VUR Flashcards
A patient presents with VUR + UTI, what history do you want to elicit?
Voiding pattern (urinary frequency or infrequent, incontinence, UTI, dysuria), bowel habits, birth history
Must do physical exam - circumcised?
What are important things to check besides history?
BP, UA, urine CX if indicated, RUS, baseline Cr (optional), DMSA (optional)
Name the VUR grading.
I - ureter
II - renal pelvis
III - pelvicocalyceal
IV - tortuous ureter
V - severe dilation, blown out kidney
What are indications for a patient to be on CAP?
Less than 1 years old
- with VUR and febrile UTI hx
- or grade III - V VUR
For a patient greater than one year old with a hx of VUR and UTI, what do you wish to know?
Bladder bowel dysfunction (treat first), VUR grade, renal scarring, recurrent febrile uti
If present > CAP + treatment of BBD
If not present (only UTI, not febrile) > SDM on surveillance or CAP
Can consider surgical correction
What are treatment options for BBD?
Biofeedback (older than 5 yo), behavioral therapy, anti-ch meds, alpha blocker, bowel management
How often do you follow patients at this point, on CAP?
Annually - history, physical, serum Cr, BP, UA, RBUS
Into adolescence.
How often do you get VCUG on patients on surveillance?
Every 12-24 mths
When do you take further action, and what do you do?
Get DMSA if scarring or abnormal Cr or BT-UTI
If fUTI - must re evaluate BBD first…and then VUR
When can we stop following?
A single VCUG with no VUR, no more imaging
What do you do for patients with BT-UTI?
SDM-
Surgical - reflux vs reimplant
Changing antibiotic - in single febrile episode, without any other issues
What imaging is performed in both endoscopic and surgical management?
RBUS
VCUG only indicated in deflux, optional for surgery
should consider continuing CAP for a bit after
What is follow up?
If kidneys normal on RUS and DMSA - optional
If kidneys are scarred or abnormal - annual follow up
What happens if there is a fUTI after intervention?
BBD, then do VCUG for possible recurrent UTI
What do you need to counsel parents about for bus of VUR?
HTN (particularly during pregnancy), renal fxn loss, recurrent UTI, familial VUR
When do you screen siblings?
Only if abnormal RUS or hx of UTI - then get VCUG. Otherwise it is optional
Incidence is 30%
What are important surgical principles for ureteral re-implantation?
- adequate mobilization of the distal ureter, so no tension
- creation of a submucosal tunnel - 5x width of the ureter
- ensure proper positioning to prevent obstruction
In which surgery do you tend to see more postoperative issues?
Extravesical - 20% chance increase for urinary retention.
What condition is bilateral VUR commonly seen?
PUV
Walk me through a ureteral reimplant, both approaches
Intravesical:
create a new ureteral hiatus - with new submucosal tunnel
- can also do ureteral tunnel to opposite UO (for small bladders)
Extravesical:
create a muscular trough for ureter
What are AE of ureteral reimplant?
recurrent UTI
obstruction, ureteral stricture
contralateral reflux
persistent reflux
urine leak
urinary retention
