Nguyen vesico uretheral reflux

8/12/2019 Nguyen vesico uretheral reflux

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Vesicoureteral Reflux:

Updates and Guidelines

Hiep T. Nguyen, MD FAAPTrans: Joao ABA Barbosa, MD

Department of Urology

Childrens Hospital Boston/ Harvard Medical School


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Over 30 years ago

In 1974, when askedabout Reflux, Sir DavidInnes Williams replied :

Reflux is old hat : now that wehave a reliable operation tofix it, it is a boring subject to

talk about!

Courtesy of S. Bauer, M.D.


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Vesicoureteral Reflux in 2011

Historical perspective

Categories of VUR

The link between UTIs and VUR

Evaluation of VUR

Goals of VUR management

How to measure success in managing VUR

Current approaches to VUR The future of VUR


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Past History of VUR

Galen recognized the valvular action of the UVJ.

1903: Sampson described ascending infections from bladder to kidneydue to reflux, later confirmed by Bompus (1924).

1916: Kretschmer study on cystography, reflux present in 4/11 children.

1930: MF Campbell noted VUR present in 12% of children studied with

cystogram. 1950-1960s: Hutch, Paquin, Litch, Gregoire, Politano etcTechniques

for surgical correction of VUR.

1960: Association of VUR with Chronic Pyelonephritis described byHodson.

1965: Recognition of intrarenal reflux by Brodeur. 1984: Ransley/Risdon Big-Bang theory confirmed experimentally in

piglet model.


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Recent History of VUR

1960s and 1970s: recognition of spontaneous VUR resolution withage (Baker et al. 1966, Edwards et al. 1977).

1960s: control of UTIs with low-dose antibiotic therapy, Smellie et al.

1979: Koff, Lapides et al. observe association of VUR and bladder

dysfunction. 1980: Merrick, use of DMSA for renal imaging.

Early 1980s: Birmingham Reflux study and IRS.

1984: Bouton, distinction between dysplasia and chronicpyelonephritis aka renal scarring.

1980s: International grading system for VUR. 1984: Puri-ODonell popularize the STING

1997:AUA VUR Guidelines.


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UVJ

Kidney

Bacteria

VUR

Embryology

(dysplasia)

Voiding dysfunction

GeneticsAge

Anatomy

(intrarenal reflux)

Host factors Virulence Resistanc

Antibiotics


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So What is Vesicoureteral Reflux?

Familial, polygenic condition characterized byregurgitation of urine from bladder up into the upper

urinary tract as demonstrated by VCUG or RNC

May be associated with a spectrum of renal parenchymallesions with or without a history of infection

Several categories of VUR seem to exist

25,000 patient visits to urologists per year


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Categories of Primary Reflux

Neonatal VUR (prenatal hydro, males, high-grade,rapid resolution, renal lesions; ?CAKUT)

Young girl VUR (UTIs, females, lower grades,variable resolution rates, voiding dysfunction, renallesions rare)

Sibling VUR (screening, UTIs and renal lesionsrare, spont. resolution)

VUR in duplex systems (CAKUT)

Megacystis-megaureter complex(CAKUT)

Each one may need to be managed differently


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UTI, VUR and Renal Injuries

9


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Sequelae of Renal Injury

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Renal dysfunction/

failure

Hypertension

most common cause(Dillon, 1975)

23-30% with scarring

develops

hypertension

pathogenesis: renin-

angiotensin system


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UTI, VUR and Renal Injury Association between UTI and VUR recognized

but not cause and effect

UTI may cause renal lesions but these are knownto occur without VUR

Pyelonephritis is not always associated with renallesions

Renal lesions may be present with no history ofUTIs

Can patients at risk, i.e. prone to renal lesions inthe face of UTIs and VUR be identified?


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So What is the Controversy? Not all children who develop a UTI have VUR

Approximately 25-35%

Work up many to find a few?

VUR resolve on its own Dependent on patient characteristics and

genetics

Evaluation for VUR is not completely benign

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Evaluation of VUR

VCUG or RNC only modalities to diagnose VUR Indications for evaluation in flux

Invasive and difficult studies esp. in older children

Timing of follow-up study not well established

Radiation exposure

Risk of iatrogenic infection


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Current Management of VUR

Options include:

non-surgical approach with prevention of UTIs,with or without antibiotic prophylaxis.

Surgical options, open or endoscopic.

VS. VS.


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No consensus but AUA guidelines published in1997 and updated 2011.

There have been NO prospective randomizedtrials comparing efficacy and risk-benefit ratios foreach options.


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VUR and the Urologist:

What do I do Now?


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Spontaneous Resolution of VUR

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?

?


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VUR and Resolution Rates Based upon patient characteristics/ genetics

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Estrada et al., 2009


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Goals of VUR Management

Improve voiding to prevent urinary stasis and high

intravesical pressures

Prevention of ascending infections and/or

pyelonephritis

Prevent renal scarring Prevent HTN and renal failure


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Goals of VUR Management

How successful have we been so far?

Can we do better?

The answers depends on what

are the outcomes we are

looking for/ measuring.


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What are the Outcomes Measures

for VUR studies ?

Eradication of VUR

Is that really the issue?

Prevention of UTIs/pyelonephritis.

Requires long-term F/U to ascertain true results.

Prevention of potentially severe consequencesof VUR (renal lesions, chronic HTN and ESRD).

Requires very long-term, longitudinal studies.

Identification of those patients at risk for long-term consequences.


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Risks and VUR

Failure to recognize and treat VUR can lead to seriousconsequences in (relatively) small number of patients.

Evaluation and treatment of VUR does offer some risks

(allergic reaction, UTI, radiation, anesthesia, surgical

complications etc). Proactive value of screening for VUR in selected patients.

Has the treatment of VUR had a positive impact on

children over the last 40 years?

YES, but impact is hard to quantitate. But can we do better?


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Depends on clinical setting. Identification of patients at risk for renal lesion

Requires proper evaluation (cystogram, DMSA

scan).

Recognition and treatment of voiding

dysfunction and constipation.

Thorough discussion with parents/care givers of

options. Follow-up mandatory

Id tifi ti f P ti t t Ri k


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Identification of Patients at Risk

for Renal Lesions

Family history of UTIs and VUR

Higher grades of VUR

Renal lesions on DMSA scan

Young age History of recurrent UTIs/pyelonephritis

Carriers of chromosomal anomalies (ACE

DD genotype, KLK1, TNF polymorphism)associated with renal scarring

Other features yet to be defined


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Options in the Treatment of VUR

Watchful Management

Antibiotics Therapy

Open Surgical Correction Endoscopic Correction

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Watchful Management of VUR Protocol:

No antibiotic prophylaxis Careful and consistent toileting with prevention

of disorders of elimination

Yearly monitoring with renal U/S

Who: Reasonable for older, toilet-trained children with

lower grades of VUR I- III

Family must be compliant

Switch to other modality of management ifUTIs

Duration of Treatment: ????


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Chemoprophylaxis for VUR Protocol:

Low dose antibiotics Advantages:

Time tested

Low rates of complications

Risk-benefit ratio low

Low cost

Disadvantages:

Not always well tolerated

Issues of compliance

Antimicrobial resistance (how often?)

Addition of probiotics


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Chemoprophylaxis for VUR

Who: Grade II-III: Controversial

Grade IV-V: Likely benefits

Family must be compliant

Switch to other modality of management if UTIs

Duration of Treatment: When to stop?

Open Surgical and Laparoscopic


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Therapy for VUR

Protocol: Several Techniques: Open and laparoscopic

Advantages:

Time tested

Good efficacy in eradicating VUR Low complication rates

Disadvantages:

Complications can be severe

Requires anesthetic/ hospital stay Expensive


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Therapy for VUR Who:

Grade 2-5 with

Breakthrough UTI

Non-compliance with other therapy

Progressive US or DMSA changes Non-resolution (>3 yrs ?)

? Family / Surgeons Preference

Duration: finite treatment time but need follow up

Long-term outcomes:

? Rate of infection may not be completely reduced

? Long-term benefits/ problems


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Endoscopic Treatment for VUR

Protocol: Injection of Deflux/ Macroplastique

Advantages:

Technically straight forward

Very low complication rates Complications are minimal

No hospitalization

Disadvantages:

Less efficacious in eradicating VUR than open surgery(especially in higher grades)

Expensive


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Endoscopic Treatment for VUR

Who:

Same indication as open/ laparoscopic surgery

Duration: finite treatment time

Long-term outcomes: No long-term studies demonstrating durability

requires F/U cystogram

Impact on long-term consequences of VUR

unknown


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Conclusions

The evaluation and treatment of VUR is evolving Long-term, prospective, randomized studies are

needed comparing various therapeutic options

Current management guide-lines should to be

updated

Parents and patients should be made aware of

all therapeutic options, advantages and

disadvantages, risks and complications Long-term follow-up is mandatory for all patients

with evidence of renal involvement


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The Future

Genetic basis of VUR better defined(chromosomal loci)

Reclassification of VUR based on genetics

Identification of renal markers associated withrenal lesions (urine proteomics)

Determination of risk factors for UTI

predisposition and/or renal damage allowing for

better patient selection for Rx Refinement in therapeutic approaches targeted

towards patients at risk


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Nguyen vesico uretheral reflux

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