VUR Flashcards
what is anti reflux mechanism -3
intramural length ureter Paquin's law 1:5 diameter to length oblique entry (duplex, more proximal and lateral) muscular attachments preventing reflux during filling and voiding
why does VUR arise
why in poles of kidney
deficiency of valvular mechanism of longitudinal muscle of intra vesical ureter
Ransley and Risdon, abnormally flat papulla at poles allow intra renal reflux of infected urine
conical deep shape vs compound shallow shape
DMSA scan process
Give isotope through cannula
Then wait 2 hours, cycles through kidney several times
Then takes a few minutes to take images
See poorly functioning right kidney
Other than cannula, not much cooperation needed from child
MAG 3 indirect process
Voiding cystogram
Indirect vs direct
Direct accurate sensitive requires catheter
MAG 3 IRC in potty trained child
Indirect nuclear medicine, MAG3 without frusemide, wait for bladder to fill
No catheter, needs IV access and child void on command
May miss reflux
conservative management reflux
Bladder management
Antibiotics - mandatory if VUR and LUTD, continue until toliet trained
prompt treatment uti lessen chance scarring and send for culture
Circumcision
Then onto deflux and reimplantation
Wipes backwards in girls Double voiding avoid constipation treat UTI urgently good fluid intake regular voiding Low grade VUR just follow up based on symptoms rather than imaging
success deflux
timing surgical intervention
When is reimplantation indicated?
First deflux 70-80% efficacy, second deflux 90%
no consensus on optimal timing of surgical intervention
circumcision may be helpful in VUR and anatomical abnormalities
types of ureteric reimplantation
Aim to use temporising measures below one year
Intravesical
Cohen cross trigonal intravesical repair
Cohen: 97% success rate correct VUR, low incidence post op obstruction
Leadbitter politano - implant higher and more medially
The Politano–Leadbetter type of reimplantation, coupled with a psoas hitch, is often preferable to the Cohen technique when reimplanting a grossly dilated megaureter.
Extravesical
Lisch Gregoir extravesical lap /robotic - suturing distal ureter onto bladder and contructing a tunnel of detrusor muscle around it
MCUG process children
Abx Day before , day of and 2 days after mum to hold child at head nurse for catheter and contrast on x ray table film AP and then lateral need to wait for child to void
Swedish reflux trial Brandstrom 2011
compared surveillance, antibiotics and endoscopic surgery
in girls prophylaxis reduced recurrence UTI and renal scarring
in girls deflux reduced UTI recurrence
Boys no benefit active treatment
RIVUR trial 2014
prophylaxis
reflux after UTI
prophylaxis reduced rate UTI but not scarring
meta analsysi
do not prevent scars with abx prophylaxis
but do reduce risk pyrexial UTI by a third
but then 8x risk of subsequent infections being resistant
monitoring of VUR
growth
BP
urinalysis
annual US
grade 3-4 resolve in 4-5 years as child’s growth elongates intramural segment ureter
what is deflux
Dextranomer microspheres of average size 80-250 um in sodium hyaluronate
1ml of mixture consists of 0.5ml microspheres and 0.5ml sodium hyaluronate
By 1 year microspheres surrounded by fibroblasts and collagen
Biodegradable substance extensively tested no evidence of immunogenic properties or potential for malignant transformation
Cochrane review of CAP 2019
CAP long term / surgical treatment / probiotics / circumcision / anticholinergics
34 studies
4001 patients
Outcomes: recurrent UTI, febrile UTI, renal scars
CAP: increased likelihood bacterial resistance
no sig difference of continuous antibiotic prophylaxis to no treatment or surgery
surgery less febrile episodes, but no difference in scar formation
chance resolution reflux
grade 1 =90% 2 = 80% 3 = 50% 4 = 20% 5 = <10%
indications surgical management
breakthrough infections
new renal scarring
not adhering medical management
