VESICOURETERAL REFLUX/VUR (KIDNEY LEAK)
Normally, during urination, there are mechanisms that ensure the urine is expelled unidirectionally from the bladder. The leakage of some of the urine towards the ureters and/or kidneys during urination due to disruptions in this mechanism for any reason is called vesicoureteral reflux.
The most common cause of kidney failure in our country is still urinary tract infections due to vesicoureteral reflux.
>How is VUR disease diagnosed?
Vesicoureteral reflux often manifests itself with febrile urinary tract infection or prenatal hydronephrosis. Diagnosis is made during the evaluation for urinary tract infection. The first evaluation test performed in a child with a urinary tract infection is urinary ultrasonography. The most important test that provides information in a child with suspected VUR is the x-ray film taken during the administration of a dyed liquid into the bladder with the help of a thin catheter in the urinary tract, called voiding cystourethrography or voiding cystourethrography.
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In the figure;in voiding cystography, the escape of the opaque substance given to the bladder from the ureter (the channel connecting the kidney to the bladder) backwards towards the kidney, from the 1st degree to the 5th degree(from left to right)The preferred method for determining kidney function and damage to kidney tissue is DMSA, that is, kidney scintigraphy. A prediction about the natural course of reflux can be made with the combined use of voiding cystography (voiding cystourethrography) and DMSArenal scintigraphy.
How often does VUR occur in whom?
Only 1-2% of all children experience reflux, but 25% of children with kidney inflammation experience reflux. 40 of them have reflux. (hydronephrosis) 17%-37% of kidney swellings detected before birth have accompanying reflux. Therefore, it should be recommended that every child with febrile urinary tract infection be screened for reflux.
Vesicoureteral Reflux Rating:
1st Degree:Bladder The filling contrast material only reaches the distal part of the ureter during urination. VUR of this degree occurs in 8% of all cases.
2. Degree:Contrast material reaches the renal calyces. However, there is no dilatation in the urinary system. 37% of the cases are in this stage.
3rd Degree:Despite moderate dilatation in the ureter, renal pelvis and calyces, the renal calyces have not yet become blunted. . 25-37% of the cases are in this group.
4. Degree:In addition to dilatation in the ureter, renal pelvis and calyces, the renal calyces are blunted. 14-24% of the cases are in this group.
5. Degree:There is advanced hydroureteronephrosis and a tortuous ureter on the side where the reflux is located. 5% of the cases are in this group.
VUR Treatment
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 prevent and monitor infections with low-dose antibiotic protection. During this period, circumcision of male babies is recommended as a preventive measure against infection.
Vesicoureteral reflux (VUR) may pass out at a rate of50%in the first 2 years. In necessary cases, 85% successful VUR treatment can be performed in experienced hands by endoscopically injecting some special fillers into the urinary tract. However, the situation is slightly different in children presenting with febrile urinary tract infection. The degree of reflux, the child's age and the level of kidney damage are important in deciding on treatment. The level of damage to the kidney can be measured numerically and visually by nuclear medicine examination (static renogram - DMSA). It usually resolves spontaneously by the age of 5, depending on the degree of vesicoureteral reflux. Close monitoring and treatment of urination disorders, if any, accelerates this process.
When is surgical treatment required for vesicoureteral reflux?
• Grade IV and grade V refluxes antim Continuation of bacteriuria despite icrobial treatment
• Presence of diseases causing secondary vesicoureteral reflux (such as bladder diverticulum, ureterocele, ureter duplication)
• Nephralgia (side pain due to reflux)
•Stopped kidney growth, increase in kidney damage and/or scarring
•Failure to properly apply medical treatment
•Advanced Children with damaged kidneys, high-grade reflux, and children over the age of 5 usually need surgical treatment.
Surgical correction of reflux can be performed by endoscopic, robotic, laparoscopic, or open surgery. . The gold standard of surgical treatment is the re-sewing of the urinary tract to the bladder through a new route. Children must stay in the hospital for at least one night after the operation. In experienced hands, the success rate is over 95%. Endoscopic treatment, which has emerged in recent years, is the injection of a special silicone-like substance into the urinary tract where the leakage occurs. With this method called STING, although the child returns to his home or school immediately after the procedure, the success rate is between 60 - 85%. STING can be tried twice and if no results are obtained, the classical surgical method should be preferred instead of more sessions.
It has been shown that reflux is transmitted hereditarily. 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 renal reflux should also be evaluated for reflux.
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