What is vesico-ureteral reflux?
Urine normally follows the following path: it is produced by the kidneys, goes into the pelvis (just outside the kidney) and into the bladder via a tube called the ureter, is stored in the bladder and then, during urination, passes into the urethra and reaches the external environment. However, in 1-2% of children, urine returns to the ureter and can reach the kidneys. This is called vesical (bladder) - ureteral (ureter) reflux.
What can reflux cause?
Reflux is associated with an increased number of urinary infections. Theoretically, as the infection starts in the bladder, if there is reflux into the kidneys, it would be easier for the infection to also reach the renal system (pyelonephritis). Therefore, it is said that children with reflux are more likely to have a kidney infection than those without reflux. This kidney infection often causes kidney damage, killing the cells that make up the functional unit of the kidneys, which are the nephrons. Therefore, the main aim of reflux treatment is to prevent urine infection, in an attempt to preserve kidney function.
What is familial reflux?
Brothers or sisters of children with reflux are more likely to also have reflux. This occurs in around 35% of siblings. As these children are also likely to contract urinary infection and kidney damage, it is recommended that they be investigated for reflux. The cause of familial reflux is not yet known and no genetic factor has yet been determined.
How is reflux classified?
Reflux is classified into 5 degrees:
Grade 1-reflux of urine into the ureter
Grade 2-reflux of urine into the kidney, but without dilation of the ureter and pelvis (system connected to the kidney)
Grade 3-reflux of urine into the kidney, with dilation of the ureter and pelvis
Grade 4 -reflux of urine into the kidney with marked dilatation of the ureter and pelvis
Grade 5 -reflux of urine into the kidney with such marked dilation of the ureter that it bends until it reaches the pelvis.
Does reflux resolve spontaneously?
It depends on a few factors, such as
Grade - The higher the grade, the lower the chance of spontaneous resolution.
Laterality - Unilateral grades 3, 4 and 5 reflux have a greater chance of spontaneous resolution than bilateral reflux.
Presence of associated vesico-urethral dysfunction - voiding dysfunction is associated with reflux in around 30% of cases. When it is treated, the rate of spontaneous resolution is 3 times higher than those without dysfunction.
Age - The older the child at the time of diagnosis, the lower the rate of spontaneous resolution. The chance of reflux resolving after the age of 6 is small.
How is reflux diagnosed?
Any child who does not yet have voluntary urination, i.e. has not yet undergone voiding training, with a urinary infection, even in the first episode, even if they are afebrile, should be investigated for reflux. Those with afebrile urinary infection after voiding training do not need to be investigated for reflux. Investigation for reflux is done with voiding cystourethrography. This test is extremely important and should not be missed. A probe is passed into the bladder, through which iodinated contrast is administered. Some X-rays are taken, which will assess whether there is any backflow of urine into the ureters and kidneys. If there is reflux, children are usually followed up with radioisotopic cystourethrography annually or every 2 years.
How are children with reflux treated?
In general, initial treatment is clinical. Cases of reflux at an advanced age, especially in females, high-grade and bilateral reflux in older children, the existence of repeated urinary infection despite the use of antibiotics, difficult clinical follow-up of the child, irregular use of antibiotic medication, evidence of increased kidney damage with clinical follow-up are excluded.
Clinical treatment consists of careful observation of the child and the use of prophylactic antibiotics, which is the use of antimicrobials in low dosages with the aim of preventing infections. The ideal antibiotics are those with a broad spectrum of action against the bacteria that commonly affect the urinary system, and those with renal excretion, since those with fecal excretion can select the fecal bacterial flora and promote multi-resistant urinary infections. One medication that meets these requirements is nitrofurantoin (Hantina) 2 mg/kg/day, single dose.
Reflux diagnosed in early life tends to resolve spontaneously, even if it is bilateral and high-grade. Surgery is only necessary in those with refractory urinary infection.
Another alternative that can be used as a first choice or when surgery is indicated is endoscopic injection. This procedure is carried out on an outpatient basis, i.e. the child is discharged from hospital on the same day as the procedure and has a cure rate of 70 to 90% for reflux grades I to III and around 50% for reflux grades IV-V.
What is anti-reflux surgery like?
Open surgery is now usually performed after the endoscopic injection has failed. Anti-reflux surgery aims to correct the defect in the junction between the ureter and the bladder that is responsible for the problem. There are several techniques for this purpose and none is truly superior to another. Therefore, the difference in the technique used will be the surgeon's preference. The surgery is performed through an aesthetically acceptable incision (for girls and boys, the scar is inside the bikini and swimming trunks). The child is left with a tube in their bladder for 1 to 3 days. The cure rate for this procedure is 97%.
What is endoscopic injection for vesico-ureteral reflux?
Periureteral injection is a minimally invasive treatment for vesicoureteral reflux. It consists of an injection of substances near the ureteral orifice in the bladder with the aim of preventing urine from returning to the ureters. This procedure is performed without a surgical incision, using only an endoscopic device.