eMedicine Specialties > Urology > Hydronephrosis and Ureter Disorders

Vesicoureteral Reflux: Treatment

Author: Marc Cendron, MD, Associate Professor of Surgery, Harvard School of Medicine; Consulting Staff, Department of Urological Surgery, Children's Hospital Boston
Contributor Information and Disclosures

Updated: Dec 15, 2008

Treatment

Medical Therapy

Three therapeutic options are available to treat children with vesicoureteral reflux (VUR). They include medical treatment, surgical treatment, and surveillance (or observation).

The International Reflux Study has found that children can be managed nonsurgically with little risk of new or increased renal scarring, provided they are maintained infection free. The chance of spontaneous resolution of reflux is high in children younger than 5 years with grades I-III reflux and in children younger than 1 year (especially boys). Even higher grades of reflux (grades IV-V) may resolve spontaneously as long as they remain infection free.

Thus, the philosophy of medical management is based on the knowledge that low-grade reflux resolves spontaneously and sterile reflux does not damage the kidney. The medical management involves administering long-term suppressive antibiotics, correcting the underlying voiding dysfunction (if present), and conducting yearly follow-up radiographic studies (eg, VCUG, nuclear cystography, DMSA scan) at regular intervals.

In 1997, the American Urological Association published a set of guidelines for the management of VUR in children that still serves as a good resource for patients, parents, and physicians.⁵ These guidelines are in the process of being rewritten.

The Pediatric Vesicoureteral Reflux Guidelines Panel has made the following recommendations for children with VUR:

Indications for antibiotic prophylaxis

• Children without renal scarring at diagnosis
  • Diagnosis made in infancy: All patients diagnosed at infancy (ie, <1 y) with grades I-V reflux should be treated initially with continuous prophylactic antibiotics.
  • Diagnosis made in children aged 1-5 years: When unilateral and/or bilateral grades I-IV reflux or unilateral grades III-V reflux are diagnosed in children aged 1-5 years, they should be treated initially with continuous prophylactic antibiotics.
  • Diagnosis made in children aged 6-10 years: Children diagnosed at age 6-10 years with unilateral and/or bilateral grades I-II reflux and unilateral grades III-IV reflux should be treated initially with continuous antibiotic prophylaxis. However, some are advocating withholding treatment in patients with grade I or II VUR, as most of these patients are at low risk for UTIs and pyelonephritis provided they have no voiding dysfunction or constipation.
• Children with renal scarring at diagnosis
  • Diagnosis made in infancy: Infants (ie, <1 y) with scarring at diagnosis and grades I-V reflux should be treated initially with continuous antibiotic prophylaxis.
  • Diagnosis made in children aged 1-5 years: Antibiotic prophylaxis is the preferred option for preschool-aged children (ie, 1-5 y) with renal scarring at diagnosis, unilateral and/or bilateral grades I-II reflux, unilateral grades III-IV reflux, and bilateral grades III-IV reflux.
  • Diagnosis made in children aged 6-10 years: In children diagnosed at age 6-10 years with renal scarring and unilateral and/or bilateral grades I-II reflux or unilateral grades III-IV reflux, antibiotic therapy is the preferred treatment option.

Correcting the voiding dysfunction nonsurgically

• Adjunctive measures for a bladder regimen include behavior modification protocol to ensure that the child empties his/her bladder completely at regular intervals (every 3 h), adequate hydration, and constipation prevention.
• Timed voiding with or without biofeedback, a regular bowel regimen, and intermittent catheterization are the cornerstones of treating dysfunctional voiding due to Hinman syndrome.
• Children with detrusor instability are treated with anticholinergic medications, fluid intake monitoring, and timed voiding observation. Ensure that the anticholinergic therapy does not exacerbate pre-existing constipation.
• Spontaneous resolution rates decrease as patient age increases and with higher grades of reflux. Consider recommending surgical intervention in children with reflux that has persisted for more than 3 years with no improvement in the grade of reflux if it is grade II or greater.
• Hydronephrosis observed on prenatal ultrasonography may be the first indication of VUR. Such neonates should receive antibiotic prophylaxis (ie, amoxicillin) and undergo VCUG within the first month after birth. At approximately 4 weeks, obtain a nuclear renal scan (ie, DMSA) if high-grade (IV or V) reflux is found.
• Correct any serum electrolyte abnormalities due to a malfunctioning kidney.

Medications

Continuous antibacterial prophylaxis decreases the incidence of pyelonephritis and subsequent renal scarring for low-to-moderate grades of reflux; therefore, nonsurgical management is appropriate for mild-to-moderate VUR (ie, grades I-IV) in the absence of breakthrough infections or anatomic abnormalities, as discussed above.

Drug Category: Antibiotics -- Therapy must cover all likely pathogens in the context of this clinical setting.

Surgical Therapy

The philosophy of surgical management is based on the knowledge that high-grade reflux and persistent reflux in adolescents is not likely to resolve with continued medical therapy, especially in grade III reflux or greater. Another consideration in opting for surgical reflux management is the effect of repeated testing on patients and parents. In addition, lack of compliance with medical treatment may also dictate a surgical approach.

Surgical therapy options include open surgical procedures and endoscopic injection of a bulking agent.

Indications for surgery

• Children without renal lesions at diagnosis
  • Diagnosis made in infancy
    • In patients diagnosed with VUR in infancy (ie, <1 y), consensus is lacking regarding the role of continued antibiotic therapy versus surgery for those with persistent grades I-II reflux after a period of antibiotic prophylaxis.
    • However, surgical repair may be recommended in patients with persistent unilateral grades IV-V reflux or bilateral grades III-V reflux after a period of antibiotic therapy should the parents prefer definitive therapy over watchful management while receiving antibiotic prophylaxis.
  • Diagnosis made in children aged 1-5 years
    • In patients diagnosed with VUR at age 1-5 years, continuous antibiotic prophylaxis is the preferred option as an initial therapy for those with unilateral grade V reflux; however, surgical repair is a reasonable alternative for grades IV and V reflux.
    • In patients with bilateral grade V reflux, surgical repair is recommended.
    • Consensus is lacking regarding the role of continued antibiotics versus surgery in children with persistent grades I-II reflux after appropriate suppressive antibiotic therapy.
    • However, surgery is recommended for children with persistent grades III-V reflux in whom antibiotic therapy has not kept them infection-free.
    • Endoscopic treatment may be recommended in children with grade III to IV who have not shown any improvement in the reflux grade, who do not wish to receive further antibiotics, or who have had UTI.
  • Diagnosis made in children aged 6-10 years
    • In patients diagnosed with bilateral grades III-IV reflux at age 6-10 years, surgical repair is the preferred option, although continuous antibiotics is a reasonable alternative.
    • Patients with grade V reflux should undergo surgical repair. In patients with persistent grades I-II reflux after a period of antibiotic prophylaxis, consensus is lacking regarding the role of continued antibiotics versus surgery.
    • However, surgery is an option for persistent reflux in children with grades III-IV reflux in whom initial antibiotic therapy has failed. They can undergo either open surgical or endoscopic treatment.
• Children with renal lesions at diagnosis
  • Diagnosis made in infancy
    • In children diagnosed in infancy (ie, <1 y) with grade V reflux and scarring, continuous antibiotic prophylaxis is the preferred option as an initial treatment; primary surgical repair is a reasonable alternative.
    • If the kidney is noted to have poor function (<15% on DMSA scan) consider removing the kidney and the ureter down to the bladder.
    • Consensus is lacking regarding the role of continued antibiotics versus surgery in patients with persistent grades I-II reflux after a period of antibiotic prophylaxis. These patients may be candidates for endoscopic treatment.
    • In boys with persistent unilateral grades III-IV reflux, surgical repair is the preferred option. In addition, boys with persistent bilateral grades III-IV reflux, girls with persistent unilateral and/or bilateral grades III-IV reflux, and any children with persistent grade V reflux should undergo surgical repair with an option for endoscopic treatment in grades II-IV.
  • Diagnosis made in children aged 1-5 years
    • In children diagnosed at age 1-5 years with bilateral grades III-IV reflux and renal lesions, antibiotic therapy is the preferred option; however, surgical repair is a reasonable alternative.
    • Patients with unilateral and/or bilateral grade V disease and scarring should undergo surgical repair as initial treatment or nephroureterectomy if the kidney has been shown to have little or no function on DMSA scan.
    • Consensus is lacking regarding the role of continued antibiotics versus surgery for patients with persistent grades I-II reflux after a period of antibiotic prophylaxis.
    • Girls with persistent unilateral and/or bilateral grades III-IV reflux and boys with persistent bilateral grades III-IV reflux should undergo surgical repair, either open or endoscopic.
    • Surgery is also an option for boys with persistent unilateral grades III-IV reflux.
    • For patients with persistent grade V reflux who have not undergone surgery as initial treatment, surgical repair is recommended.
  • Diagnosis made in children aged 6-10 years
    • Patients diagnosed with bilateral grades III-IV reflux or grade V reflux at age 6-10 years can undergo surgical repair as initial treatment.
    • Consensus is lacking regarding the role of continued antibiotics versus surgery for patients who have persistent grades I-II reflux after a period of prophylaxis.
    • Patients with persistent unilateral grades III-IV reflux who have not undergone surgery as initial treatment should be offered either open surgical repair or endoscopic treatment.

Ureteral reimplantation

Surgery (ureteral reimplantation or ureteroneocystostomy) is the definitive method of correcting primary reflux, especially in the setting of anatomic abnormalities. Surgical principles of successful reimplantation include (1) creating a long submucosal tunnel to provide a 5:1 tunnel-to-diameter ratio, (2) providing good detrusor muscle backing, (3) avoiding ureteric kinking, and (4) creating a tunnel in the fixed area of the bladder.

Standard antireflux ureteral reimplantation procedures include the transtrigonal (Cohen), intravesical (Leadbetter-Politano), and extravesical detrusorrhaphy techniques. The common goal of these operations is to prevent VUR by creating an effective flap-valve mechanism at the ureterovesical junction.

Potential complications due to ureteral reimplantation of the ureters include bleeding in the retroperitoneal space, infections, ureteral obstruction, injury to adjacent organs, and persistent reflux. These occur in less than 1% of cases.

Of note, surgical correction of VUR has not been demonstrated to decrease the frequency of recurrent UTIs. Most of these infections occur in the lower tract, thereby indicating that the risk to the kidneys may have been reduced by preventing ascent of the bacteria to the upper urinary tract. The antireflux does not completely prevent pyelonephritis, as a small percentage of patients who have undergone antireflux surgery re-present with pyelonephritis. These infections may be due to the host predisposition to infection rather than to anatomic factors.

Endoscopic treatment

Puri and O'Donnel popularized endoscopic treatment of reflux in the 1980s. The principle of the procedure is to inject, under cystoscopic guidance, a biocompatible bulking agent underneath the intravesical portion of the ureter in a submucosal location. The bulking agent elevates the ureteral orifice and distal ureter in such a way that the lumen is narrowed, preventing regurgitation of urine up the ureter but still allowing its antegrade flow. The procedure is performed with general anesthesia on an outpatient basis and has received increasing attention.

Over the last 20 years, several bulking agents have been evaluated. These include polytetrafluoroethylene (PTFE or Teflon), collagen, autologous fat, polydimethylsiloxane, silicone, chondrocytes and, more recently, a solution of dextranomer/hyaluronic acid (Deflux). Concerns about PTFE particle migration have precluded FDA approval for use in children.

Other compounds such as collagen and chondrocytes have not stood the test of time. Recently, dextranomer/hyaluronic acid (Deflux, Q-Med USA) was FDA-approved for the treatment of VUR in children. Initial clinical trial showed that this method was effective in treating reflux. A recent meta-analysis by Elder et al demonstrates that, after one treatment, the resolution rate of reflux per ureter for grades I and II was 78.5%; grade III, 72%; grade IV, 63%; and grade V, 51%, all compounds being considered.⁶ Retreatment can be performed up to 3 times, bringing the aggregate rate of resolution to 85%. Improvement in injection techniques may yield better results. Unfortunately, long-term studies have not yet been carried out to assess the longevity of the material and its effectiveness over time in curing reflux. Complications are rare with the procedure, with transient ureteral obstruction and UTIs being the most commonly reported.

Preoperative Details

• Prior to antireflux surgery, obtain informed consent.
• Discuss potential risks and complications (eg, persistent reflux, ureteral stricture, development of de novo contralateral reflux, ureteral obstruction, infection, bleeding).
• Document the absence of UTI prior to surgery. If a UTI is noted, surgery should postponed until the infection is treated and eradicated.
• If infection is present, eradicate it by administering preoperative broad-spectrum intravenous or oral antibiotics.

Intraoperative Details

• After satisfactory induction of a general anesthetic, place the patient in a supine fashion, with legs in the frog-leg position.
• Sterilize the patient with povidone-iodine soap from umbilicus to mid thigh and drape the patient so that that the urethra may be accessed with the lower abdomen in the center of the field.
• Create a low transverse incision approximately 1 cm above the symphysis pubis.
• Carry the incision down to the rectus abdominis muscle.
• Divide the rectus fascia in the midline and mobilize it from the underlying rectus muscles.
• Bluntly separate the rectus and pyramidalis muscles at the midline, thus exposing the prevesical space and bladder.
• Carefully dissect the peritoneum off the dome of the bladder and develop the lateral perivesical space.
• At this point, further dissection varies based on the type of ureteral reimplantation planned.

Extravesical (Lich-Gregoir) reimplantation

• Fully mobilize the bladder from the space of Retzius and lateral pelvic sidewalls with a gentle blunt dissection.
• Insert a self-retaining abdominal wall retractor.
• Identify the ipsilateral obliterated hypogastric artery.
• Locate the ureter medial to the pelvic portion of the obliterated hypogastric artery. Free the refluxing ureter down to its insertion into the bladder wall.
• Use electrocautery to incise the bladder muscle down to mucosa for a distance of 3-5 cm from the ureterovesical junction. Undermine the lateral edges of the incision to create a trough that forms a new bed for the ureter.
• Carefully lay the ureter in the newly created trough. Then, close the detrusor muscle over the ureter with interrupted 2-0 or 3-0 absorbable sutures.
• Consider leaving a closed-suction drain in the prevesical space and leave the Foley catheter indwelling.
• Remove the Foley catheter 24-48 hours after surgery and remove the drain 24 hours later.

Extravesical detrusorrhaphy (Hodgson-Zaontz)

• Following the initial dissection, extravesically dissect out the ureter down to the ureterovesical junction. Dissect the terminal ureter free from perivesical tissues but leave its attachment to the bladder mucosa intact.
• Perform electrocautery to incise the bladder muscle down to the mucosa for a 5-cm arc around the ureterovesical junction. Undermine the lateral edges of the incision to create a trough that will form a new bed for the ureter. It is important not to open the mucosa of the bladder.
• Telescope the ureter into the bladder so it courses within a long subepithelial tunnel. Neither a ureteral stent nor a perivesical drain is needed.
• Leave the indwelling Foley catheter overnight.

Intravesical reimplantation

• Following the initial dissection, open the bladder in the midline using electrocautery.
• Place a self-retaining retractor.
• Cannulize the refluxing ureter with a 3.5-5F feeding tube. Secure the tube to the distal ureter with a traction suture.
• Create a circumferential incision around the ureteral orifice. With careful dissection, the distal ureter is completely freed from the intramural portion of the bladder.
• Then, fashion a new submucosal tunnel 4-5 times the diameter of the ureter using sharp and blunt dissection.
• The nomenclature for the different types of intravesical reimplantation vary based on the location of the new ureteral hiatus (where the ureter enters the bladder wall) and the course of the ureter, as follows:
  • The Politano-Leadbetter repair creates a new ureteral hiatus more cephalad to the original ureteral hiatus.
  • The Glenn-Anderson repair creates a new ureteral hiatus more distal to the original hiatus.
  • The Cohen repair creates a ureteral tunnel that is directed laterally across the trigone (transtrigonal) toward the contralateral side.
• After reimplanting the ureter with adequate detrusor backing, a feeding tube may be left in the ureter to prevent ureteral obstruction from postsurgical edema. Currently, a trend has emerged for not leaving a stent in the ureter unless transient obstruction is a concern.
• The feeding tube may be brought out either through the urethra in females or through a separate stab incision in the lower quadrant of the abdomen. It may also be brought out through the incision.
• Drain the bladder with a Foley catheter.
• Close the bladder in 2 layers with running 3-0 absorbable sutures.

Endoscopic treatment

• After induction of satisfactory general anesthesia, the patient is placed in the relaxed lithotomy position and the genitalia and perineum are prepared in a sterile manner.
• Cystourethroscopy is carried out using a deflected lens scope. The bladder and ureteral orifices are inspected.
• An injection needle is then advanced, bevel up to the ureteral orifice. The orifice is kept open by hydrodistending it with irrigation fluid; the needle is then advanced into the ureter. A submucosal puncture is made and the bulking material is slowly injected.
• As it spreads in the submucosal space, the material elevates the intravesical ureter, and the orifice acquires an inverted smile appearance. The needle is slowly withdrawn after between 0.5 and 2 mL of material has been injected. A second injection may be carried out at the base of the newly created mound to further elevate the ureteral orifice.
• The bladder is emptied and reinspected. Any bleeding vessels may be cauterized with a Bugbee electrode.

Postoperative Details

• Continue intravenous antibiotic administration until the patient is tolerating a diet.
• Manage bladder spasms with anticholinergic medication or belladonna and opium (B&O) suppositories. Valium can also be helpful for severe bladder spasms.
• Discharge the patient within 1-2 days.
• Continue postoperative antibiotic prophylaxis until radiographic findings confirm complete resolution of reflux.

Follow-up

• Obtain a postoperative renal ultrasonography in 1-2 months.
• Perform nuclear cystography in 3 months if endoscopic treatment has been performed. The current trend is to forego the follow-up cystography, as 98% of findings are negative after an open surgical repair.
• Perform interval renal ultrasonography annually for 3 years.
• During the scheduled follow-up studies, monitor patient blood pressure and renal function and perform urinalysis.
• After confirming resolution of reflux, discontinue antibiotic prophylaxis.
• For excellent patient education resources, visit eMedicine's Kidneys and Urinary System Center. Also, see eMedicine's patient education article Bladder Control Problems.

Complications

Persistent, transient, contralateral reflux

Persistent reflux of the reimplanted ureter and development of de novo reflux of the contralateral side are usually temporary and resolve spontaneously. Transient postoperative reflux is usually caused by detrusor instability of the healing bladder.

Persistent reflux of the ipsilateral ureter in the absence of secondary causes (eg, poorly compliant bladder) is usually caused by a technical error. Some technical problems associated with ureteral reimplantation include inadequate ureteral mobilization, short intramural tunnel, inadequate anchoring of the ureter, and inappropriate placement of the ureteral orifice. Reoperate in this setting or consider endoscopic treatment if the reflux is grade III or less.

Most contralateral reflux is caused by recurrent or previously undiagnosed reflux that is now evident in the absence of the pop-off valve, which was previously provided by the refluxing ureter. Physicians can manage most of these patients conservatively, and patient symptoms usually subside spontaneously.

If a patient experiences persistent or severe vesicoureteral reflux (VUR) following repair, perform a thorough workup, including urodynamics, imaging, and cystoscopy. Correct failed repairs or poor tunnels with repeat surgical repair.

Postoperative ureteral obstruction

Ureteral edema, intraureteral blood clots or mucous, bladder spasms, or submucosal bladder hematoma may cause acute ureteral obstruction in the early postoperative period. Ureteral angulation or ureteral hiatus that is made too tight may also cause acute ureteral obstruction. Ischemia, an incorrect tunnel construction, or an incorrect tunnel position may cause chronic postoperative ureteral obstruction.

When diagnosing ureteral obstruction, conduct renal ultrasonography, intravenous pyelography, or nuclear renography to confirm diagnosis. Most postoperative ureteral obstructions resolve spontaneously; however, temporary ureteral stenting may be necessary. Nephrostomy tube placement is rarely required. Ureteroscopic dilation and stent placement may correct mild obstruction or stenosis. Percutaneous placement of a nephrostomy tune may be necessary if a transvesical approach is not achievable.

Repeat reimplantation may be required for more severe cases. Ensure that the ureter is transected outside the bladder during reoperation and consider using a psoas hitch or transureteroureterostomy because of its inadequate length.

Bladder diverticula may complicate reimplantation surgery either at the site of bladder closure or at the reimplantation site. This may necessitate reoperation if the diverticula drains poorly or is associated with reflux or an obstruction.

Urinary extravasation indicates incomplete healing of the bladder or implanted ureterovesical junction. Prolonged catheterization or stenting is warranted.

Hematuria

Gross hematuria after ureteral reimplantation is common. Persistent bleeding or clots indicate inadequate hemostasis at the time of operation. Hematuria is often self-limited and does not require operative intervention; however, continue prolonged catheterization until hematuria resolves. Patients rarely need transurethral fulguration or reoperation.

Urosepsis

Urosepsis is due to an untreated UTI or ureteral obstruction. To prevent sepsis, clear preoperative urine cultures of infection. If ureteral obstruction causes urosepsis, relieve the obstruction promptly and institute the appropriate antibiotics.

Anuria

Anuria is rare and may indicate dehydration or bilateral ureteral obstruction. Provide therapy via intravenous fluid challenges and furosemide. Check ureteral catheters for patency. If ureteral catheters were not used, obtain upper tract imaging studies such as ultrasonography to rule out bilateral ureteral obstruction. Manage bilateral ureteral obstruction with percutaneous nephrostomy tubes.

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