Vesicoureteral Reflux: VUR
Urinary leakage to the kidneys (Vesicoureteral reflux) is the flow of urine collected in the urinary bladder back to the kidneys, contrary to normal. It is the most common urological problem in children and one of the most controversial issues in pediatric urology. This backflow (reflux) may cause kidney damage in the long term by causing the kidneys to come into contact with both high pressure and dirty urine.
Vesicoureteral Reflux in Children
The cause of vesicoureteral reflux in children may be a genetic structural disorder at the point where the urinary tract opens to the urinary bladder, or an anatomical or physiological stenosis at the point where the urinary bladder opens to the outside may cause high pressure in the urinary bladder, causing secondary leakage.
All Reflux is observed in 1-2% of children, but 25-40% of children with kidney inflammation have reflux. Accompanying reflux is present in 17-37% of prenatally detected kidney swellings (hydronephrosis). Due to this high frequency, it should be recommended that every child with febrile urinary tract infection be screened for reflux. Reflux has been shown to be hereditary. Reflux was detected in 30% of children whose siblings had reflux and in 70% of children whose parents had reflux. For this reason, siblings and future children of children with reflux should also be evaluated for reflux.
Untreated reflux is the most common cause of high blood pressure in childhood, and 10 to 20% of children with untreated reflux develop kidney failure. Although there is still no consensus on the optimal treatment scheme, the main aim of the treatment is to prevent permanent kidney damage by protecting the kidney against infected urine through antibiotic suppression therapy or surgical methods. In order to determine the appropriate treatment scheme, the degree of reflux should be determined and kidney functions should be evaluated.
Diagnosis
In the first stage, a simple evaluation of the kidneys and other urinary system organs is performed with an ultrasonography. The most commonly used radiological method to determine the presence of reflux and to classify it according to the changes it makes in the urinary tract, if any, is to use a special radiopaque coating of the urinary bladder. It is a voiding cystourethrography (MSUG, voiding cystourethrography) in which the leak is revealed fluoroscopically under x-ray by filling it with a liquid.
Radionuclide cystography has been recommended. In this method, which is based on filling the urinary bladder with a low radioactive substance and detecting whether there is leakage to the kidney with the help of cameras, only limited information can be obtained about the structure of the channels, which has caused this method not to be preferred by urologists. With these methods, leakage to the kidney is graded from 1 (least) to 5 (most serious).
Scintigraphy:
DMSA is the preferred method for determining kidney function and damage to kidney tissue. kidney scintigraphy. A prediction about the natural course of reflux can be made with the combined use of voiding cystourethrography (voiding cystourethrography) and DMSA renal scintigraphy.
Cystoscopy:
Cystoscopy, which is a method of examining the inside of the urinary bladder using special endoscopes, which used to be a mandatory examination, is now only used to evaluate the canal openings before surgery in children who are planned for surgical treatment.
Treatment
In the treatment of vesicoureteral reflux in children, if there is constipation in the patients, it should be detected and treated before follow-up and treatment. Because constipation also has an increasing effect on Vur clinic. Treating constipation can improve the degree of reflux. Likewise, in patients with bladder dysfunction, treating bladder dysfunction after urodynamics is performed and revealed can reduce the degree of reflux.
Follow-up and Prophylactic (Protective) Antibiotics:
Informing the family to prevent urinary tract infection. It consists of preventive steps, preventive antibiotics, constipation treatment, treatment of urination dysfunction, if any, and follow-up with monthly checks.
The basis of treatment is early diagnosis and close follow-up, and in this way, the aim is to protect the kidney tissue. Since reflux may resolve spontaneously as the child grows, the first step in treatment is to encourage all patients to drink large amounts of fluid until they are one year old, ensure complete emptying of their bladder, and administer low-dose antibiotics. Infections are prevented and monitored with k protection. In this period, circumcision of male babies is recommended as a preventive measure against infection.
In children between the ages of 1-5, it is more accurate to continue monitoring grade I, II and III reflux, while it is more accurate to continue monitoring grade IV and V reflux. It is more appropriate to consider surgical treatment in those with reflux and in children who have febrile urinary tract infections despite antibiotic protection during follow-ups, who have new damage areas in their kidneys, or who have anatomical disorders such as the double collecting system.
All girls over the age of 5 who continue to have reflux symptoms. While surgical correction is recommended for children, no further treatment, including antibiotic suppression therapy, is required for boys after the age of 5, except in very rare cases.
2. Surgical Treatment:
Surgical correction of reflux can be achieved by endoscopic, robotic, laparoscopic or open surgery.
Endoscopic Treatment:
The treatment option that can be preferred in many non-severe reflux cases. It is seen as.
Open Surgery:
Correcting reflux with these methods is based on reshaping the entry points of the urinary ducts into the urinary bladder. These types of surgeries are tolerated by children without much difficulty, and children can usually return to their daily activities in as little as a week.
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