Journal Archives - Volume 6
Editorial: The indications for surgery for vesico-ureteric reflux (VUR) have evolved from the observations made from several studies in the past. These include some controlled trials. While taking these into consideration, the treatment of VUR must be individualized. However, there remain some grey zones. Although the present criteria for surgical intervention are widely accepted, the long-term safety of continued non-operative management has constantly been under scrutiny. The currently accepted end-points of medical management are inconsistent. The ongoing risk of renal damage when patients are being followed up on medical management cannot be ignored. Patients who undergo surgery have variable criteria and none of them meet all the criteria for surgical intervention. These criteria are also irreversible. In a recent study, we demonstrated that all children, except one, who required surgery as per the internationally accepted criteria, had shown an activation and a progressive increase in plasma renin activity (PRA). It is, therefore, imperative to establish a more sensitive marker, such as PRA, in order to decide the most appropriate time for surgical intervention in medically managed patients with VUR and to prevent the deleterious effects of the activation of the renin-angiotensin-aldosterone system (RAAS). Although the detrimental effects of RAS activation are significant, there are conflicting data on the association of angiotensin-converting enzyme (ACE) genotype and renal damage. Deletion polymorphism of the ACE gene has been studied as a risk factor for renal damage in patients with congenital uropathies. We have demonstrated that the D allele may be one of the genetically predisposing factors that may contribute to adverse renal prognosis in patients with VUR. The potential usefulness of evaluation of the genotype extends beyond the prognostication of parenchymal damage to the identification of patients who may benefit from ACE inhibitors and angiotensin II antagonists.
Abstract: Vesico-ureteric reflux (VUR) is known to occur in families. The aim of this review is to summarize worldwide data regarding the incidence and nature of VUR in siblings of children with VUR. Siblings of patients with VUR have a much higher incidence of reflux than in the normal population, and there is a direct relationship between the patient's age and the incidence and severity of reflux. The majority of investigators advocate screening of asymptomatic siblings of patients with VUR in an attempt to prevent progressive renal scarring. When VUR is discovered in symptomatic siblings, it is usually high grade and associated with a high incidence of reflux nephropathy. Randomized controlled studies are needed to compare renal damage in refluxing patients detected through screening with patients diagnosed after urinary tract infection in order to establish how much renal damage may be preventable through screening asymptomatic siblings.
Abstract: There are many conditions associated with vesico-ureteric reflux (VUR). This linkage is consistent with the current theory of the origin of primary reflux. The site of origin of the ureteric bud from the Wolffian duct plays a crucial role in determining the subsequent development of the ureter and associated kidney. An abnormal vesico-ureteric junction may arise from maldevelopment or delayed maturity and thus lead to so-called primary VUR. In another group of patients, VUR can occur as a consequence of the changes in the bladder wall and especially the trigone as a result of bladder outlet obstruction or altered bladder innervation, and thus may lead to so-called secondary VUR. This chapter focuses on issues regarding the evaluation, treatment options and outcome of patients with VUR, and some associated anomalies.
Abstact: Follow-up imaging studies are an integral part of the management of vesico-ureteric reflux (VUR). Radiation dose reduction can be obtained when digital radiography systems are used instead of conventional films. Manipulation of the images can also be done to provide finer details. The study can be stored in storage devices and transferred to a picture archiving and communication system (PACS). Where necessary, conventional spot films can be replaced by digital imaging using photostimulable imaging plates, thereby reducing the dose. Decreased exposure time and image manipulation are added advantages. Positioning the instillation of contrast (PIC) at the ureteral orifice cystogram, a slightly more invasive technique, is also claimed to be more sensitive than routine voiding cystourethrography (VCUG). Sonographic VUR detection has become more sensitive following the use of ultrasound contrast agents. Combined with harmonic imaging methods, even intrarenal reflux can be detected. The advantage is a total lack of radiation and lesser patient discomfort.
Abstarct: During the past several years, radionuclide cystography (RCG) has gained increasing acceptance for the initial diagnosis and follow-up of vesico-ureteric reflux (VUR) including familial reflux, for the evaluation and assessment of VUR following medical management and/or anti-reflux surgery and for serial evaluation of bladder dysfunction (e. g. neurogenic bladder) for reflux. The advantages of RCG include low gonadal radiation exposure (100 to 200 times less than with voiding cystourethrography (VCUG), high temporal resolution and high sensitivity for the detection of VUR. Apart from diagnosing VUR, RCG can also provide information regarding the volume of the bladder (volume of the bladder at the first occurrence of reflux, at the time of maximum reflux during filling and/or voiding and residual bladder volume), volumes of reflux (initial, maximum, residual), average voiding rate and time and bladder pressures.
Abstract: The past few years have seen rapid changes in the understanding of the pathophysiology of many congenital and acquired malformations. Paediatric urology has also been affected by this conceptual revolution. With better understanding of the natural history and crucial role of bladder dynamics in the evolution and resolution of primary vesico-ureteric reflux (VUR), management has shifted from immediate surgical intervention to conservative management. This article aims to review the literature available on the role of bladder dynamics in the causation, perpetuation and management of primary VUR in children.
Abstract: Primary vesico-ureteric reflux (VUR) is thought to be caused by an abnormality of the vesico-ureteric junction, which allows retrograde flow of urine up the ureter. About one-third of children with urinary tract infection (UTI) are consistently found to have reflux. It is believed that VUR predisposes to UTI and facilitates ascent of infection into the renal parenchyma causing renal damage. VUR has been actively treated for over four decades since the time the association between reflux and scarring was described. Earlier, it was common practice to correct VUR by surgical reimplantation of the ureter. However, findings from comparative trials of surgical and medical management have revealed that the two are similar in efficacy. As a result, medical treatment has gradually replaced surgery and become the cornerstone of therapy for the majority of patients with VUR.
Abstact: The surgical correction of vesico-ureteric reflux (VUR) was pioneered by Leadbetter and Politano and by Paquin. They established the surgical principles of a successful ureteral reimplantation including (1) adequate ureteral exposure and mobilization; (2) meticulous preservation of blood supply; and (3) creation of a valvular mechanism whose submucosal tunnel length to ureteral diameter ratio exceeded 4:1. The same principles were subsequently used in developing other surgical techniques by Glenn and Anderson, and Cohen. Recent advances in laparascopic surgical technique and miniaturization of equipment has led some authors to explore laparoscopic ureteral reimplantation in order to minimize postoperative morbidity.
Abstract: Endoscopic subureteral injection of tissue-augmenting substances has become an alternative to long-term antibiotic prophylaxis and surgical intervention in the treatment of vesico-ureteric reflux (VUR) in children. We present our and worldwide experience with endoscopic treatment of reflux using the various tissue-augmenting substances presently available. In terms of effectiveness and long-term successful results, polytetrafluoroethylene is still the most reliable injectable material for the endoscopic treatment of VUR. However, the potential for migration of the polytetrafluoroethylene particles cannot be brushed aside. There are now new injectable tissue-augmenting substances available for endoscopic correction of VUR; of these, Deflux appears to be a promising alternative to Teflon.