Vesicoureteral reflux primarily affects newborns, infants, and young children under the age of two, with about 1% to 3% of children suffering from this condition. However, vesicoureteral reflux can also affect older children and rarely impacts adults. This reflux results from a problem with the valve mechanism between the ureter and the bladder. The condition may improve over time, but in some cases, Surgery for vesicoureteral reflux is the only solution.
What is vesicoureteral reflux?
Vesicoureteral reflux is characterized by the backward flow of urine from the bladder to the ureters and kidneys, resulting from a problem with the valve mechanism between the ureters and the bladder. The kidneys filter the blood and send urine to the bladder through tubes known as ureters, which connect to the bladder via a one-way valve. This valve allows urine to enter the bladder without flowing back into the ureters. When this valve does not function properly and urine flows in the opposite direction, it is called vesicoureteral reflux.
What are the causes of vesicoureteral reflux?
Vesicoureteral reflux has various causes depending on the type of reflux, which can be divided into two types:
Primary vesicoureteral reflux is the most common type. Infants are born with this condition due to a problem with the valve located between the ureter and the bladder. Because of this issue, the valve does not close effectively, causing urine to flow back through the ureters, which carry urine from the kidneys to the bladder.
As children grow, the length of the ureters increases, and the valve function may improve, potentially helping to correct the backward flow of urine over time. This type is sometimes considered hereditary, but the exact cause remains unknown.
Secondary vesicoureteral reflux often occurs due to improper bladder emptying. Several potential causes exist, such as a tissue fold preventing complete urine evacuation from the bladder or the narrowing of the muscles that connect the bladder to the urethra. Additionally, the nerves responsible for controlling bladder emptying may be damaged.
What are the symptoms of vesicoureteral reflux?
Symptoms of vesicoureteral reflux often arise due to a urinary tract infection. Although this infection may not always cause clear signs, many individuals notice some symptoms, which include:
- Urgent and frequent need to urinate
- Burning sensation during urination
- Frequent urination in small amounts
- Cloudy urine or urine with an unpleasant odor
- Fever
- Pain in the side, thigh, or abdomen
For infants or young children, it may be difficult for them to express their feelings, but signs may include:
- Fever without an apparent cause
- Loss of appetite
- Restlessness or discomfort
If left untreated, vesicoureteral reflux may lead to complications in older children, such as:
- Bedwetting
- Bowel movement issues like constipation
- High blood pressure
- Presence of protein in urine
- Urgent need to urinate frequently
- Urinary leakage, also known as incontinence.
How is vesicoureteral reflux diagnosed?
Vesicoureteral reflux is often detected during a doctor’s evaluation of a urinary tract infection. After an infection occurs, some basic tests may be requested to diagnose the condition.
- Voiding Cystourethrogram (VCUG): This X-ray test examines the urinary system. A small catheter is inserted into the bladder through the opening from which urine exits (the urethra). A special liquid called a contrast agent fills the bladder through the catheter. When the bladder is full, the patient will urinate into a special container while on the X-ray table. X-rays are taken while the bladder is filling and when the patient urinates, showing whether there is any backward flow of urine into the ureters and kidneys.
- Radionuclide Cystogram (RNC): This test is similar to VCUG, where a catheter is inserted into the urethra and bladder, but a different liquid highlights the urinary system. RNC is considered more sensitive than VCUG but does not provide much detail about the bladder’s anatomy.
- Ultrasound of the kidneys and bladder: This test uses sound waves to examine the kidneys for scarring and to determine their size. The technician applies warm gel to the abdomen and back and moves a device resembling a microphone over the same areas.
- Dimercaptosuccinic Acid (DMSA) Scan: This imaging test detects the presence of scarring in the kidneys due to urinary tract infections.
Additional Tests
After diagnosing vesicoureteral reflux, the patient should regularly undergo the following tests:
Blood Pressure Checks: Kidney problems may increase the risk of high blood pressure.
Blood Tests: High levels of protein or creatinine indicate kidney damage.
Urine Tests and Cultures: Protein in urine is a sign of kidney damage, and bacteria in urine indicate an infection.
How is Surgery for vesicoureteral reflux performed?
Surgery for vesicoureteral reflux is a procedure aimed at repairing the connection point between the bladder and the ureters to prevent the backward flow of urine, thereby reducing the likelihood of future recurrences. Surgical options depend on the patient’s age, symptoms, type of vesicoureteral reflux, and severity. There are two main options for surgery: ureteral reimplantation or endoscopic injection.
Surgery for vesicoureteral reflux through ureteral reimplantation
There are several techniques for performing this surgery, which is often done under general anesthesia with the possibility of an overnight hospital stay. Surgery for vesicoureteral reflux through ureteral reimplantation involves repairing the connection between the bladder and the ureter by incision in the lower abdomen and reconnecting the ureter to a new position on the bladder. This procedure is also known as ureteral reimplantation into the bladder, where the surgeon enters the bladder to make the repairs.
Surgery for vesicoureteral reflux through ureteral reimplantation can be performed via open surgery or laparoscopically, with the surgeon discussing the benefits and risks of each method with the patient. Ureteral reimplantation outside the bladder is also an option, which is less invasive.
A systematic review in 2022 showed that both methods (external and internal) are equally effective in correcting vesicoureteral reflux. Each has its own advantages and disadvantages. The physician will help determine the most suitable option for the patient.
The success rate of Surgery for vesicoureteral reflux through ureteral reimplantation surgery exceeds 90%, even in advanced stages of vesicoureteral reflux.
Surgery for vesicoureteral reflux through endoscopic injection
Surgery for vesicoureteral reflux through endoscopic injection requires general anesthesia. During this procedure, a small amount of a bulking agent, such as hyaluronic acid/dextranomer, is injected into the bladder wall near the ureteral opening. The injection causes swelling in the bladder tissue, acting as a substitute valve mechanism.
Surgery for vesicoureteral reflux through endoscopic injection is typically outpatient, allowing the patient to return home the same day. The physician can discuss the risks and benefits of this type of treatment with the patient. The success rate for Surgery for vesicoureteral reflux through endoscopic injection ranges from 71% to 83%, depending on the technique used.
Other methods for treating vesicoureteral reflux
Surgery for vesicoureteral reflux is not the only available option; medication may also be considered.
Vesicoureteral reflux often improves naturally as the child grows and the urinary system develops. The doctor may prescribe antibiotics to treat or prevent urinary tract infections during this time.
However, the long-term use of antibiotics to prevent urinary tract infections is a controversial topic, as continuous use may lead to the development of resistance. The American Academy of Pediatrics (AAP) recommends using prophylactic antibiotics primarily for children with higher grades of vesicoureteral reflux while monitoring to see if they will outgrow the condition.
Advantages and Disadvantages of Surgery for vesicoureteral reflux
Surgery for vesicoureteral reflux is an effective option for treating this condition in most cases, but each procedure has its advantages and disadvantages.
Advantages and Disadvantages of Surgery for vesicoureteral reflux through ureteral reimplantation
Advantages of Surgery for vesicoureteral reflux through ureteral reimplantation include:
- It has the highest success rate in correcting reflux
- It can be performed using robotic, laparoscopic, or traditional techniques
- It is a well-known and reliable method for over 40 years
- It carries a low risk of postoperative complications
the disadvantages of Surgery for vesicoureteral reflux through ureteral reimplantation include:
- It is an invasive procedure that may require several days of hospitalization
- The cost may be higher when using robotic assistance, and may not be available at all facilities
- Internal methods may lead to increased postoperative pain and longer hospital stays
- External methods may increase the risk of urinary retention after surgery, requiring a longer period for urine drainage via catheter
- It may take up to 6 weeks to resume daily activities
Advantages and Disadvantages of Surgery for vesicoureteral reflux through endoscopic injection
Advantages of Surgery for Surgery for vesicoureteral reflux through endoscopic injection include:
- Patients can return home the same day
- Normal activities can be resumed within a few days
- It is the least invasive option available
- It is effective in cases that are difficult to treat by other methods
The disadvantages of Surgery for vesicoureteral reflux through endoscopic injection include:
- It has a lower success rate compared to ureteral reimplantation
- Success rates can vary significantly based on the patient’s age, stage of vesicoureteral reflux, and the injection technique used
- It may cause inflammation due to the body’s reaction to the bulking agent
- It is a newer procedure and lacks long-term data on the effectiveness of injectable agents
- The cost is similar to that of ureteral reimplantation surgery
Recovery Period After Surgery for Vesicoureteral Reflux
Surgery for vesicoureteral reflux through ureteral reimplantation typically requires a hospital stay. During this time, a urinary catheter is used to facilitate urine drainage without putting pressure on the bladder, with close monitoring of pain levels. The patient may leave the hospital with a urinary catheter or a drain near the incision, which will be removed later.
Strenuous activities are not recommended for at least three weeks after surgery, and taking baths is prohibited for five days. Children can return to school one week after surgery or when they stop taking opioid pain relievers.
In the case of endoscopic injection, patients can return home the same day, and there is no need for a urinary catheter, allowing for the resumption of normal activities the next day.
In most cases, the doctor will prescribe antibiotics for a specific period, and the patient may need to undergo annual kidney ultrasounds to ensure there is no obstruction. If there are any scars on the kidneys, the doctor may recommend annual blood pressure checks. Urinary tract infections can occur after Surgery for vesicoureteral reflux, but they are usually limited to the bladder.
Can vesicoureteral reflux be prevented?
There is no known way to prevent vesicoureteral reflux, but specific steps can be taken to improve overall urinary tract health. It is recommended to:
- Drink adequate amounts of water
- Change diapers immediately after defecation or urination
- Urinate regularly and avoid holding urine
- Seek appropriate treatment for constipation or urinary or fecal incontinence when necessary.
Possible Complications After Surgery for Vesicoureteral Reflux
Fortunately, Surgery for vesicoureteral reflux is considered a low-risk procedure for patients in generally good health. Common complications occur in 1-2% of patients and include ureteral obstruction or persistent reflux.
Obstruction issues may be temporary, but in some cases, the kidney may require drainage using a tube inserted from the side or through the bladder. In rare instances, additional surgery may be needed to address the obstruction or ongoing reflux.
Other rare complications include infection at the surgical site and bleeding.
Vesicoureteral reflux can be effectively managed with early diagnosis and appropriate treatment. Treatment options range from simple monitoring to surgery, depending on the reflux grade and symptom severity. Continuous follow-up is essential to prevent complications and protect the kidneys in the long term.
Sources:
