Vesicoureteral reflux (VUR) is retrograde flow of urine from the bladder to the upper urinary tract. It can be primary due to deficiencies in the ureterovesical junction or secondary due to bladder dysfunction. Diagnosis involves urine tests, ultrasound, VCUG, DMSA scan and urodynamic studies. Most low-grade reflux resolves spontaneously while high-grade reflux is less likely to resolve. Management includes antibiotics and watchful waiting or surgical correction via open or endoscopic techniques like injection of bulking agents. The goal is to prevent urinary tract infections and renal damage.

1. VUR
Resident: Dr SD Sanyal
Moderator: Lt Col MS Vinod
Cl Spl Surg & Paediatric Surgeon

2. Introduction
• Vesicoureteral reflux (VUR) represents the retrograde flow
of urine from the bladder to the upper urinary tract
• Galen and da Vinci:
- First references to VUR by Western medicine
- UVJ as a mediator of unidirectional flow of urine
from the kidneys to the bladder
• Hutch(1952): Relationship between VUR and chronic
pyelonephritis in paraplegic patients
• Hodson(1959):UTI and renal scarring carried a high
likelihood of VUR in children

3. Inheritance & Genetics
• The prevalence of reflux is higher in siblings
• There is a tendency for an autosomal
dominant pattern of inheritance
• Probably many genes are involved:
- PAX2
- GDNF-RET
- UPK3
- AGTR2-ACE

4. Anti-Reflux Mechanism
• Functional integrity of the ureter:
- Antegrade peristalsis
• Anatomic composition of the UVJ:
- 5:1 ratio of tunnel length to ureteral diameter
in nonrefluxing junctions ( Paquin, 1959 )
• Functional compliance of the bladder

6. Etiology
• Primary Reflux:
- fundamental deficiency in the function of the
UVJ
- bladder and ureter remain normal
- reflux occurs despite an adequately low-pressure
urine storage profile in the bladder
- length-diameter ratio is almost always less than
that described by Paquin
- inadequate tunnel length has greater implication

7. Etiology
• Secondary reflux:
- normal function of the UVJ being
overwhelmed
- bladder dysfunction : congenital, acquired, or
behavioral
- considered secondary if absence was
documented at some point before its
detection

8. Etiology
• Anatomical causes:
- PUV’s
- Prostatomegaly
- Ureteroceles
- Ureteral duplication
• Neuro-functional causes:
- Neurogenic bladder – Spina bifida
- Infant voiding patterns
- Dysfunctional voiding
- Uninhibited bladder contractions
- Constipation

9. International classification(VCUG)

10. Radionuclide Classification(DRCG)
• grade 1 = grade I of the international grading
system
• grade 2 = grade II-III
• grade 3 = grade IV-V

12. Clinical features
• Features of recurrent UTI:
- Fever
- Flank pain
- probability of finding VUR in children with UTI
is 29% to 50%
• Renal failure
• Palpable renal mass

13. Diagnosis & Evaluation
• Urine microscopy & culture:
- Infant: placement of an adhesive urine collection bag
over the genitalia
- Patients who void spontaneously : clean voided
midstream catch
- Topical cleansing of the area to reduce contamination
and false-positive culture
- Repeated catheterization for the acquisition of
specimens
- SPC

14. Diagnosis & Evaluation
• Radiographic evaluation:
- Indications:
1. children younger than 5 years
2. all children with a febrile UTI
3. any male with a UTI regardless of age or
fever, unless sexually active

15. Diagnosis & Evaluation
• Imaging modalities :
- USG
- DRCG
- VCUG
- Scintigraphy

16. Diagnosis & Evaluation
• Other modalities:
- Uroflowmetry & urodynamic studies
- Cystoscopy & PI Cystogram

17. Sonography
• Quantitative assessment of renal dimensions :
- used to monitor renal growth
- impact of any intercurrent febrile episode on renal
growth
- need for further assessment of renal
function by scintigraphy or the need for
correction of reflux
• Degree of corticomedullary differentiation
• Imaging of perfusion abnormalities :
- Renal resistive index measurements
- Contrast-enhanced harmonic ultrasound

18. VCUG
• Provides information on :
- functional dynamics
- structural anatomy
• Parameters observed:
A. Static films
- bladder contour - presence of diverticula
- ureteroceles - grade of reflux
- configuration & blunting of calyces - bladder neck anatomy
- urethral patency
- intrarenal reflux

19. VCUG
B. Dynamic films:
- Passive/active reflux
C. Delayed or postvoid films:
- Crucial in documenting clearance of contrast
from the upper tracts
- Dilated PCS + Retained contrast = PUJO
• Contraindicated in active cystitis
- Exceptions: In children with a h/o recurrent
pyelonephritis and repeatedly negative voiding
studies in the intercurrent periods

20. DRCG
• Radiation exposure 1% of VCUG
• Little anatomic detail is afforded
• Ideal for:
- screening
- monitoring the natural history
- surgical follow-up of reflux
• Greater sensitivity in grades II to V reflux
• Grade I reflux into distal ureter  poorly
detected

21. Scintigraphy
• DMSA:
- detection of reflux-associated renal damage
- acute pyelonephritic changes
- follow-up of reflux
• SPECT:
- 3D images

22. Uroflowmetry & Urodynamic study
• For establishing bladder functioning
• Lack of smoothness of the flow-velocity curve =
incomplete relaxation of the bladder outlet
during voiding
delays the natural history of reflux resolution or
even
perpetuate reflux
• Increased PVRU may be a risk factor for UTI

23. Cystoscopy
• Routine use is not mandated
• Role immediately prior to surgery for confirming:
- orifice position
- duplication
- proximity of diverticula to the orifice
- urethral patency
- endoscopic Mx(DEFLUX)
• PIC:
- to detect reflux under GA in pts with febrile UTIs
but a normal VCUG

24. Associated anomalies
1. PUJ Obstruction
- incidence of VUR associated with PUJO = 9% -
18%
- the incidence of PUJO in patients with reflux =
0.75% to 3.6%
- incidence with high-grade reflux = five times
more likely than lower grades of reflux

25. Associated anomalies
2. Ureteral duplication:
- VUR is the most common
abnormality associated
- reflux occurs most commonly
into the lower pole

26. Associated anomalies
3. Bladder diverticulae:
- outpouching of mucosa between detrusor
muscle bundles without any true muscle backing
itself
- Cause of reflux:
1. paraureteral diverticulum
2. large paraureteral diverticulum could expand
within Waldeyer's fascia and cause ureteral
obstruction/ project forward into the bladder
and obstruct the bladder outlet

28. Associated anomalies
4. Renal anomalies:
- Renal agenesis: 46% association
- MCDK: 28% association
- Presence mandates VCUG
5. Megacystis-Megaureter syndrome:
- More common in males
- Differentiation from PUV

29. Associated anomalies
6. Pregnancy associated reflux:
- Women with hypertension and an element of
renal failure are particularly at risk
7. Other anomalies:
- VACTERL anomalies
- CHARGE syndrome
- Imperforate anus

30. Natural history
• Spontaneous resolution:
- At birth, the probability of spontaneous
resolution of primary reflux is inversely
proportional to the initial grade
- If a patient is encountered at a later age,
resolution from any point in time forward will
depend on the initial grade of reflux

31. Natural history
• Resolution by grade:
- Most cases of low-grade reflux (grade I and II)
will resolve : 63-85%
- Grade III reflux will resolve in approximately
50% of cases
- Higher-grade reflux (grades IV and V and
bilateral grade III) : 9-25%

32. Natural history
• Resolution with age :
- Age has greater significance than grade
- Most prevalent in neonates and young
children and will demonstrate the greatest
tendency to resolve in this group

34. Management
• Principles of management:
1. Spontaneous resolution of reflux is very
common
2. High-grade reflux is less likely to resolve
spontaneously
3. Extended use of prophylactic antibiotics &
“ Watchful waiting”
4. The success rate with surgical correction is very
high

35. Medical management
• Watchful waiting
• Antibiotic prophylaxis:
- Amoxycillin < 2mths
- Co-trimoxazole > 2mths
- Alternatives: Nitrofurantoin/ Pro-biotics
• Breakthrough pyelonephritis
- indication for termination of medical mgt

36. Indications for surgery
ABSOLUTE INDICATIONS :
 Breakthrough urinary tract infections
 Failure of medical management
– - patient noncompliance
– - persistance of reflux with prolonged medical management.
– - progressive deterioration in renal function.
 Ureteral obstruction assoc with VUR
 Refluxing ureter opening into bladder diverticulum
 Cystoscopic observation of golf hole orifice
RELATIVE INDICATIONS :
– Presence of massive reflux – gr IV & V
– Reflux associated with paraureteral diverticulum
– In girls whose reflux persists after they have reached the full somatic
growth potential at puberty.
– Parental preference

37. Surgical management
The principles of surgical correction :
- Exclude secondary reflux
- Adequate ureteral mobilization and protection of the
ureteral blood supply
- A generous submucosal tunnel should be fashioned
- Attention should be directed to angulation and twisting
- Bladder tissues must be handled gently
- Always consider bladder function preoperatively, as
well as in all cases of persistent or recurrent reflux
- Indications for correction of reflux are the same
regardless of whether the planned approach is open,
endoscopic, or laparoscopic.

38. Surgical modalities
• Endoscopic management
• Ureteric reimplantation
 open
 laparoscopic
SUCCESS RATE > 90% for all open surgical
procedures

39. Classification
According to approach :
• Intravesical
• Extravesical
• Combined
According to the position of the sub mucosal
tunnel in relation to the original hiatus :
• Suprahiatal
• Infrahiatal

40. Cohen’s Transtrigonal
• Intravesical, infrahiatal procedure
• Simple, safe and most commonly used
• Avoids complications of neo-hiatus formation
• Good for small capacity bladder
• Success > 95%
Problem :
• Difficult retrograde catheterization of ureters.

41. Cohen’s Transtrigonal

42. Surgical procedures
• Politano-Leadbetter:
- Intravesical-Suprahiatal
• Glenn Anderson:
- Intravesical-Infrahiatal
• Lich-Gregoir:
- Extra-vesical

43. Endoscopic management
• Injection of a bio- compatible bulking agent
beneath intravesical portion of ureter in sub-
mucosal tunnel
• Elevates the intra-vesical ureter  narrowing
of lumen
• Prevents regurgitation of urine & allows
antegrade flow

44. Technique

45. Endoscopic management
ADVANTAGES
• OPD based treatment
• less morbidity, no mortality
• No surgical scar
• Success rate almost equivalent to open surgery for primary
reflux.
DISADVANTAGES
• Cost
• Lower success rate compared to surgery for high grade reflux

46. Indications
• Primary reflux
• Secondary reflux
- Dysfn voiding
- Neurogenic bladder
- Duplex system
• Failed open re-implant

47. Surgical outcomes
Success rates:
• Open - 98%
• Endoscopic – 80-89%

48. Complications
• Early:
- Haematuria
- Urosepsis
• Late:
- Reflux: Persistant/Transient/Contralateral
- Ureteral obstruction

49. Follow up
• Discharged on uro-prophylaxis
• Monitoring of pt’s
- BP
- renal function
- urine analysis
• Follow up USG and urine c/s after 1 mth
• VCUG after 3 mnths
• Discontinuation of uroprophylaxis on resolution
of reflux
• DMSA after 1 yr

50. Thank You