CHANGES IN THE TREATMENT OFVESICO-URETERAL REFLUX Sarel Halachmi MD. Rambam Medical Center Haifa
Vesico – Ureteral reflux • Reflux is one of the most common and perplexing problem encountered by urologists…the recommendations for management have been altered, continue to be rewritten and undoubtedly will change in the future… • Atala & Keating , Campbell’s Urology 2002
What is reflux • Reflux is a dynamic even in which urine is flowing from the bladder towards the kidney. • In many species reflux is normal event, but considered pathologic in humans.
historical milestones understanding the pathogenesis of reflux • Leonardo da Vinci – the UVJ is a unidirectional flow valve. • Pozzi 1893 – first describe VUR in human • Sampson 1903 – understanding the UVJ valve mechanism. • Hutch 1952 – described the relationship between VUR and reflux nephropathy.
Pathogenesis of reflux– the simple explanation NON REFLUXING REFLUXING
Surgical correction of refluxunderstanding the pathogenesis gave rise to many surgical correction techniques. Art of reconstructive surgery
Surgical correction of reflux • Safe and sound procedures. • High success rate 90-98%. • Low complication rate < 2% • Short to average hospitalization 2-7 days. השד אינו נורא כ"כ
Pathogenesis of reflux – wider viewcomplex of anatomic and functional problems. • Anatomical • Short & lateral ureteral tunnel. • Deficient trigonal development • Functional • Dysfunctional voiding • Microbial • Bacterial colonization & virulence • Genetic & embryonic developmental • Renal dysplasia
Historical milestones • Ransley and Risdon – 1978 Sterile reflux does not cause renal scarring
alternative to surgical treatmenta pill a day keeps the surgery away Medical VS. Surgical
New renal scars in children with severe VUR: a 10-year study of randomized treatment.Olbing H, Smellie JM, Jodal U, Lax H.Pediatr Nephrol. 2003 Evaluation of new scars formation in children with high grade reflux. Medical treatment for reflux After 5 years
Between 5 to 10 years New renal scars in children with severe VUR: a 10-year study of randomized treatment.Olbing H, Smellie JM, Jodal U, Lax H.Pediatr Nephrol. 2003
Medical treatment is effective as surgical treatment. • Most of the new scars were formed till the age of 5 years.
What is driving us to treat reflux medically • Sterile reflux does not cause scars. • Medical treatment is as effective as surgical treatment. • Older kids infrequently have new scars. • High spontaneous resolution rate 50-80%.
There is a price for non surgical treatment • Annual cystography, sonography, and isotope scanning. • Time and money consuming. • Invasive procedures. • Repetitive radiation to the gonads. • Iatrogenic child abuse. • Chronic antibiotics treatment.
Persistent asymptomatic refluxShould we continue treat?Should we continue to observe?Until when? Should we operate?Whom, and when? VCUG - ROOM
Persistent refluxto treat or not to treat? • Pros • Increased risk of pyelonephritis in sexually active girls. • Increased risk to the pregnant woman and embryo (?). • Low spontaneous resolution rate beyond puberty • Cons • The kidney is more resistive to infection. • Lower risk of new scars. • Kidney growing potential already achieved.
Persistent reflux in females • Martinell et al Pediatr Nephrol 1996. • 87 girls with UTI and reflux. • Long term F/U • In 16 girls reflux persist after puberty. • This group had higher rates of pyelonephritis and renal scars.
Persistent sterile refluxis it harmful to the kidneys? • American arm of the international reflux study. • Examine the growth of 164 renal units in patients with grade 4 VUR. • All had medical treatment • No UTI’s documented • 56% of the renal units did not grow as expected from nomograms. • Willscher et al J. Urol 1976 • Improvement of renal growth following the correction of asymptomatic reflux.
Reflux in pregnancy • Heidrick et al obstet gynecol 1967 • 321pregnant women evaluated for VUR. • VUR rate was 2.8% • VUR did not affect neither the mother nor the embryo. • Williams, lancet 1968, Marinelli, BMJ 1990 • Higher rate of pyelonephritis during pregnancy in mothers with VUR. • No effect on pregnancy outcome.
VUR during pregnancy • El Khatib Clin Nephrol 1994 • Jungers Kidney Int. 1996 • Only Females with pre existing reflux nephropathy are at higher risk for: • Hypertension • Pre-eclampsia • Premature birth • Fetal loss • Renal failure
Persistent reflux • We still need more studies in order to have accurate guidelines for management.
And while we are dealing with those complex issues there is a “new” player is on the field ENDOSCOPIC TREATMENT
Endoscopic treatment for VUR • Already been in use for at least 12 years. • “Easy” day surgery procedure. • Reasonable success rate ~80%. • Very low complications rate.
Endoscopic management of VUR • P. Puri, B. Odonnel AAP 2003 • Injection is easy, has high success rate and minimal morbidity. • Lets inject any baby with reflux, and forget from all troubles.
conclusions • The treatment of reflux changed dramatically in the last decade. • Most kids with reflux are treated medically. • Injection therapy replaced traditional surgical treatment, with lower success rate but with lower morbidity. • Still many issues remained without clear management guidelines.