An introduction to VUR for residents in urology and for medical students.

1. Vesicoureteric Reflux
Dr. Pradeep Deb

2. • Retrograde flow of urine from the bladder to
the upper urinary tract

3. • the prevalence of reflux was estimated to be
approximately 30% in children with UTIs and
• 17% in those who had imaging cystography
for other reasons, such as hydronephrosis
(Sargent,2000)

4. A recent study showed that the
• male:female prevalence of VUR can be as
high as 3:1 at 0 to 6 months of age but
• shifts to approximately 1:1 by 21 to 24
months of age (Capozza et al.,2017)

5. Genetics
• Autosomal dominant
• In Young sibling – 32%
• In Older sibling - 7% (Progressive Renal damage +)
• Identical twins -100%
• Complex polygenetic mech. regulate UVJ
formation
• Pax2 (10q)
• Gdnf & RET receptor
• Angiotensin receptor 2
• ACE
CAKUT(cong. anomalies
of kidney and urinary
tract)

6. Functional Anatomy of anti-reflux
mechanism
Balance of 3 factors:
1. Functional Integrity of ureter: neuromuscular ante-
grade propulsion activity by peristalsis
2. Anatomic composition of UVJ: 5:1 intramural
length, fixation of ureter b/w intra and extra
vesical points
3. Neuromuscular co-ordination Between UVJ and
UB:

7. Types of VUR
• Primary : Congenital Anti-reflux deficiency
• Secondary : Bladder pathology
excessive storage and emptying pressure
overwhelming anti-reflux mechanism

8. Causes of secondary VUR
• Anatomical causes
– PUV (48-70%)
– Ureterocele prolapsing to B.N. (reflux in C/L ureter)
– Distal obstruction(prostate etc,)
• Neuro-functional causes
– Neurogenic Bladder
– OAB
– DSD
– Bladder and bowel dysfunction

9. UTI and VUR
• Infection related cystitis  Bladder irritability and
dysuria  upsetting voiding pattern & lowering the
threshold for reflux
• Endotoxin  ureteric atony Reflux
• Reflux is not a general cause of UTI
• Facilitates Pyelonephritis

10. Grading of reflux
• International classification of VUR:
– VCUG based
– Standardizes description, eases research,
– Most imp factor predicting spont resolution
• Radionuclide cystography grading
– I 1
– II 2 + 3
– III 4 + 5

14. Presentation
• Asymptomatic
• Follow up case of antenatal HDN
• Pyelonephritis / UTI
• Renal dysmorphism
• Obstructive features in case of secondary VUR
• CKD

15. Diagnosis &Evaluation
• Confirmation of UTI, BP, KFTs, Urinalysis
• Indication of Radiological investigation:
– Children < 5yrs (AAP recommendation <2yrs)
– Febrile UTI (second febrile UTI)
– Male child with UTI
1. USG:
– Structural defects (in Grade III,IV,V)
– 25% normal, not exclude VUR
– Reasonable minimum evaluation in any infant/child with UTI
– Screening of siblings
– Done >1 wk age (oliguria after birth)

16. 2. Cystograms VCUG
Indications:
– USG finding of HDN, developmental anomalies, febrile
UTI
• Indirect:
– Excretory urography
– Less invasive, false positives
• Direct:
VCUG, Radionuclide cystogram
USG (with colour doppler /sono contrast)

17. • Fluroscopic study is the gold standard
• Static images:
– UB contour
– Diverticuli, ureterocele
– reflux grade
– Configuration & blunting of calyces
– Intra renal reflux
• Dynamic imaging
– passive/active reflux
– Bladder neck anatomy, funneling
– Delayed / post-voidal films: concomitant PUJO

18. • Considerations:
– Fluid volume instilled
– Presence of infection/inflammation
– Shy bladder, multiple filling-voiding cycles

19. Radionuclide cystography
• Following reflux diagnosis on VCUG, for surgical follow up
• Tc 99m Pertechnetate
• Greater sensitivity in grade 2 – 5 reflux
• Disadvantage:- 1.little anatomical details
2.detecting Grade I reflux

20. • UDS/VUDS if secondary VUR with neurogenic
causes suspected

21. TOP DOWN APPROACH (Hansson et al)
Febrile UTI
DMSA scan
+ -
VCUG No evaluation
Aimto detect children with significant VUR

22. NICE (National Institutes for clinical excellence) guidelines
Screening USG Normal No evaluation
Abnormality
(HDN)
Cystography
<6 months
• Do not recommend early DMSA or VCUG, advise these only on
abnormal USGs

23. American Academy of Paediatrics
Diagnosis and Management of UTI in 2 to 24 month children

24. Cystoscopy
• Rarely adds value to diagnosis
• Useful before open surgery to
– Confirm UO position/duplication
– Clarify urethral patency

25. PIC cystography (Edmondson et al,2006)
• Positioning of the instillation of contrast at the
ureteric orifice
• Placing beak of 9.5/14 fr cystoscope near UO and
instilling contrast from 1 meter height under
fluoroscopic guidance to see reflux
• To detect occult reflux In Children with febrile UTI &
negative VCUG

26. • Nonrandomized studies reveal decreased UTI rates in
patients treated for PIC-discovered reflux
• Disadvantage:
– Does not allow age-adjustment of instilling pressures,
leading to treatment of physiologically insignificant reflux

27. Assessment of Upper tract
• Goal:
– Ongoing / Resolved reflux
– Differentiate from
• intrinsic developmental disturbances,
• MRD,
• antegrade flow resistance

28. USG
• monitor renal growth and status over time
• Help guide need for further evaluation, scintigraphy
• Perfusion abnormality(Resistive Index measurement)
on color doppler USG correlate with high grade reflux ,
pyelonephritis and scintigraphy findings
• Normal USG – can never rule out reflux

29. Renal scintigraphy
• Gold standard
• Tc99m DMSA, taken up by functional PCT
• Uses: no consensus on precise indications
– Decide on need of further evaluation (VCUG) after
febrile UTI
– Renal scarring- diagnosis and follow up
– Relative renal function and decision between surgical
correction of reflux Vs. nephrectomy
– Cortical maldevelopment
– Pyelonephritis diagnosis & follow up
(resolution/scarring)

30. Cortical scars on DMSA

31. • SPECT imaging- more sensitive
• Disadvantage: cannot differentiate
maldevelopment / dysgenesis Vs scarring - ?
Over treatment

32. Factors associated with Scarring
1. Age: inversely proportional
Big Bang Theory (Ransley & Risdon)
 Scars most likely to occur after first pyelonephritis
 Further scarring in absence of pyelonephritis unlikely
2. Papillary anatomy :

33. – Compound (polar) papilla open at right angles-
primary site of reflux & scarring
3. Bacterial virulence
4. Host susceptibility & response

34. 5. Hypertension :
20% develop arterial HTN
deranged renal micro vascular mechanisms associated with
parenchymal defect
Successful correction of reflux unlikely to ameliorate BP
Tash et al(2003) : Removal of renal segments verified by selective
renal vein sampling of arteriolar and segmental vessel renin level,
normalizes BP
complete removal of a small unilateral congenitally dysmorphic or
globally scarred and shrunken kidney also may correct
renovascular hypertension (Dillon and Smellie, 1984),

35. 6. Renal growth:-
reflux correction Improved renal growth
7. Renal failure and somatic growth
– MRD + Renal scarring
– Hyper-filtration, Proteinuria, Microalbuminuria, RTA
– Fall in somatic growth, catch-up growth after correction

36. Associated anomalies with VUR
1. PUJO (9-18%):
– Reflux assessment difficult
– 3 signs suggest presence of PUJO in reflux:
1. ureter dilated with contrast with minimal PCS filling
2. contrast entering PCS is dilute and faint
3. Lack of prompt PCS drainage
– Diagnosed PUJO must be corrected before reflux
2. Ureteral Duplication
– Reflux more in lower pole (lateral and superior insertion) – Weigert-
Meyer rule
3. Bladder diverticulum
– Usually have no bearing on management and progression
– If ureter opens inside diverticula- no spont. resolution, Sx must

38. 4. MCKD/ renal agenesis: 26% incidence of
contralateral VUR: VCUG must
5. Megacystis-megaureter
– due to massive bilateral VUR leading to
decompensation of UB due to large refluxing
volumes returning to UB
– Differentiate from PUV by VCUG (posterior
urethra normal)
– Vesicostomy initially, followed by surgical
correction
6. Other anomalies: vertebral, anal, cardiac etc

39. Pregnancy and VUR
Increased bacteriuria, higher urine volumes,
slower drainage
Higher risk of pyelonephritis
Prone for preeclampsia, UTI, fetal loss
Correction of reflux before pregnancy
recommended

40. Natural history and management
• Spontaneous resolution :-
– Related to initial VUR Grade, Age, laterality (U/L>B/L), mode of
presentation (asympt>sympt), renal cortical abnormalities,
bladder dysfunction
– Process:-
– remodeling of VUJ
– progressive elongation & consolidation of intramural ureter
– stabilization of bladder dynamics
Resolution by grade:
I/II 85%
III 50%
IV
V <25%
Resolution by grade:
I/II 85%
III 50%
IV
V
Resolution by Age:
• Inversely proportional to
age
• High grades show poor
resolution irrespective of
age
• B/L < U/L

41. Principles of management
• 1. Spontaneous resolution of reflux is very
common and facilitated by correction of BBD.
• 2. Higher grades of reflux are less likely to resolve
spontaneously, especially when diagnosed in
older children after UTI.
• 3. Sterile reflux is unlikely to cause significant
renal damage.
• .

42. • 4. Prevention of UTI is more important than
VUR resolution.
• 5. The use of prophylactic antibiotics is safe
and beneficial, particularly in high-risk
patients.
• 6. There is a role for medical management for
most forms of reflux

43. • Low dose Antibiotic Prophylaxis: 1st line for all
• Early consideration for surgery if:
– Past or recurrent pyelonephritis
– scarring on DMSA
– high grade reflux
– deranged renal function
– Congenital renal dysmorphisms
– older age

44. • wait till 5 years of age( provided no recurrent
infections)
• After that age, kidneys become less prone to
scarring after pyelonephritis:
– In male child discontinue antibiotic with little/no
follow up lifelong as long as no pyelonephritis
– Female: traditionally surgical to prevent pregnancy
complications, new studies showing <10% risk of
pyelonephritis
• Adult patients presenting with flank pain/ febrile
UTIs/ pyelonephritis: surgery

45. Medical Management : watchful waiting
• low dose antibiotic prophylaxis
Single bedtime oral antibiotics(DOC <2mnth-
amoxicillin/trimethoprim, >2mnths-
septran>nitrofurantoin)
• Termination of medical management
Breakthrough febrile UTI. Causes
• Antibiotic sensitive : non compliant patients, low dose
• Antibiotic resistance : residual UB vol. too high, too high
dose
• Antibiotic terminated few days after VCUG documented
reflux correction
Pyelonephritis

46. EAU 2019 guidelines

47. LANDMARK STUDIES
• International Reflux Study in Children:
o Surgery more effective in reducing pyelonephritis than CAP
o Both modality are equally effective in reducing new scar,CKD
• Birmingham Reflux Study :
o Both modality are equally effective in reducing new scar
• RIVUR Study : CAP Vs placebo
o Antibiotic prophylaxis reduced recurrent UTI by 50%
o Incidence of scarring is unaffected
• Swedish Reflux Study : CAP Vs endoscopic correction Vs
surveillance
o New scars are more prevalent after febrile UTI
o Rate of new renal damage was low in boys

48. Endoscopic Mx of VUR
• O’Donnel & Puri
• STING Technique(Sub ureteric Teflon injection)
• Success rate 90% in low grade reflux

49. • Dublin Group modification (sub-mucosal intra-mural
implantation) : inserting needle directly inside ureter to
increase length of intravesical ureter
• Kirsch et al modified it by adding a second injection inside
orifice – Double HIT (double hydrodistension implantation
technique)- cause coaptation of both orifice and intramural
tunnel
• Volcano appearance : 87% success rate
• Follow up :
o At 3 month with VCUG if reflux persist  Re-implant
after another 3months if reflux persists  open surgery

50. HIT
STING
HIT
HIT

52. Surgical Management
• Absolute Indications:
 Failed Medical Management
 Ureteric Obstruction
 Refluxing ureter opening into Bladder Diverticulum
• Relative Indications :
 Massive reflux (Grade IV & V)
 Reflux associated with para ureteral diverticulum
 Persistence reflux even after puberty

53. Principles
• Exclude secondary VUR
• Adequate And tension free mobilization of ureter
• 5:1 height vs. width of Sub mucosal tunnel (Paquin 1959)
• Hiatus, Tunnel,Anastomosis
• Muscular Backing

54. Types
INTRAVESI
CAL
EXTRAVESI
CAL
COMBIN
ED
Lap ROBOTIC
SUPRA
HIATAL
Leadbetter
–politano
Lich-Gregoir Paquin
Techniq
ue
Gil-Vernet procedure RALUR
Extravesical Reimplant
(Lich-Gregoir)
INFRA
HIATAL
Glenn-
Anderon
Cohen
cross
trigonal
Cohen cross trigonal
reimplant

55. POLITANNO-LEADBETTER

60. Advantage
1. Politano-Leadbetter
• Long tunnel can be created
• Psoas hitch can be used to
further augment the reflux
mechanism
2. Glenn Anderson
• No kinking
3. Cohen cross trigonal
• No difficulty distal
anastomosis
• No kinks
• Away from bladder neck so
leaves room for bladder neck
reconstruction
• M.C. used
Disadvantage
• Post operative ureteric
obstruction (kinking)
• Difficult distal ureter
anastomosis
• Superolateral positioned UO
difficult to catheterize for
stenting/dye studies etc.

61. Lich Gregoir Technique
• Modification (Daines, Hodgson, Zaontz)
– Anchoring the ureter with advancement suture
– Combined advancement of the ureter and lengthening the tunnel
proximally
• Advantages:
– Bladder not opened-no haematuria/bladder spasms
– Easy simple technique
• Disadvantage:
– nerve damage due to detrusor dissection causing transient voiding
insufficiency (20%)
Injury to pelvic plexus is avoided by dissection between
mesoureter and ureteral adventitia

63. • Paquin: combined intra + extra vesical
• Ureter approached, divided at VUJ and
submucosal tunnel created extravesically
• original hiatus closed
• new hiatus created superiorly to original one
intravesically
• Rest part done intravesically
• Advantage:
– Suited for dilated ureter and complex/redo cases
due to versatility offered by combined approach

64. Laparoscopic procedure
• Gil-Vernet procedure :
– Sub mucosal approximation of two ureters in midline
– Transvesical approach
– Recurrence of reflux – least successful
1. Splitting of trigone
2. Lateral displacement of ureter
• Lap Extravesical Procedure
– Lich-gregoir technique
• endoscopic cohen cross trigonal Approach using
CO2 insufflation of bladder

65. Follow up after surgery
• Originally low grade reflux
– USG at 2-3 months, some dilatation may persist
for 3 months
– VCUG optional
– If persistent/ worsening HDUN, UTI, discrepancy in
renal growth etc then full evaluation
• Originally high grade reflux
– Full evaluation USG and VCUG at 2-3 months

66. Complications of re-implantation
• Early:- Persistent reflux
Contra lateral reflux
(relative non-interference of C/L trigone)
Obstruction(with in 2 weeks)- DJS/PCN insert, most resolve
• Late:-
– Obstruction
– Supra-hiatal (twist / ischemia)
– Hiatal (High re-implantation phenomenon)
– Tunnel (compression / ischemia)
– Orifice (Ischemia / Inadequate sub mucosal tunnel)
– Recurrent/ persistent reflux

67. Thank you