Vesicoureteral reflux (VUR)

Introduction:

Vesicoureteral reflux (VUR) represents one of the most significant risk factors for acute pyelonephritis in children

Spontaneous resolution of VUR occurs in 78–90% of grades I–III VUR that is diagnosed during evaluation of antenatal hydronephrosis.

Grades IV and V may spontaneously resolve but usually require surgical intervention

Classification of vesicoureteral reflux (VUR)

Grade I- Reflux of urine in non dilated ureter

Grade II- Reflux of urine into a non dilated pelvis

Grade III- Reflux of urine into a dilated ureter up to the renal pelvis with possible blunting of calyceal fornices.

Grade IV- Reflux of urine into a grossly dilated ureter with moderate blunting of the calyces.

Grade V- Reflux of urine into a massively dilated and tortuous ureter with loss of the papillary impressio.

  

Management:

The objectives in the current treatment
the prevention of episodes of acute pyelonephritis with its associated morbidity and mortality.

to prevent the scarring of the kidney associated with vesicoureteral reflux (reflux nephropathy), which increases the risk of hypertension and renal failure.

Indications for surgical treatment

1.Breakthrough febrile UTIs despite adequate antibiotic prophylaxis
2. Severe reflux (grade V or bilateral grade IV) that is unlikely to spontaneously resolve,especially if renal scarring is present
3.Poor compliance with medications or surveillance programs
4.Poor renal growth or function or appearance of new scars. 


Surgical management of VUR : Ureteric Reimplantation:

Principle-Reconstruction of the ureterovesical junction (UVJ) to create a lengthened submucosal tunnel for the ureter,which functions as a one-way valve as the bladder fills

Types of Surgical repair:

Cohen procedure
Politano-Leadbetter
Lich-Gregoir,
Psoas hitch technique  

Surgical management of Ureteropelvic junction (UPJ) obstruction:

The goals in treating patients with ureteropelvic junction (UPJ) obstruction are to improve renal drainage and to maintain or improve renal function.

Surgical Treatment:

Endopyelotomy,
Open pyeloplasty
Laparoscopic pyeloplasty
Robotic-assisted laparoscopic pyeloplasty.

The principles of surgical repair:

Formation of a funnel
Dependent drainage
Watertight anastomosis
Tension-free anastom

Types of pyeloplasty

Anderson-Hynes dismembered pyeloplasty
 Foley Y-V plasty
Culp and DeWeerd
Scardino and Prince

Endopyelotomy

1. The stricture should be short (< 1.5 cm), and no crossing vessels should be defined on imaging
2. An endopyelotomy incision is performed through the area of obstruction with a laser, electrocautery, or endoscopic scalpel.
3. This is followed by prolonged ureteral stenting, for a period of 4-8 weeks. 
4. When open pyeloplasty fails, endopyelotomy is particularly useful

Laparoscopic pyeloplasty

This procedure is replacing open pyeloplasty as the criterion standard with 95% success rates.Significant learning curve associated with laparoscopic suturing

Complications:

Complications from open surgical pyeloplasty include UTI and pyelonephritis,urinary extravasation and leakage, recurrent ureteropelvic junction (UPJ) obstruction, or stricture formation.