Severe Vesicoureteral Reflux Research Articles

Value of cystourethroscopy in the assessment of children with recurrent urinary tract infections and/or enuresis.

Forty-one children ages 6-14 years consecutively referred for recurrent urinary tract infections (RUTI) and/or enuresis constituted the study group. Cystourethroscopy (CUS) was carried out in 40 children and pathologic findings were revealed in 70% of children with RUTI in the absence of vesico-ureteral reflux (VUR). However, only in 4 patients did CUS influence treatment. Based on these data we conclude that routine CUS is not justified in the evaluation of this group of children unless anatomical infravesical lesions are suspected. VUR was proven in 44% of children with RUTI. In 86% of these ureters abnormal ureteric orifices were demonstrated. We therefore find CUS to be valuable in the assessment of children with both RUTI and VUR, because this examination is helpful in selecting patients who might need operation for severe VUR. CUS was not of therapeutic benefit to children with enuresis. Five patients with macroscopic haematuria during urinary tract infection were not managed differently following CUS.

Vesicoureteral Reflux and Reflux Nephropathy

Vesicoureteral reflux (VUR) is mainly a primary phenomenon due to incompetence of the ureterovesical junction, mostly affecting a pediatric population. During micturition cystourethrography (MCU) reflux into the kidney--intrarenal reflux (IRR)--is occasionally seen. In areas with IRR the kidney surface may subsequently be depressed and the papillae retracted (reflux nephropathy (RN]. VUR may lead to hypertension and/or end-stage renal failure. Most commonly, VUR is discovered during evaluation for urinary tract infection, but it may also be present in patients with hypertension, toxemia of pregnancy, chronic renal failure and proteinuria, and it may be found in siblings of patients with VUR. For the time being VUR is demonstrated at radiographic MCU, whereas RN is diagnosed by demonstration of focal scars and of abnormal parenchymal thickness at urography. In children with VUR and no abnormalities of calyces or parenchymal defects standardized measurement of the parenchymal thickness at three sites may identify kidneys which are likely to develop focal scars. Quantitation of focal scarring should be performed in connection with a measure of the overall kidney size. The occurrence of IRR is dependent of the papillary morphology, intrapelvic pressure and urine flow. There may be an important relationship between renal ischemia and IRR in producing a 'vicious circle of deleterious effects' which, combined with parenchymal extravasation, may lead to RN. Treatment of VUR includes medical and surgical management. Since renal scarring may occur in infancy, prevention should focus on infants and young children. Infants and young children with severe VUR may have normal urograms. Therefore a MCU should also be performed, preferably with the recommended standardized technique.

Radiological abnormalities in infants with urinary tract infections.

An intravenous urogram and micturating cystourethrogram were carried out in 100 infants presenting with documented urinary tract infections. Ninety three cases were identified by suprapubic aspiration and 7 by culture of two voided urine samples containing greater than 100 X 10(6) organisms per litre. The urinary tract abnormalities were analysed in respect of their clinical importance, patient's age, sex, and prematurity (in the 10 preterm infants). Radiological abnormalities were found in 47% of the infants (40% of boys; 63% of girls). Twenty nine per cent of the infants had a urinary tract abnormality regarded as clinically important--namely grade 3 or 4 vesicoureteric reflux, reflux nephropathy, or obstructive lesions requiring surgery. Six of the 10 preterm infants had radiological abnormalities. Spontaneous resolution or improvement occurred within 6 months of birth in three of the four preterm infants with severe vesicoureteric reflux.

Prospective Trial of Operative Versus Non-Operative Treatment of Severe Vesicoureteric Reflux: Two Years’ Observation in 96 Children

No AccessJournal of Urology1 Mar 1984Prospective Trial of Operative Versus Non-Operative Treatment of Severe Vesicoureteric Reflux: Two Years’ Observation in 96 Children Birmingham Reflux Study Group Birmingham Reflux Study Group More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(17)50537-6AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Prospective Trial of Operative Versus Non-Operative Treatment of Severe Vesicoureteric Reflux: Two Years’ Observation in 96 Children." The Journal of Urology, 131(3), p. 617 © 1984 by The American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 131Issue 3March 1984Page: 617 Advertisement Copyright & Permissions© 1984 by The American Urological Association Education and Research, Inc.MetricsAuthor Information Birmingham Reflux Study Group More articles by this author Expand All Advertisement PDF downloadLoading ...

Vesicoureteral Reflux in the Adult. I. Factors in Pathogenesis

The morphologic and functional findings in 67 adults with primary bilateral vesicoureteral reflux were analyzed. A significant correlation was found between the severity of vesicoureteral reflux and the extent of renal scarring but the position and shape of the ureteral orifices did not influence the degree of reflux or scarring. Large bladder capacity was a common finding, especially in patients with residual urine or with renal insufficiency. However, bladder capacity did not correlate with the grade of vesicoureteral reflux. Patient age at the time of the first recognized urinary tract infection, and the frequency and pattern of subsequent infections did not have any influence on the severity of the renal scarring. The interpretation of these findings in the light of the current hypotheses on the pathogenesis of reflux nephropathy is discussed.

Renal growth and operative correction of severe vesicoureteral reflux in children.

We report about 32 operated children with 40 complicated refluxes. 10 of the operated children suffered from double kidneys with double ureters. We examined these children before and 3 years after the operation. The data were registrated according to the recommendations of Jacobsson, Claesson, Olsson and Ringertz. We operated on 22 children because of 30 complicated refluxes, 20 out of the 30 measured kidneys showed normal data before the operation, 8 of these 20 kidneys developed normally after the operation, 12 times this was not the case. However, all of these unsatisfactory or worsened data were within the standard deviation. In this group pathological values were not found. Among 10 out of 30 renal units which were out of the standard deviation, when measured before the operation, 3 kidneys improved and showed data within standard deviation after the operation. 7 kidneys continued to have pathological data, all out of the standard deviation. 2 of these 7 afflicted kidneys showed even worse values after the operation in comparison to the preoperative pathological values.

Cutaneous Vesicostomy in Infancy

Cutaneous vesicostomy was performed on 10 infants or young children with hydroureteronephrosis. The etiology of the upper urinary tract dilatation was neurogenic bladder dysfunction secondary to myelodysplasia in 8, and severe vesicoureteral reflux and urinary sepsis in 2. The vesicostomy resulted in marked improvement in the drainage and appearance of the upper urinary tract in each child. When other methods of managing the underlying lower urinary tract dysfunction were deemed more appropriate, the vesicostomy was closed. Cutaneous vesicostomy proved to be an effective, simple and easily reversible means of treating selected infants with lower urinary tract dysfunction.

Antibody to Tamm-Horsfall protein in patients with urinary tract obstruction and vesicoureteral reflux.

Urinary tract obstruction and vesicoureteral reflux, which are often associated with urinary tract infections, may lead to progressive renal damage. Relatively little is known about the pathophysiology of this process, and a need exists for noninvasive methods of its detection in its early stages. Because urine is refluxed into the venous and lymphatic drainage of the kidney in severe vesicoureteral reflux and urinary tract obstruction, an immune response to urinary tract components might play a role in the pathophysiology of progressive renal damage and serve as a serologic marker for its presence. A solid-phase radioimmunoassay for a protein found only in the urine (Tamm-Horsfall protein [THP]) was developed and used to measure antibody to THP in the serum of 60 subjects. Significant elevations of antibody to THP were observed in five of 15 patients with obstruction and infection of the urinary tract and in one of 10 patients with infection alone, when these patients were compared with 12 healthy control subjects. Similar elevations of antibody to THP were not seen in uninfected patients with urinary tract obstruction or in patients with low-grade vesicoureteral reflux or sepsis of nonrenal origin. These results suggest that the measurement of antibody to THP might be useful in the identification of patients with obstruction and infection of the urinary tract.

Bladder training and surgical correction of vesicoureteral reflux: useful association.

18 children, from 1 year of age to 15, presenting lower motor neuron bladder (myelomeningocele) were studied. All had overflow incontinence and urinary infection resistant to all trials of treatment, attributed to severe vesicoureteral reflux. The failure of training on bladder emptying for urinary infection control and/or the severity of reflux and its consequences over upper urinary tract, motivated the reflux surgical correction associated to bladder training as a first step alternative treatment to urinary diversion.

The radiological contribution toward the diagnosis of chronic pyelonephritis.

It is now universally obvious that any discussion on chronic pyelonephritis necessitates exact definition. There has been so much loose talk on the subject that some doubt arises as to whether there really is any such entity. Let us take for our definition “those changes in the kidney which result directly from bacterial infection” and confine ourselves to what appear to be acceptable facts. Of these the first in importance from a radiological point of view is that the condition must be focal. This is a basic concept. Generalized changes resulting from bacterial action have simply not yet been described unless they follow the confluence of focal lesions, and conditions in the kidney which are not focal in character are therefore not of direct bacterial origin. The second fact of importance is that the late infective process, which usually commences in the medulla, is a localized area of fibrosis or scar, usually large and affecting the whole of the thickness of the renal substance. The outer surface is dragged inward, and the renal papilla outward with secondary distortion of the calyx (Fig. 1). The surface depression is irregular, with well defined edges, and may vary in diameter from a few millimeters to several centimeters. The surrounding renal tissue is completely normal or hypertrophied. Indeed, one of the dramatic features of the coarse scar is the sudden change from gross abnormality to normality at its edges. In this it resembles an infarct. These large scars are the hallmark of the renal condition known as primary atrophic pyelonephritis. Their size is a peculiar feature of the disease and requires stressing (Fig. 1). Small scars from infection inevitably occur, but it is not proved that they have any more significance than small scars elsewhere in the body. Certainly, the presence of a few small scars scattered throughout a kidney, even if proved to be of bacterial origin, can scarcely justify an overall diagnosis of chronic pyelonephritis. The stem of the affected calyx may not be dilated unless the scar is very large. With associated obstruction or severe vesicoureteral reflux some dilatation is to be expected, but neither gross reflux nor obstruction are necessarily a part of the primary picture. The cup of the calyx is no longer a cup, the papilla no longer projects into it. From being, as it were, just the porcelain of the cup the calyx now becomes both porcelain and the space within it and presents a clubbed appearance with a smooth margin quite unlike the ragged cavity found in active tuberculosis or in extensive papillary necrosis. The renal substance between the clubbed calyx and the surface may be only slightly reduced in thickness in an early stage but becomes progressively narrower as contraction advances until only a few millimeters of scar tissue remain of the normal 2.5 cm of renal substance.