Vesicoureteral reflux
Vesicoureteral reflux is an abnormal physiological phenomenon caused by various primary or secondary causes of urine reflux from the bladder into the ureter or renal pelvis and calyces. vur is prone to ureteral and renal effusion, secondary infections and stones, impairing renal function, which can then lead to a series of reflux nephropathy (RN) such as renal scarring, renal atrophy, renal failure, etc. Severe cases progress to end-stage renal disease (ESRD), which is one of the main causes of pediatric dialysis It is one of the main causes of pediatric dialysis and kidney transplantation.
Diagnosis
I. Clinical manifestations
Urinary tract infection is the most common clinical symptom, and the possibility of VUR should be considered for recurrent urinary tract infection in children under 5 years old. Children may present with urinary frequency, urinary urgency, urinary pain and fever. When aseptic reflux occurs, children may present with renal colic and pain in the lower back during bladder filling or urination. Some children present with symptoms of acute pyelonephritis and present with pain and fever in the affected lumbar region. Children with severe bilateral VUR are prone to renal hypertension.
Auxiliary tests
(A) Routine urine and bacterial culture (recommended)
Routine urine can determine whether the patient has urinary tract infection, and bacterial culture + drug sensitivity helps to select antibiotics for reasonable treatment.
(II) Voiding cystourethrography (VCUG) (recommended)
VCUG is the basic method to confirm the diagnosis of VUR and the standard technique for grading. Based on the findings of VCUG, the International Committee for the Study of Reflux classifies VUR into five grades: Grade I: urine reflux into a non-dilated ureter. Grade II: Urine reflux into the non-dilated pelvis and calyces. Grade III: Mild to moderate dilatation of the ureter, pelvis, and calyces, with mild blunting of the cup. Grade IV: Moderate ureteral tortuosity and dilated pelvic calyces. Grade V: severe dilatation of ureter, pelvis and calyces with loss of papillae; twisted ureter; reflux in the renal parenchyma. grading of VUR reflux helps to select the treatment plan.
(iii) Renal scintigraphy (recommended)
Technetium-dimercaptosuccinic acid (99mTc-DMSA) scintigraphy can be used to assess cortical function in both kidneys as an indirect means to diagnose reflux itself, detect reflux-related renal damage, changes in acute pyelonephritis and follow-up and the presence or absence of renal scarring. Renal scarring is classified into four grades based on 99mTc-DMSA scan photographic signs: grade I: one or two scars, grade II: more than two scars but normal renal parenchyma between the scars, grade III: diffuse damage throughout the kidney of a type that resembles the manifestation of obstructive nephropathy, i.e., total renal atrophy with or without scarring of the renal contour, grade IV: end-stage, atrophic kidney with little or no DMSA uptake (less than 10% of total renal function). of 10%).
(iv) Urodynamics (optional)
Urodynamic testing is used in cases of urinary incontinence or positive residual urine to confirm functional abnormalities of the lower urinary tract. Urodynamic examination is more important in cases of secondary reflux due to fundic vertebral fissure or VCUG confirmed with posterior urethral valves.
(v) Cystoscopy (optional)
Cystoscopy is of little value for the diagnosis of VUR. In patients who are to be treated non-operatively, cystoscopy can provide insight into other anatomical abnormalities such as double ureteral malformations and ectopic ureteral openings.
(vi) Ultrasound (B-ultrasound) (optional)
Ultrasound can be used to initially assess the morphology and parenchymal thickness of both kidneys and hydronephrosis of the ureters. However, ultrasound has limitations in the detection of renal scarring and cannot be graded for VUR.
(vii) Intravenous pyelogram (IVU) (optional)
IVU can show hydronephrosis of kidney and ureter, assess the thickness of renal parenchyma and the presence of urological malformations, but the sensitivity of diagnosing renal scar is lower than that of radionuclide scan.
【Treatment】.
The principle of VUR treatment is to prevent urinary tract infection and to prevent persistent impairment of renal function and related complications. Specific treatment should be selected according to the patient’s clinical symptoms, degree of VUR reflux, affected renal function, age, presence of urinary tract malformation, and complications.
(i) Watchful waiting
(ii)Drug treatment
(iii)Surgical treatment
Indications for surgery.
1.Children aged 1 to 5 years with reflux level Ⅳ to V;
2.Female children >5 years old;
3, I to III degree children in the follow-up process, the reflux level aggravated;
4, drug treatment cannot effectively control urinary tract infection or recurrent urinary tract infection; 5, the presence of urinary tract abnormalities such as ectopic ureteral opening.
Surgical treatment includes open surgery, laparoscopic surgery, and endoscopic treatment.