A) PRIMER VUR
In the normal conditions, the urine coming to the bladder via ureter does not move to the upper system thanks to the anti-reflux mechanism. This forms the most important part of this anti reflux mechanism, after passing the bladder Wall and moves under the bladder mucous and it is sub mucous part of the urethra.
Normally when the bladder is filled with urine ( the pressure inside during resting and filling phase is maximum 10 cm water (H2O) ) and while urinating( the pressure in the bladder reaches to the maximum being 40 cm H2O) and lower part of the urethra (distal) staying under different pressures gets closed and prevent the urine from going to upper side. If the sub mucous urethra size is 4-5 times bigger than the dimension of the urethra, it is said that it won’t be reflux.
VUR is the most common urinary infection reason seen at children group. In the normal individuals, microorganisms continuously arrive to urinary system from the outer genital system toward upper side(asan) . The most effective weapon of the urinary system against these infection factors is discharging all urine inside. During VUR, at each urination, one part of the urine in the bladder escapes to the upper system via urethra. The microorganisms in this undercharged urine reproduce and cause urinary infection. Urine escaped to upper side with pressure, gets the tubes in the kidney wider ( pelvic laical system) and get then kidney parenchyma thinner and most importantly causes that infected urine to enter in this collective canals in the kidney( intra renal reflux) and scarification in the parenchyma.
In this way, the most unwanted but expected result of the VUR: chronic pyelonephritis appears. The most common reason of the chronic pyelonephritis at children group is VUR.
There is continuously repeating urinary infection history in the history (anamnesis). Any particularity is not detected in the physical examination. Final diagnosis and grading of VUR is made, as stated above, placing catheter into the bladder and inserting colored substance into the bladder and the urine cystography (voiding cysturethrograph VCUG)
Grading is important for the treatment planning and tracking
Ist grade: there is reflux only in the lower end of the urethra
IInd grade: there is reflux in all system until calyces however there is no dilatation
IIIrd grade: there is dilatation with reflux in all systems. Papilla are seen (goblet structure of the calyces is not changed)
IVth grade: Dilatation has increased even more. The most important difference from III is that the images belonging to papillary have disappeared (calyces have blunted)
Vth grade: Pelvic Alicia dilatation and advanced level calicle blunt and also the urethra have widened and have a curved structure
After the diagnosis, especially bilateral reflux cases kidney structures and functions should be assessed. Glomerular filtration rate must be detected and the its function at that time must be known which is important for the follow up.
DMSA kidney cystography is the best method showing the parenchyma scares.
Treatment must be planned quickly to be able to prevent the complication of VUR.
There is generally two important approaches in the VUR treatment. Especially for the low leveled reflux in which scar does not occur, pediatric prefer conservative approach while the urologist prefer the quicker and invasive approach. The aim in the conservative approach is to keep the child under the lower dosed antibiotic protection for long term. The disadvantage of this method is the side of effects to be occurred in the body of the child of giving child antibiotics for more than 10 years and the cost of drug usage. Besides, the surgical approaches have above % 80 success rates and following the early intervention the reflux is fixed.
In the conservative approach: anti biotherapy must be applied in accordance with the urine culture and anti biogram when infection symptoms are detected in the urine for the I and IIIrd level of reflux and later after stopping the antibiotic, lower dosed antibiotic treatment with trimetoprin + sulfametaksazol and prophylaxis must be followed. When the infection disappears, the reflux may disappear on its own in a few months. However I and IInd level of refluxed that does not disappear in spite of this treatment may require a more advanced level of surgical intervention.
Today’s surgeries are applied in two different methods:
A. Minimal invasive techniques
B. Invasive techniques
Suburethral Teflon Injection (STING)
A number of liquid teflons are injected under ureter orifice through entering the bladder with cystoscope, which is a minimal invasive method. With this method, while valve mechanism is made to function better via supporting the rear ureter wall, the submucosal ureter piece is prevented from moving, which is claimed to be shortened in peeing while detrusor, the bladder muscle is stretching. Thanks to this method, a 75 – 80 % success has been reported. This method can be used also in other materials than teflon. The patient can be discharged after this day-application, with no need to be nursed. In case the application is unsuccessful, it can be repeated. Chance of success is more likely to be achieved especially in refluxes stage 1 and 2.
Uretero Neocystostomy (rearrangement of ureterovesical compound)
The common goal in this surgical technique which can be carried out with different methods as an invasive way of approach is to extend the submusocal piece of ureter. The surgery can be performed with closed laparoscopic technique or open surgical techniques. Cohen’s transtrigonal ureter reemplantation is the most used one among open surgical techniques. In this method applied in bilateral VUR, the prepared ureters are passed through new tunnels created under mucosa and make a permanent opening to the bladder. The chance of success is about 80 – 85 %.
B) SECONDARY VUR
In some cases, VUR can emerge despite the fact that ureterovesical compound is normal.
The most frequent reason of secondary VUR is infravesical obstructions such as neurogenic bladder, posterior urethral valve, and traumatic uretra strictures. Urinary infection which is the result of VUR sometimes may the reason of VUR itself. Inflammation created in bladder mucosa and submucosal ureter by the infection reaching the bladder somehow leads them to thicken and ruin the antireflux mechanism. Therefore, urinary infection should be detected before VCUG has been carried out, and if it has been detected, it should be treated and VCUG should be shot one week after the urinary infection has been determined to have been removed. The main pathology should be removed in obstruction related refluxes. Surgical approach should be applied if reflux continues to exist in spite of it.