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Vesico-ureteral reflux (VUR) is a well known heterogeneous disease. It can be described as a disease process coupled with an anatomical abnormality at the uretero-vesical junction (Tarcan, Tiney, Temiz and Simsek 2011, p. 1011). It can also be described as an abnormal urinal flow from the bladder to the upper urinary tract. VUR is usually categorized into either primary or secondary reflux (Tarcan, Tiney, Temiz and Simsek 2011, p. 1011).
Of the two, primary reflux is the most common. It is as a result of an incompetent uretero-vesical tunnel (Tarcan, Tiney, Temiz and Simsek 2011, p. 1011). Under normal circumstances, the ureter passes through the detrusor muscle and ends at the ureteral hiatus thus the intramural ureter. A short intramural ureter results into failure of the flap-valve mechanism (Tarcan, Tiney, Temiz and Simsek 2011, p. 1011).
Secondary VUR is associated with abnormal high pressure build-up in the bladder. It follows that a flap-valve mechanism failure at the intramural ureter is due to this high pressure (Pennesi, Travan, Peratoner et al 2008, p. 1489). Posterior urethral valves and neurogenic bladder are normally associated with clinical conditions that lead to secondary reflux. The retrograde flow of urine is checked as the intramural ureter is passively compressed while the bladder fills (Pennesi, Travan, Peratoner et al 2008, p. 1489). The disorder has been subjected to great scrutiny, especially in relation to the general importance of the disorder as a clinical entity in renal development and function (Pennesi, Travan, Peratoner et al 2008, p. 1489).
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An international classification for grading of VUR has been developed. figure 1. According to this classification, grade 1 VUR is reflux into non dilated ureter. Grade 2 is reflux into non dilated renal pelvis and calyces. Grade 3 is reflux into mild to moderately dilated renal pelvis, calyces and ureter with mild blunting of fornices, grade 4 id dilatation of renal pelvis and calyces with moderate ureteral tortuosity. Grade 5 is gross dilatation of ureter, renal pelvis, calyces, ureteral tortuosity, and loss of papillary impressions (Khoury & Bagli 2007). It is a matter of debate that which grade of VUR is associated with greater risk of complications.
Statistics reveal that 1% of normal children are usually affected by this disorder. Approximately, 30-50% of children with urinary tract infections are also affected. It should also be noted that 10% of children with prenatally diagnosed hydronephrosis have been reported to have the disorder (Pennesi, Travan, Peratoner et al 2008, p. 1489). However, its treatment has since remained to be clouded with a lot of controversies in pediatric urology, in addition to the fact that it represents one of the most significant risk factors for acute pyelonephritis in children (Pennesi, Travan, Peratoner et al 2008, p. 1489). Common knowledge has it that pediatric nephrologists, pediatric urologists and pediatrics in general, have frequently encountered VUR. This has led to the conclusion that VUR is a prevalent disorder (Pennesi, Travan, Peratoner et al 2008, p. 1489).
Chances of renal damage, especially in children over one year of age can be reduced through management and identification of VUR. When a child has UTI in proximity with VUR prevalence then he or she is likely to contract pyelonephritis and UTI. Renal scarring is a clear indicator of pyelonephritis (Pennesi, Travan, Peratoner et al 2008, p. 1489). A child is more disadvantaged when he or she has both pyelonephritis and VUR as compared to when he or she only has pyelonephritis. The risk of permanent renal injury and morbidity of acute pyelonephritis can be lowered by administering VUR treatment (Pennesi, Travan, Peratoner et al 2008, p. 1489). Three most common methods of treating VUR include curative interventions, continuous antibiotic prophylaxis and observation (Pennesi, Travan, Peratoner et al 2008, p. 1489).
Imaging studies for the diagnosis of VUR in children reveal that there is a strong correlation between detection of renal scarring and existence of VUR in children aged less than one year. However, the focus of imaging in older children should be the kidney as detection of reflux had a poor correlation with scarring (Gleeson & Gordon, 1991). Renal ultrasound studies have also failed to demonstrate sensitivity as well as specificity in detecting VUR in children diagnosed with UTI for the first time (Mahant, 2002). It has now been established that most children diagnosed with VUR do not improve with the currently available therapeutic modalities and treatment needs to be individualized according to peculiarities of a particular case (Cooper, 2009).
Treatment of Vesico-Ureteral Reflux
Antibiotic prophylaxis in prone children have been the hallmark of a therapeutic strategy against VUR until a date. Incidence of repeated UTI infections in infants and young children are indicative of VUR,and antibiotic therapy is initiated after confirmation of the diagnosis through cystourethrogram and ultrasound studies (Khoury & Bagli 2007) . The American Urological Association recommends continuous antibiotic therapy in young children once UTI infection has been diagnosed, and primary VUR grade III-V has been established. Latest research, however, reveals skepticism for this approach. Studies have indicated that antibiotic prophylaxis does not reduce the recurrence rate of pyelonephritis and incidence of renal damage in children younger than 30 months of age diagnosed with VUR grade II through IV (Pennessi, 2011).
Surgical intervention is recommended when there has been no improvement in symptoms within one year (Khoury & Bagli 2007). Secondary VUR is better amenable to treatment using surgical interventions for removing the obstruction. Current indications for the surgical correction of VUR depend on the presence or absence of renal scars. If no scars are present, anti reflux surgery is only indicated in high-grade bilateral VUR. Anti reflux surgery is divided into three type open, laparoscopy and endoscopic sub-ureteral injection.
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The technique of endoscopic sub-ureteral injection for treating VUR was first described in 1981 and further developed by O’Donnell and Puri in 1984. There have been several studies showed its simplicity, safety, quickness, and effectiveness with 70%–90% success rate (Mahant, Friedman and MacArthur, 2002, p. 419).Treatment Treatment of vesico-ureteral reflux (VUR) with endoscopic sub-ureteral injection is known as the alternative to open anti-reflux surgery for patients with high-grade VUR, also it is alternative to prophylactic antibiotics for patients with lower-grade VUR (Mahant, Friedman and MacArthur, 2002, p. 419).
Prophylactic antibiotic use does not correct the VUR or decrease in the incidence of UTIs (Pennessi et al, 2011), In a cohort study,611 children who had a first UTI. Ant-imicrobial prophylaxis were not associated with decreased risk of recurrent UTI (HR, 1.01; 95% CI, 0.50-2.02), but was a risk factor for anti-microbial resistance among children with recurrent UTI (HR, 7.50; 95% CI, 1.60-35.17) (Conway, 2007). So it is reasonable outcomes for studies comparing antibiotics and endoscopic sub-ureteral injection (Mahant, Friedman and MacArthur 2002, p. 419). Furthermore, knowing demographic characteristics (gender, race/ethnicity and age), medical history (circumcision), and VUR grade may predict of developing frequent UTIs and change the management plan later.