It is described as urine leaking back from the bladder to the kidneys. The most important function of the kidneys is to clean harmful substances from the blood and excrete them as urine. After urine is produced by the kidneys, it is transported to the bladder (bladder) through tubes called ureters and stored, and then it is removed from the bladder out of the body through a channel called urethra (urinary tract) during the urination process. Meanwhile, in normal people, urine does not leak back to the kidneys. If urine leaks back to the kidneys, this is called vesicoureteral reflux (VUR). In other words, vesicoureteral reflux is the leakage of urine that accumulates in the urinary bladder back into the upper urinary tract during urination.
In some children, abnormal urination characteristics may reveal reflux. Refluxmay create a tendency for infections in children, causing pyelonephritis, which we call kidney infection, and ultimately kidney damage. More severe reflux may cause greater kidney damage. In cases where reflux is excessive, it may cause deformity by causing the ureters and kidneys to grow and expand. In general, frequent urinary tract infections make the diagnosis. ;Reflux may not cause pain, discomfort, or problems with urination.
Reflux occurs in approximately 1-2% of healthy children. The age at diagnosis is 2-3 years, but diagnosis can be made at any age, such as in infancy or older children. Three-quarters of the children treated are girls. In some children, reflux may be familial.
The disease is diagnosed with a test called voiding cystourethrography. A thin and soft tube called a catheter is placed in the urethra, which we can describe as the pathway through which urine comes out. The bladder is filled with a medicated liquid, which becomes visible when X-rayed, until it is completely filled. The child is then asked to pee. Meanwhile, films are shot one after the other to see if there is any backward escape. This test usually takes 15-20 minutes. It continues between. Sometimes, some children may develop an infection during this test due to the use of a catheter. It is recommended to give antibiotics before and after the test. Ultrasound, kidney scintigraphy or color film (IVP) may also be required to determine whether reflux and urinary infection damage the kidneys.
In children with reflux The aim of the treatment is;
- Infection of the kidney
- Preventing damage to the kidney and the complications explained above.
There are three treatment options:
- Medical treatment
- Surgical treatment
- Observation.
Medical treatment includes antibiotics and correction of the child's urination habits. . The aim of this treatment is to prevent infections that may occur during the spontaneous healing process of VUR.
Surgical treatment can be performed by open or closed method, which we call endoscopic, depending on the degree and characteristics of reflux. Open surgery is preferred in cases of refractory or high-grade reflux. The average hospital stay after surgery for reflux is 2-5 days and varies depending on the surgical technique used. In recent years, the length of hospital stay and the duration of the operation have become much shorter. Endoscopic surgery involves entering the child's urinary tract with a camera system and normalizing the wide ureter openings by injecting a substance. With this method, the hospital stay is quite short.
These children should be followed up periodically and observed for urinary infection. Urinalysis and urine culture should be performed in sick children to show whether the disease is due to urinary infection. Blood pressure monitoring is important in children with kidney damage. Bladder films are taken to monitor the improvement, continuation or worsening of reflux.
Vesico Ureteral Reflux Diagnosis, Follow-up and Surgical Treatment (urine leaking back to the kidneys in children)
Vesicoureteral reflux (VUR) is the reflux of urine in the bladder into the upper urinary tract and is a pathological condition that is not seen in normal healthy children. It is one of the diseases that pediatric urologists encounter most frequently, especially in the childhood age group.
Importance of VUR: In urinary system pathologies, the aim is to protect the kidney. Since life expectancy is long, especially in children, all pathologies that may cause permanent damage to the kidney are of particular importance. Urinary infection and VUR are common pathologies in children and can cause a negative cycle. When diagnosis and treatment are inadequate, it leads to renal scarring, hypertension and eventually chronic renal failure. VUR is a disease that is the result of multifactorial pathologies or can lead to other pathologies. For this reason, those who care for this group of patients should approach VUR in a multidisciplinary manner and protect the child's kidney in the best way possible with early diagnosis and appropriate treatment modality.
VUR IN HISTORICAL PERSPECTIVE >
VUR has been known since the Middle Ages, when the antireflux mechanism was first proposed by Galen and later demonstrated by Leonardo da Vinci with drawings and the physical rules of hydrodynamics. However, there was no progress in this regard until the late 19th century. After being described at the end of the century, HIT; It helped to understand the embryology and physiology of the urinary system and the congenital anomalies that occur in this system, and finally drew attention to the existence of pediatric urological diseases, leading to the establishment and popularization of pediatric urology as a urological sub-specialty. We can list the important milestones in the historical development of VUR as follows:
* In 1883, Semblinow demonstrated VUR experimentally in rabbits and dogs for the first time. .
* VUR in humans was first demonstrated by Pozzi in 1893, with urine coming from the cut distal ureteral end during nephrectomy.
* Sampson described the ureteral valvular mechanism in 1903. described and stated that reflux caused by inadequate valvular structure leads to renal infections.
* In 1898, Young and Wesson showed that situations in which normal ureterovesical junction anatomy is preserved prevent the formation of reflux.
* 1916. Krethschmer, bladder surgeon in introduced cystography into clinical use, but its relationship with reflux has not yet been elucidated. showed that its length and the surrounding trigone change with the muscular development.
* In 1959, Hodson pointed out that reflux was commonly found in children with urinary infection and renal scarring.
* Following Tanagho's experimental study in 1965 showing that reflux occurs with the incision of the trigonal muscle structure distal to the ureteral orifice, Ransley and Risdon in 1975 suggested that resection of the submucosal ureteral tunnel "roof", that is, weakening of the muscle structure supporting the ureter, It has been shown that it causes reflux.
* In 1974, King and his colleagues demonstrated spontaneous resolution of reflux with growth in children with reflux who did not receive surgical treatment. Then, in 1979, Smellie and Normand published their studies showing that a low renal scar rate could be achieved with medical monitoring in children receiving antibiotic therapy.
* In 1981, Matouschek used endoscopic Teflon injection in the treatment of VUR for the first time, and then O'Donnell in 1984. and Puri popularized this technique as the STING (Subureteric Teflon Injection) procedure.
* In 1986, Kiriluta and his colleagues demonstrated the relationship between the maturation of bladder adrenergic nerve fibers and reflux.
INCIDENCE
* In 42% of children with prenatally detected hydronephrosis or other renal disorders, reflux is detected in the postnatal period evaluation.
* In the antenatal period. In these children whose reflux is suspected and detected in the postnatal period, the degree of reflux is higher and it is often bilateral, but the probability of it disappearing within two years is higher than in older children. Its high frequency is also a factor.
* Among children with hydronephrosis identified in the antenatal period, postnatal 70-80% of those with confirmed VUR in the preterm period are males, thus the male/female ratio for the antenatal period is 4/1.
* Postnatal imaging studies in these babies reveal hydronephrosis, renal cyst, renal dysplasia. or persistent upper urinary tract disorders such as renal agenesis (Shapiro, 1998).
* In cases of multicystic kidney or unilateral renal agenesis, VUR can be detected in the contralateral kidney. The most common urological abnormality in renal agenesis cases is VUR.
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