Vesicoureteral reflux – current treatment options

[Treatment of vesicouretheral reflux in pediatric patients]

BACKGROUND/AIM

Vesicouretheral reflux (VUR) is an inherited abnormality of the urinary tract caused by dysfunction of vesicouretheral junction frequently accompanied by recurrent urinary infection. The optimal treatment method of VUR is still controversial. The aim of the study was to analyze medical charts of children with VUR with special focus on the results of endoscopic treatment with Deflux.

METHODS

This retrospective study analyzed the medical charts of all children diagnosed with VUR at the Institute for Children and Youth Health Care of Vojvodina, in five years period. The analyzed data were: age, gender, grade, bilateral or unilateral presence of reflux, distribution to the sides of the body, urinary tract infections, associated anomalies and complications of VUR, treatment methods and the success rate of endoscopic correction with Deflux. Data processing was performed using the standard statistical methods.

RESULTS

The study included 167 patients (101 females and 66 males) with 231 refluxing ureters. The patients age at diagnosis was 1 month to 18 years (mean 4.6 years). Frequencies of different grades of VUR at initial investigation were: 17%, 27%, 22%, 21% and 13% for grades I to V, respectively. VUR was unilateral in 103 patients (left in 65 and right in 38), and bilateral in 64. Urinary tract infections were present in 78.4% of patients, reflux nephropathy in 38.3%, hypertension in 3.0%, chronic renal insufficiency in 4.8%, associated anomalies in 39.5% of patients. The treatment method was recorded in 154 cases. Medically were treated 80 patients, and surgically 74. Endoscopic injection of Deflux was carried out in 59 patients. From 79 ureters treated, five had grade I reflux, 11 grade II, 23 grade III, 27 grade IV, and 13 grade V. In 46 patients Deflux injection was carried out once. A second injection was required in eight, and third injection in five patients. Reflux was absent in 42 of the treated patients (71.2%) and 15 patients (25.4%) had a decreased grade of reflux after the treatment Overall success rate was 96.6%.

CONCLUSION

Endoscopic subureteral injection of Deflux is a minimally invasive method for VUR treatment in pediatric patients.

Clinical course of 735 children and adolescents with primary vesicoureteral reflux

The purpose of this retrospective cohort study was to report the clinical course of children with primary vesicoureteral reflux (VUR). Between 1970 and 2004, 735 patients were diagnosed with VUR and were systematically followed in a single tertiary renal unit. Patients were followed up for a mean time of 76 months (6 months to 411 months). The events of interest were reflux resolution, renal damage, urinary tract infection (UTI), chronic kidney disease (CKD), and hypertension. Survival analysis was performed in order to evaluate reflux resolution and CKD. Renal damage was detected at admission in 319 patients (43.4%). Continuous low-dose antibiotic prophylaxis was administered to 624 patients (91.2%); 499 (73%) patients subsequently had no UTI or fewer than three episodes. The median time of persistence of reflux according to Kaplan-Meier analysis was 38 months for grade I/II [95% confidence interval (95% CI), 33-43], 98 months for grade III (95% CI, 78.5-105), and 156 months for grade IV/V (95% CI, 122-189). Twenty patients (3%) developed hypertension. It was estimated that the probability of CKD was 5% at 10 years after diagnosis of VUR; for children diagnosed after 1990 the probability of CKD was only 2%. Renal function impairment occurred in patients with severe bilateral reflux or in patients with contralateral renal hypoplasia. There has been an improvement of prognosis for patients diagnosed in the past 15 years.

THE ROLE OF ENDOSCOPIC TREATMENT OF VESICOURETERAL REFLUX: A 17-YEAR EXPERIENCE

PURPOSE

During the last 20 years endoscopic treatment of vesicoureteral reflux (VUR) has gained popularity in European countries. We performed a retrospective analysis of our 17-year experience with more than 1,000 patients treated to assess whether technique, indications or results of endoscopic treatment of VUR have changed over time.

MATERIALS AND METHODS

From January 1986 to June 2002, 1,244 patients underwent endoscopic treatment for grades II to IV VUR. Polytetrafluoroethylene was injected as the bulking material in the first 14 cases, after 1989 bovine cross-linked collagen was used in 442 and since 1995 dextranomer/hyaluronic acid copolymer was used in 788. Urinary tract ultrasound was performed 1 and 6 months, and micturition cystourethrogram was done 3 and 12 months after endoscopic treatment. All patients included in the study completed a minimum 12-month followup.

RESULTS

Endoscopic treatment was always performed in 1 day. Complications were observed in 0.5% of cases. After 1 or 2 injections the micturition cystourethrogram showed no significant VUR (absent or grade I) in 77% of cases. The success rate was 88%, 75% and 52% for grades II, III and IV VUR, respectively. With increasing experience not only primary VUR, but also secondary reflux was considered eligible for endoscopic treatment, and the number of grade IV VUR cases treated by endoscopy also increased. The presence of voiding dysfunction was identified as a limiting factor in the success of endoscopic treatment.

CONCLUSIONS

The short hospital stay, acceptable success rate and absence of significant complications prompt us to consider endoscopic treatment as first choice treatment of VUR rather than long-term prophylaxis and open surgery. Even grade IV VUR and VUR in complex anatomical situations can be successfully treated by endoscopy. Patients with voiding dysfunction should be identified and adequately treated before any endoscopic attempt.