Vesicoureteral reflux

Vesicoureteral reflux: with scarring o n A.

The vesicorenal reflux (synonyms: vesicoureteral reflux, vesico - uretero - renal reflux, VRR, VUR, English vesicorenal reflux ) is a non-physiological reflux of urine from the bladder via the ureters ( ureters ) into the renal pelvis.

  • 6.1 Conservative Therapy
  • 6.2 Endoscopic therapy
  • 6.3 Surgical treatment
  • 6.4 Treatment of secondary reflux

Molding

The vesicorenal reflux is divided into a primary and a secondary congenital, acquired form.

The urine reflux begins in the filling phase of the bladder, it is called a low pressure VUR. Can the reflux only in the emptying phase of the bubble show is called a high-pressure VUR.

Primary reflux

Congenital reflux based on an anomaly in the ureteral orifice in the bladder wall. The submucosal course of the ureter is shortened. This can not be adequately sealed the urinary bladder in an intravesical pressure rise through the bladder muscles.

Secondary reflux

The acquired form of vesicorenal reflux is caused by the direct damage to the formerly intact ureteral orifice ( ureteral orifice ).

The following causes are possible:

  • Specific and nonspecific cystitis
  • Neurogenic bladder dysfunction
  • Infravesicular urinary tract obstruction, such as urethral valves, urethral strictures

Classification of reflux

The International Reflux Study Committee in 1985 developed a general classification of severity of vesicorenal reflux:

  • Grade I: Reflux into the ureter, the renal pelvis is not reached
  • Grade II: The Reflux reaches the renal pelvis, the calyces is not jammed
  • Grade III: The renal pelvis is slightly dilated, the collecting system is blunted unchanged or slightly
  • Grade IV: Moderate dilatation of the renal pelvis, the calyces are blunted the Fornizes, the impressions of the renal papillae still visible
  • Grade V: The ureter is greatly dilated with buckling ( kinking ), the cavity system is greatly expanded, the papillary impressions are no longer visible in the majority.

Epidemiology

The incidence in children is 1 %. The ratio of boys to girls at about 1 -year-old is 1:5-6. Fair-skinned are 10 times more frequently affected than dark-skinned. Red-haired children have a higher risk. When diagnosed patients, the risk for siblings is also to have a reflux at about 30%. Of the children with urinary tract infections, vesicoureteral reflux show a 30-40%. 20-30 % of children at diagnosis of renal scars already.

60 % of newborns have a reflux, whereas only 5 % of the 5 -year-old have a reflux, this can be attributed to the maturation of the vesicoureteral junction.

Symptoms

Early symptoms:

  • Asymptomatic per se
  • Severe reflux leading to second- time urination due to reflux of refluxate into the bladder after micturition first, with development of a new ventricular filling pressures
  • No primary kidney affection

Due to the non-physiological Rückstauung of the urine the way for bacterial infections and ascension is prepared. This manifests itself in recurrent urinary tract infections to highly febrile pyelonephritis with flank pain.

Late symptoms may include:

  • Arterial hypertension
  • Renal failure
  • Renal growth retardation
  • Unclear failure to thrive in infancy
  • Urinary incontinence

Diagnostics

After detailed history taking the following tests are carried out in the rule:

  • Determination of creatinine
  • Urinalysis
  • Urine culture
  • Sonography
  • Miktionscystoureterogramm or Miktionsurosonografie in infection- free interval
  • Urodynamics
  • Possibly Nierenszintigrafie

Therapy

The therapy depends on the shape of the present vesicorenal reflux.

Conservative therapy

Depending on the grade of reflux and age of the patient, there is a spontaneous cure rate of between 4% (grade 5) and 87 % ( grade 1) (so-called maturation ). There should be an infection prophylaxis be performed, since the occurrence of urinary tract infections reduces the chance of spontaneous healing.

Endoscopic therapy

Injecting material (for example, hyaluronic acid, stabilized ) by means of cystoscopy in order to narrow the ureteral orifice of the same. The success rate is depending on the material and experience between 50 and 90 %. The procedure can be repeated several times.

Surgical treatment

Implementation of an open or endoscopic antireflux. The success rate of this standard method is about 95%.

Transvesical antireflux after Politano - Leadbetter: Cut the ostium of the bladder wall and mobilization Selbiger. It creates a more cranial and lateral situated passage for the ureter, thus creating a longer submucosal course of the ureter. After reimplantation of the ureter ostium occurs near the previous mouth.

Transvesical antireflux Cohen: Cut the ostium of the bladder wall under reimplantation on the contralateral side.

Extravesical antireflux to Lich - Gregoir: Lateral and cranial division of the detrusor muscle at the ostium while sparing the mucosa. After the closure over the ureter occurs.

Treatment of secondary reflux

In secondary reflux is always removing the cause of reflux in the foreground. The therapy procedures given above are possibly carried out in addition.

Congenital disorder Fornix Recidivism (medicine) Voiding cystourethrogram
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