What is Vesicoureteral Reflux?
Vesicoureteral reflux is a condition in which urine flows backward from the bladder into the kidneys. It is common among newborn infants and young children and can cause inflammation of the urinary tract. Without treatment, infection can spread to the kidneys, leading to the loss of kidney function and kidney failure. It is a congenital anomaly. Kidneys regulate the fluid balance in the body by filtering out wastes, and excess water and minerals in the blood. The urine collected in the kidneys is transferred to the bladder through tiny vessels called ureters. The urine from the kidneys is stored in the bladder. At the junction point of the ureters with the bladder, there is a tunnel-shaped check-valve mechanism that prevents flow of the urine from the bladder back to the kidneys. When there is no such check-valve, reflux of the urine from the bladder to the kidneys may occur. The urine that flows back may lead to serious kidney damage. As infants grow, their ureters get elongated and they have stronger muscles, and thus, their valve mechanisms improve. As kids grow, the reflux problems minimize and eventually disappear. Vesicoureteral reflux is a condition that can be likened to the reversal of the traffic on a one-way road. At advanced ages, secondary reflux may develop. In other words, a person may have a normal check-valve mechanism, but this mechanism may be impaired due to increases in the pressure inside the bladder because of occlusions in the bladder exit and contraction disorders of the bladder muscles or damage to the bladder nerves, and eventually, that person my develop vesicoureteral reflux.
What are the symptoms for vesicoureteral reflux?
Burning sensation during urination, high-frequency and small amount of urination, inflammatory and foul-smelling urine, low back pain and abdominal pain are symptoms of vesicoureteral reflux. Fever is a major symptom indicating that inflammation has spread to the kidneys. Diagnosis based on the condition of the kidney is more complicated because other conditions may give the same symptoms. For this reason, high fever, diarrhea, loss of appetite and unease that cannot be explained should be examined with care. As the infant grows older, the symptoms become more obvious. Nocturnal enuresis, constipation, traces of stool in underwear, high blood pressure, detection of protein in the urine and symptoms of kidney failure appear.
Nowadays, it is possible to examine the visceral organs of infants using ultrasonography of pregnant women. In this way, kidneys, bladders and ureters of infants can be studied. This allows physicians to detect anomalies in infants before birth.
If the rectal temperature of infant up to three months is 38 degrees Celsius or above and that of an infant above three months is above 38.9 degrees Celsius, the parents should refer a pediatric urologist or a pediatrician who is experienced on the subject. This fever implies that serious damage to the kidneys has started.
Which children have higher incidence rates of vesicoureteral reflux?
During urination, the bladder contracts and simultaneously the mechanisms that hold the urine back at the bladder exit are released. The urine is expelled with a perfect coordination. If the bladder muscles contract, but the mechanisms that hold the urine back are not released simultaneously, this is called lack of coordination between the bladder and urination. The bladder may not be emptied completely due to this lack of coordination, and the pressure inside the bladder may eventually increase. In other words, this lack of coordination may lead to vesicoureteral reflux. The children with this lack of coordination should be monitored for the potential occurrence of vesicoureteral reflux. A similar mechanism exists for expelling stool out of the body. Lack of coordination, in this case, leads to constipation. This, in turn, triggers vesicoureteral reflux. It is therefore quite important for parents to be cautious about constipation and urination disorders in their children.
Vesicoureteral reflux is more common among Caucasians. Vesicoureteral reflux is more destructive in girls. Vesicoureteral reflux in the kids aged 2 years and below is more dangerous as the kidneys have not developed fully. For this reason, greater caution is needed.
Genetic factors, too, play a role in vesicoureteral reflux. If any of the parents had this condition, it is very likely for their children to develop it as well. If any of the siblings has vesicoureteral reflux, then other siblings may suffer from it. Therefore, all siblings should be examined for vesicoureteral reflux.
Is vesicoureteral reflux dangerous?
Damage to the kidneys is closely related to the degree of reflux. The more severe the vesicoureteral reflux is, the more damage is done to the kidneys. The resulting inflammation of the kidney creates scar tissue in the kidney tissue. This leads to permanent damage to the kidneys. This damage, in turn, results in kidney-induced high blood pressure. If it is left untreated, the kidney loses its functions completely.
Diagnosis of Vesicoureteral Reflux
Urinalysis is performed. Ultrasonography images of the kidneys, bladder and urinary tracts provide a certain understanding of structural defects in the organs.
Voiding cystourethrography (VCUG): A small catheter is inserted into the urinary tract of the child in supine position and the bladder is filled with a radiocontrast agent. This agent makes the organs visible under x-ray. X-rays are taken when the bladder is full and during the urination. The bladder becomes visible. It makes it possible to see any reflux from the bladder to the kidneys. This method reveals whether there is any vesicoureteral reflux and its degree, if any. In this method, it is possible to make a diagnosis using one or two x-rays. Testicles and ovaries are very sensitive to radiation dose. More x-rays taken mean exposure to extra radiation. For this reason, care should be paid to avoid unnecessary radiation exposure to patients.
Renal scintigraphy: In this method, radioisotopes are injected intravenously. It helps to find out any damage to the kidneys and its degree, if any.
Degrees of Vesicoureteral Reflux
In voiding cystourethrography, vesicoureteral reflux is grade in five degrees. The scoring is done based on the amount of the urine flowing from the bladder to the kidneys. The first degree is the mildest one. In the first degree, the reflux is up to the half of the ureter. In the fifth and most advanced degree, all ureters have expanded and are tortuous, and renal pelvis has expanded and the kidneys have become thinner. The urine flows from the bladder to the kidneys completely.
Treatment of Vesicoureteral Reflux
Treatment is closely related to the degree of vesicoureteral reflux. In mild and moderate cases of reflux, nonsurgical treatment called wait-and-see or active follow-up is applied as the check-valve mechanism will develop as the child grows older. In advanced case of vesicoureteral reflux, surgery is inevitable.
Drug Therapy in Vesicoureteral Reflux
Urinary tract infections should be treated using proper antibiotics. In this way, infections are prevented from spreading to the kidneys. The child is evaluated at certain intervals. If needed, scintigraphy may be taken in order to understand the damage to the kidneys.
Surgery for Vesicoureteral Reflux
There are three surgical methods used to treat vesicoureteral reflux: Open surgery, robot-assisted laparoscopic surgery (closed method), and endoscopic surgery (closed method).
The primary purpose of these methods is to create the check-valve mechanism that would prevent reflux. This would eliminate the flowing of the urine from the bladder to the kidneys and, in this way, protect kidneys.
Open Surgery for Vesicoureteral Reflux:
The aim of the open surgery to recreate the check-valve mechanism by forming a long tunnel to the ureter inside the bladder. We will first discuss the standard open surgery and then, move on to the technique we employ. Pediatric surgeries should be performed by expert pediatric urologists as the tissues of children are tender and have a tiny structure.
In the standard open surgery, a 4-5-cm incision is at the lower side wall of the abdomen. The muscles are incised to access the bladder section. The ureter is found. The bladder is incised and its inside is accessed. A long tunnel is created beneath the mucosa inside the bladder. This tunnel will function as the check-valve mechanism. J stent is placed inside the ureter. This stent is kept until the wounds are healed. The bladder is closed. After a period of 15-20 days, the stent is removed while the patient is under anesthesia. The catheter placed in the urinary tract is removed 3-7 days later.
Our technique, on the other hand, is more complicated, and requires more experience, then the standard surgical method. Yet, it is less traumatic for the patient. There is no need to place a catheter in the bladder, stent in the ureter and drain for the wound. As the bladder is not incised, no postoperative spasm of the bladder is seen. The patient can be discharged from the hospital on the same or next day. The child quickly attains his/her normal physical activity. Postoperative urination problems are not seen.
In our technique, no incision is made at the side wall of the abdomen. A 4-5-cm longitudinal incision is made in the section below the umbilicus and above the public bone where the bladder is located. In the section, there are two rectus muscles located sided by side. These muscles are not incised, but they are separated from each other at the junction. The bladder section is accessed. The unhealthy ureter is found. The bladder is not incised and its inside is not accessed. The surgical operation is performed at the back of the bladder. The ureter is not incised and its integrity is preserved. The ureter is freed from the adjacent ligaments up to the entry into the bladder. A 3-cm incision is made on the bladder muscle at the projection of the ureter. The bladder muscle is peeled off up to the mucosa. The inside of the bladder is not accessed. The ureter is placed inside this bed in the mucosa. The tunnel made inside the bladder in the standard surgical procedure is created at the back of the bladder and without entering the bladder. No stent is placed. No drain is needed for the wound. No catheter is placed inside the bladder. Even in advanced cases, it is possible to use the same small incision for intervention at both sides. The patient can be discharged on the same or next day. The child quickly retains his/her normal physical activity. Unlike the standard procedure, there is no need for a second surgical operation to remove the stent.
In cases of bilateral vesicoureteral reflux, the child may not be able to urinate for 1-2 days after the surgery. In such cases of bilateral vesicoureteral reflux, the general conviction is that the nerves at the back of the bladder may have been damaged. Yet, this is not the case as our technique is implemented at the upper part where the ureter nerves do not exist. In such a case, either his/her parents drains the urine using a small catheter or a catheter is placed for 1-2 days. And the child retains his/her normal urination.
The postoperative patient comfort is quite high as the muscle or bladder is not incised and the integrity of the ureter is preserved during the operation.
Closed Surgery for Vesicoureteral Reflux:
In the robot-assisted laparoscopic surgery, steps similar to the open surgery are used. Unnecessary entry into the abdominal cavity is made. The abdominal cavity is filled with carbon dioxide so that the instruments can be used easily. The operation is performed completely inside the peritoneum, but the bladder and ureter are extraperitoneal organs. This method disregards the placement of the organs. In robotic surgery, the duration of the operation is very long.
Endoscopic surgery: This method may be useful in lower-degree vesicoureteral reflux. A tube with an illuminator at its end is used to enter the bladder. An agent is injected into the submucosal tissue where the ureter merges into the bladder. It is an easy operation. A single operation may not prove useful even for moderate cases of vesicoureteral reflux. Several operations may be needed. This means repeated anesthesia for the child.