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Urology

Center for the Evaluation and Management of Vesicoureteral Reflux (VUR)

Vesicoureteral reflux (VUR) is the retrograde flow of urine from bladder to the upper urinary tract and is a common anomaly affecting perhaps one percent of all children in the United States. A heterogenous disease, VUR is typically diagnosed after repeated urinary tract infections (UTI's), and approximately one-third of children with febrile urinary tract infection will eventually be diagnosed with VUR. In addition to UTI, patients with VUR may also present with voiding dysfunction, constipation, and/or fecal soiling.

VUR is more prevalent in Caucasian children than in African American children, and females are twice as likely as males to be affected with VUR. Males are often diagnosed earlier. Typically they present with more severe reflux at baseline and have a greater prevalence of generalized renal damage. Females, however, have a high risk of dysfunctional voiding and recurrent urinary tract infections.

VUR predisposes patients to pyelonephritis through the facilitation of bacteria transported from the bladder to the upper urinary tract. It is postulated that immunological and inflammatory reactions resulting from the infections may potentially cause permanent renal injury and/or scarring. Renal scarring, if severe, may cause decreased renal function, end-stage renal disease and renin-mediated hypertension, as well as growth problems. VUR also is associated with morbidity during pregnancy in females who have had VUR during childhood. The risk of complications increase the earlier the VUR presents, and approximately 30 percent of patients with VUR will have evidence of renal scarring at the time of initial diagnosis.

Diagnostic Approaches

The diagnostic approach to vesicoureteral reflux includes a renal ultrasound and a voiding cystourethrography (VCUG). A VCUG is recommended for patients from newborn to three years of age after the first febrile urinary tract infection. The procedure may also be conducted in selected older children. Other diagnostic procedures include radionuclide cystography (RNC), which is less widely used, and DMSA radionucleide renal scan to look for renal scarring.

VUR may be described as either primary or secondary. Primary reflux is designated as reflux seen in otherwise normal lower urinary tract. Secondary VUR is most often associated with outlet obstruction or voiding dysfunction. VUR is generally classified in five grades from I being the least to V being the worst.

Management of VUR

Despite an increased understanding of the etiology, epidemiology and clinical consequences of VUR, the management of these patients remains controversial and differences can be found among various medical specialties, practice sites and countries. The primary goal of treatment is to prevent symptomatic pyelonephritis and long-term renal complications such as renal scarring and renal failure.

Therapy options include:

• medical management with long-term antibiotic prophylaxis
• curative surgical correction including both conventional open surgery and endoscopic treatment
• combination of conventional surgery plus long-term antibiotics

Medical Management
Specific treatment recommendations are based on the grade and severity of reflux. The American Academy of Pediatrics, the American Urologic Association, as well as the Swedish Medical Research Council have all recommended antimicrobial prophylaxis for children with VUR, but all acknowledge that this recommendation is not supported by well-designed randomized clinical trials.

Long-term antibiotic prophylaxis alone is usually used for lower grades of reflux but there has been some open criticism and concern about its use.

Surgery and Endoscopy
Open surgical procedures, such as ureteral reimplantation, have been found to be highly effective, however, require an open surgical procedure. A less invasive procedure involving the endoscopic injection of material (Deflux™) into the bladder has been increasingly popular and has gained FDA approval in the United States. Deflux™ is a substance that has been shown to be both safe and effective.

The Division of Pediatric Urology of Morgan Stanley Children's Hospital has been in the forefront of bringing the use of endoscopic treatment of VUR with Deflux to the United States and has spearheaded the use of this substance in the Greater Metropolitan area. The experience of the Division of Pediatric Urology is extremely broad and a number of publications in peer review literature have been generated from our group concerning endoscopic treatment of VUR.