ureter
is directed superior to the
contralateralorifice
- The second tunnel is
directed towards the
inferior edge of the orifice
of the laterally displaced
ureter
98
Chennai.

99
Chennai.

 Most popular extravesical technique
 Advantages:
◦ Simple to learn & least invasive
◦ Bladder is not opened
◦ Bladder spasms & hematuria are less
 Disadvantages:
◦ 20 % children with bilateral procedures develop
transient voiding inefficiency (due to neural
injury)
◦ Associated bladder pathologies missed
10
0
Chennai.

Obliterated umblical
A is divided.
The ureter is
identified and gently
grasped.
10
1
Chennai.

Bladder is reflected medially.
Ureter is circumferentially mobilized at the hiatus by incising the de
10
2
Chennai.

-The serosal and muscular layers are
opened about 4 to 5 cm along a
straight course cephalad and lateral
from the UVJ
-The detrusor is dissected off the
mucosa on either side of the incision
for a width slightly larger than the
circumference of the ureter
-This dissection is best carried out
from proximal to distal
10
3
Chennai.

-Vest-type sutures are placed from
the detrusor at the distal limit of
dissection to the proximal ureteral
adventitia & back again through the
same tissue planes. Tying of the
vest sutures advances & anchors
the ureter on to the trigone
-Bladder mucosa
is elevated off muscle
wall
-Inadvertent injury of
the mucosa is closed
with 6-0 polyglactin
figure of eight suture
10
4
Chennai.

-Bladder is decompressed before reapproximation of
the detrusor with 3-0 polyglactin suture
-Long submucosal tunnel is created
-Foley is left for 24 to 48 hrs. Some recommend not
leaving a catheter
10
5
Chennai.

‘New hiatus is created from outside the
bladder’ (over comes the difficulty of Politano
Leadbetter)
◦ Ureter approached extravesically
◦ Right angle applied at UVJ – original hiatus closed
◦ New hiatus created cephalad
◦ Adequate submucosal tunnel created
◦ Ureter reimplanted
 Advantages:
◦ Offers versatility in approaching the ureter
◦ Well suited for dilated ureters & failed reimplants
10
6
Chennai.

Early:
 Persistent reflux: spontaneouly resolves by 1 yr
 Contralateral reflux
 Obstruction:
 maybe due to twisting or kinking of the ureter
in the new tunnel, intramural blood clots or
extramural compression by submucosal edema
or hematoma at the site of anatamosis
 PCN or DJ stent
10
7
Chennai.

Long-term
 Obstruction:
 Suprahiatal: twists of the ureter & ischemia
from poor handling
 Hiatal: High reimplant phenomenon
 Tunnel: not adequately developed
 Orifice: apex of the ureteral spatulation
 Recurrent or persistent reflux:
 Short tunnel
 Failure to taper the excessively wide ureter
 Failure to recognize secondary reflux
10
8
Chennai.

 1981, Matouschek, used PTFE
 O’Donnell and Puri, 1986, (STING - Subureteric Teflon
Injection)
 Advantage - Outpatient procedure
 Disadvantage
◦ Durability  doubtful
◦ Not a permanent solution
◦ Doubtful Cost effectivity
10
9
Chennai.

• Prophylactic antibiotics
• Preferably done under Anaesthesia
• Cystoscopy is done to look for inflammatory
changes
• 3.7 – 5 Fr needle
• Regular or Ratcheted syringe
• 3 Fr ureteric catheter
• Needle with bevel facing up at 6’o clock
• Enter mucosa 2-3mm distal to UVJ and
advance submucosally for 5mm
• 0.1 to 0.2ml Injected to produce mound
• Volcano appearance with meatus on top of
mound
11
0
Chennai.

11
1
Chennai.

Appearance of
the orifice before
hydrodistention
11
2
Chennai.

The entry point
of the needle is
2 mm distal to
the 6 o’clock
position
11
3
Chennai.

Appearance of
the mound after
completion
11
4
Chennai.

11
5
Chennai.

11
6
Chennai.

 Antibiotics for 3 months
 Follow up USG and VCUG
 Repeat injection after 6 months if persistent
reflux
 If still no resolution - open surgery
11
7
Chennai.

 Non toxic
 Stable & Non migratory
 Non inflammatory but should be
encapsulated by fibrosis
 Easy to inject
 Viscous enough to prevent leakage
 Should maintain the injected volume & the
mound shape
11
8
Chennai.

11
9
Chennai.

 Advantages :
◦ Inexpensive
◦ Viscous
 Disadvantage :
◦ Migration is a problem
 86 – 95% success rate
12
0
Chennai.

 3% incidence of allergy
 Minimal local inflammation
 Less viscous
 Results not durable
12
1
Chennai.

 Soft and flexible
 PDS suspended in bioextractable carrier gel
(polyvinyl pyrrolidone)
 No intense local inflamamtion
 80 – 90% success
12
2
Chennai.

 Cross linked dextranomer polyspheres
suspended in sodium hyaluronate
 FDA approved
 68-89% success
 Natural product
 Easily administered
 Preferred agent
12
3
Chennai.

 75 – 125um particles
 Easily injected
 67 – 75% success
12
4
Chennai.

• Fat, Collagen, Muscle
– Advantage
• They are not foreign – no bothersome reactions
– Disadvantage
• Volume loss (100% for fat)
• Chondrocytes
– Chondrocytes grown in culture
– Suspended in sodium alginate, calcium sulphate
solution
– 55 – 65% success
12
5
Chennai.

 Persistence of VUR in 10 to 30%
 Ureteral obstruction: <0.5%
 Transient flank pain, emesis: 2%
 UTI: 5%
12
6
Chennai.

 Poor technique: improper injection site, low
injected volume, endpoint of injection unclear
 Absorption of material: 20% by 2 wks, upto
40% by 1 yr
 Local bulking agent migration
 Very superficial implant injection into the
mucosa may result in splitting of mucosal
tissue with implant expulsion upon increased
bladder pressure
12
7
Chennai.

12
8
Chennai.

Pediatric urology : Vesicoureteric reflux(vur)- overview

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