Surgical Correction Of Reflux Research Articles

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The traditional management of children with vesicoureteral reflux (VUR) and ureteropelvic junction obstruction (UPJO) is pyeloplasty as the initial step, and if the high-grade reflux remains symptomatic after pyeloplasty, surgical correction of the reflux is the next step. 1 Maizels M. Smith C.K. Firlit C.F. The management of children with vesicoureteral reflux and ureteropelvic junction obstruction. J Urol. 1984; 131: 722-727 PubMed Google Scholar It was postulated that the nearby obstruction to the renal parenchyma might cause more renal damage, so it should be managed sooner rather than later. Moreover, in a few pediatric urology centers, this concept has ultimately been changed by surgical correction of reflux (ureteral reimplantation) initially, followed by pyeloplasty in persistent UPJO. 1 Maizels M. Smith C.K. Firlit C.F. The management of children with vesicoureteral reflux and ureteropelvic junction obstruction. J Urol. 1984; 131: 722-727 PubMed Google Scholar However, we hypothesized that the secondary UPJ kinking could be eliminated gradually by endoscopic correction of reflux without compromising the distal ureteric neurovascular bundles and distal ureteral fibrosis during the ureteric reimplantation. Editorial CommentUrologyVol. 81Issue 5PreviewConcurrent vesicoureteral reflux (VUR) and ureteropelvic junction obstruction (UPJO) represent a potential diagnostic and therapeutic dilemma because it can sometimes be difficult to determine if the UPJO is primary or secondary to VUR. In some series, a pyeloplasty rate of 75% has been reported in children who present with simultaneous VUR and UPJO.1 The management algorithm used in the treatment of patients with simultaneous VUR and UPJO therefore carries with it significant therapeutic and costs implications, especially in this era of robotic-assisted ureteropelvic junction repair. Full-Text PDF

Editorial Comment

Concurrent vesicoureteral reflux (VUR) and ureteropelvic junction obstruction (UPJO) represent a potential diagnostic and therapeutic dilemma because it can sometimes be difficult to determine if the UPJO is primary or secondary to VUR. In some series, a pyeloplasty rate of 75% has been reported in children who present with simultaneous VUR and UPJO. 1 Bomalaski M.D. Hirschl R.B. Bloom D.A. Vesicoureteral reflux and ureteropelvic junction obstruction: association, treatment options and outcome. J Urol. 1997; 157: 969-974 Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar The management algorithm used in the treatment of patients with simultaneous VUR and UPJO therefore carries with it significant therapeutic and costs implications, especially in this era of robotic-assisted ureteropelvic junction repair. If we can reduce the need for ureteropelvic junction repair in this population, we can reduce the morbidity and costs. The Outcome of Initial Endoscopic Treatment in the Management of Concomitant Vesicoureteral Reflux and Ureteropelvic Junction ObstructionUrologyVol. 81Issue 5PreviewTo report the results of a single-center experience with the endoscopic injection of Deflux as the initial minimally invasive approach in patients with vesicoureteral reflux (VUR) and coexisting obstruction at the ureteropelvic junction (UPJO) level who presented with VUR. Full-Text PDF ReplyUrologyVol. 81Issue 5PreviewThe traditional management of children with vesicoureteral reflux (VUR) and ureteropelvic junction obstruction (UPJO) is pyeloplasty as the initial step, and if the high-grade reflux remains symptomatic after pyeloplasty, surgical correction of the reflux is the next step.1 It was postulated that the nearby obstruction to the renal parenchyma might cause more renal damage, so it should be managed sooner rather than later. Moreover, in a few pediatric urology centers, this concept has ultimately been changed by surgical correction of reflux (ureteral reimplantation) initially, followed by pyeloplasty in persistent UPJO. Full-Text PDF

Fatal Renal Failure in a Spinal Cord Injury Patient with Vesicoureteric Reflux Who Underwent Repeated Ureteric Reimplantations Unsuccessfully: Treatment Should Focus on Abolition of High Intravesical Pressures rather than Surgical Correction of Reflux

A 29-year-old man developed paraplegia at T-10 level due to road traffic accident in 1972. Both kidneys were normal and showed good function on intravenous urography. Division of external urethral sphincter was performed in 1973. In 1974, cystogram showed retrograde filling of left renal tract, which was hydronephrotic. Left ureteric reimplantation was performed. Following surgery, cystogram revealed marked retrograde filling of left renal tract as before. Penile sheath drainage was continued. In 1981, intravenous urography revealed bilateral severe hydronephrosis. Left ureteric reimplantation was performed again in 1983. Blood pressure was 220/140 mm Hg; this patient was prescribed atenolol. Cystogram showed gross left vesicoureteral reflux. Intermittent catheterisation was commenced in 2001. In 2007, proteinuria was 860 mg/day. This patient developed progressive renal failure and expired in 2012. In a spinal cord injury patient with vesicoureteral reflux, the treatment should focus on abolition of high intravesical pressures rather than surgical correction of vesicoureteric reflux. Detrusor hyperactivity and high intravesical pressures are the basic causes for vesicoureteral reflux in spinal cord injury patients. Therefore, it is important to manage spinal cord injury patients with neuropathic bladder by intermittent catheterisations along with antimuscarinic drug therapy in order to abolish high detrusor pressures and prevent vesicoureteral reflux. Angiotensin-converting enzyme inhibitors or angiotensin-receptor-blocking agents should be prescribed even in the absence of hypertension when a spinal cord injury patient develops vesicoureteral reflux and proteinuria.

Incidence of new onset metabolic acidosis following enteroplasty for myelomeningocele

245Urological Surveyresults demonstrated that male gender, age less than one year at diagnosis, lower grade of reflux at presentation and unilateral reflux were all predictors of spontaneous resolution, which is consistent with previous studies. In addition, they were able to demonstrate that reflux improvement on imaging one year after diagnosis, as well as improvement in reflux grade from the previous year at any point during follow-up, were both independent predictors of resolution. This study has important clinical implications when counseling with parents over the decision to con-tinue waiting for spontaneous resolution versus pursuing surgical correction of reflux. Though many of us have assumed that improvement in the grade of reflux is a positive indicator of a greater likelihood for spontaneous resolution, we now have data to back up our assumptions.

Cochrane review: Interventions for primary vesicoureteric reflux

AbstractBackgroundVesicoureteric reflux (VUR) results in urine passing, in a retrograde manner, up the ureter. Urinary tract infections (UTIs) have been considered the main cause of permanent renal parenchymal damage in children with reflux. Management of these children has been directed at preventing infection by antibiotic prophylaxis and/or surgical correction of reflux. Controversy remains as to the optimum strategies.ObjectivesTo evaluate the benefits and harms of different treatment options for primary VUR.Search strategyRandomised controlled trials (RCTs) were identified from the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, reference lists of articles and abstracts from conference proceedings. Date of last search: June 2006Selection criteriaAny treatment of VUR including surgery, antibiotic prophylaxis of any duration, non‐invasive techniques and any combination of therapies.Data collection and analysisTwo authors independently searched the literature, determined study eligibility, assessed quality, extracted and entered data. For dichotomous outcomes, results were expressed as relative risk (RR) and 95% confidence intervals (CI). Data were pooled using the random effects model.Main resultsEleven studies (1148 children) were identified. Seven compared correction of VUR (by surgery or endoscope) plus antibiotics for 1‐24 months with antibiotics alone, two compared antibiotics with no treatment and two compared different materials for endoscopic correction of VUR. Risk of UTI by 2, 5 and 10 years was not significantly different between surgical and medical groups (2 years RR 1.07, 95% CI 0.32 to 2.09; 5 years RR 0.99, 95% CI 0.79 to 1.26; 10 years RR 1.06, 95% CI 0.78 to 1.44). Combined treatment resulted in a 50% reduction in febrile UTI by 10 years (RR 0.54, 95% CI 0.55 to 0.92) but no concomitant reduction in risk of new or progressive renal damage by 10 years (RR 1.03, 95% CI 0.53 to 2.00). In two small studies no significant differences in risk for UTI (RR 0.75, 95% CI 0.15 to 3.84) or renal damage (RR 1.70, 95% CI 0.36 to 8.07) were found between antibiotic prophylaxis and no treatment.Authors' conclusionsIt is uncertain whether the treatment of children with VUR confers clinically important benefit. The additional benefit of surgery over antibiotics alone is small at best. Assuming a UTI rate of 20% for children with VUR on antibiotics for five years, nine reimplantations would be required to prevent one febrile UTI, with no reduction in the number of children developing any UTI or renal damage.Plain language summaryIt is unclear whether the identification and treatment of children with vesicoureteric reflux has any clinically important benefitVesicoureteric reflux (VUR) is the backflow of urine from the bladder up the ureters to the kidney. People with VUR are thought to be more likely to get urinary tract infections (UTIs) involving the kidney tissue, which may cause permanent kidney damage. Current treatment options include surgery, surgery plus long‐term antibiotics, long‐term antibiotics alone and endoscopic (injection of a substance around the entry of the ureter into the bladder) correction using different materials. Surgery decreased the number of feverish UTIs, but did not change the number of children developing any UTI or kidney damage. In small studies, antibiotics did not change the number of children developing UTI compared with no treatment. More studies are needed.

Urinary tract infections revisited

Urinary tract infections (UTIs) remain a significant clinical problem, despite antibiotic treatment and surgical correction of reflux and malformations. Here we propose that novel molecular tools may be applied to modernize and individualize the diagnosis and therapy of UTI. Determinants of bacterial virulence and host resistance are relatively well understood at the molecular level, and technology for their detection is within reach.

Antireflux Surgery Normalizes Cyclooxygenase-2 Expression in Squamous Epithelium of the Distal Esophagus

In some patients GERD presents with heartburn and regurgitation symptoms but a relative paucity of endoscopic and clinical findings, while in others symptoms may be minor or absent yet there is significant mucosal damage on endoscopy including the presence of Barrett's esophagus. The initial injury of gastroesophageal reflux is to the squamous esophageal mucosa, but while substantial research has been devoted to determining which genes are involved in the progression of Barrett's to dysplasia and cancer, little is known about the gene expression alterations in the squamous mucosa of patients with reflux. We hypothesized that the expression of cyclooxygenase-2 (Cox-2) might be increased in the squamous esophageal mucosal of patients with reflux, and might be a molecular indicator of reflux injury. Further, we hypothesized that Cox-2 expression in the squamous mucosa would be reduced following the elimination of reflux with an antireflux operation. Biopsies of the distal esophageal squamous mucosa were taken 3 cm above the squamocolumnar junction (SCJ) in 28 GERD patients before and after Nissen fundoplication. Following microdissection and RNA isolation, quantitative real-time PCR was used to measure Cox-2 gene expression in paraffin-embedded (N = 16) and fresh frozen (N = 12) tissue. Biopsies from patients (paraffin N = 15, frozen N = 14) with normal acid exposure and no evidence of mucosal injury were analyzed as controls. Median Cox-2 expression in the squamous epithelium from paraffin embedded biopsies in patients with reflux disease was significantly increased compared to controls (p = 0.04). The presence of esophagitis or Barrett's esophagus did not significantly alter the expression of Cox-2 compared to patients with nonerosive reflux disease (NERD). After antireflux surgery median Cox-2 expression values were significantly reduced (p = 0.0003) and were normalized to levels similar to controls without reflux (p = 0.74). Similar results were observed in the prospectively obtained fresh frozen tissue. Cox-2 gene expression is increased in the distal esophageal squamous mucosa of most patients with GERD, and the elevation was similar whether there was mucosal injury in the form of esophagitis or Barrett's or no visible mucosal injury. This suggests that increased Cox-2 expression may serve as a molecular marker of reflux disease. The increased Cox-2 expression in patients with reflux was usually normalized following antireflux surgery. These findings demonstrate for the first time that gene expression can be altered by surgical correction of reflux. Thus, in addition to symptom control and improvement in the quality of life, perhaps future studies assessing the efficacy of antireflux therapy should also focus on the impact of the therapy on gene expression in the esophageal squamous mucosa.

Interventions for primary vesicoureteric reflux.

Vesicoureteric reflux (VUR) results in urine passing, in a retrograde manner, up the ureter. Urinary tract infections (UTIs) have been considered to be the main cause of permanent renal parenchymal damage in children with reflux. Therefore management of these children has been directed at preventing infection by antibiotic prophylaxis and/or surgical correction of reflux. However controversy remains as to the optimum strategies for management of children with primary VUR. To evaluate the benefits and harms of the different treatment options for primary VUR. Published and unpublished randomised controlled trials (RCTs) were identified from the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, reference lists of articles and abstracts from conference proceedings. RCTs were included if they compared any treatments of VUR including surgery (open and closed techniques), antibiotic prophylaxis of any duration, non-invasive techniques such as bladder training and any combination of therapies. Two reviewers independently searched the literature, determined trial eligibility, assessed quality, extracted and entered data. For dichotomous outcomes, results were expressed as relative risk (RR) and 95% confidence intervals (CI). Data were pooled using the random effects model. Ten trials involving 964 evaluable children comparing long-term antibiotics and surgical correction of VUR with antibiotics (seven trials), antibiotics with no treatment (one trial) and different materials for endoscopic correction of VUR (two trials) were identified. Risk of UTI by 1-2 and 5 years was not significantly different between surgical and medical groups (by 2 years RR 1.07, 95% CI 0.55 to 2.09; by 5 years RR 0.99; 95% CI 0.79 to 1.26). Combined treatment resulted in a 60% reduction in febrile UTI by 5 years (RR 0.43, 95% CI 0.27 to 0.70) but no concomitant significant reduction in risk of new or progressive renal damage at 5 years (RR 1.05, 95% CI 0.85 to 1.29). In one small study no significant differences in risk for UTI or renal damage were found between antibiotic prophylaxis and no treatment. It is uncertain whether the identification and treatment of children with VUR confers clinically important benefit. The additional benefit of surgery over antibiotics alone is small at best. Assuming a UTI rate of 20% for children with VUR on antibiotics for five years, nine reimplantations would be required to prevent one febrile UTI, with no reduction in the number of children developing any UTI or renal damage.

Antibiotics and surgery for vesicoureteric reflux: a meta-analysis of randomised controlled trials

Aims: To evaluate the benefits and harms of treatments for vesicoureteric reflux in children. Methods: Meta-analyses of randomised controlled trials using a random effects model. Main outcome measures were incidence...

Reflux-induced renal parenchymal injury: evaluation by urinary enzyme management

The urinary enzymes N-acetyl-B-D-glucosaminidase (NAG) and gamma-glutamyltransferase (GGT) were measured in four paediatric cohorts. Group 1 (21 children) suffered from severe vesico-ureteric reflux (VUR), group 2 (9 children) had active e urinary sepsis without reflux, group 3 constituted the control group (84 children), and group 4 comprised 21 children who had undergone successful endoscopic corrective surgery for VUR. Excretion of both NAG and GGT was significantly greater in group 1 than in groups 2 and 3 (P < 0.05). Within group 1, those with reflux in association with a single ureteric system demonstrated greater enzyme excretion than those with reflux in a duplex moiety (P < 0.05). Following surgical correction of reflux (group 4), there was a significant reduction in urinary enzyme excretion (P < 0.001). A spectrum of renal tubular damage exists in association with VUR. Urinary enzyme measurement is an invaluable technique in the evaluation of such renal damage in reflux, and in quantitatively assessing the efficacy of treatment.

Endoscopic subureteric collagen injection (SCIN): a new alternative treatment of vesicoureteric reflux in children

Endoscopic subureteric injection has become an accepted form of treatment for vesicoureteric reflux in children in selected cases. However, the commonly injected substance Teflon has raised doubts as to its long-term safety. Glutaraldehyde cross-linked bovine collagen, which is not associated with the feared side effects of Teflon (granuloma formation, particle migration), seems to be an adequate replacement. At the Departement of Paediatric Surgery of the Basel University Children's Hospital 54 patients with a total of 82 refluxing units were treated with the subureteric collagen injection (SCIN) in the period between June 88 and August 90; 45 patients were female and 9 were male. The average age at treatment was 4.9 years (2 months– 15.2 years). Micturating cystourethrograms performed 3 months after injection showed disapperance of reflux in 61.3% (49 ureters).If improvement to grade I and II reflux was included, the success rate increased to 77.5%. After two SCIN procedures 77.6% of the ureters became free of reflux. Including improvement to grade I and II reflux, the success rate increased to 83.8%. The mean follow-up time was 11.5 months (2–27 months). Injection-related complications were not observed. Although the overall results were not as good as those after surgical correction of reflux and the long-term effects of the collagen implants are not yet known, SCIN seems to be a simple alternative treatment for vesicoureteric reflux in children.

Vesicoureteral Reflux in the Adult. III. Surgical Correction: Risks and Benefits

Antireflux surgery was successful in 97 per cent of 67 adults with primary bilateral vesicoureteral reflux. Mean followup was 43 months. Of the patients 93 per cent became free of acute pyelonephritis, although 50 per cent continued to experience occasional cystitis. Surgical correction of reflux had no beneficial effect on renal size, renal scars or significant proteinuria with impaired renal function. Antireflux surgery does not appear to be justified in cases of proteinuria unless recurrent symptomatic pyelonephritis becomes uncontrollable. Additionally, antireflux surgery did not appear to have any beneficial effect on hypertension or large bladder capacity. However, calculogenesis remained inactive with this and other adjunctive therapies.

Gastric emptying and gastroesophageal reflux: Effects of surgery and correlation with esophageal motor function

A new method of measuring gastric emptying for solids was developed and validated. With this new method, gastric emptying of solids was evaluated in 40 patients with gastroesophageal reflux. Gastric emptying of solids was delayed in 42 percent of patients independent of the severity of the reflux symptoms. Liquids emptied in a normal fashion, supporting the observations of others that liquid emptying is not a valid measure of gastric emptying. A high incidence of esophageal motor abnormalities was present in these patients when tested with radionuclide transit studies using a liquid bolus. The coexistence of esophageal and gastric emptying abnormalities was present in 45 percent of patients who had delayed gastric emptying of solids. Three months after surgical correction of reflux as measured by pH study, abnormalities in both the esophagus and stomach remained unchanged. Since the symptoms were corrected, delayed gastric emptying is not adequate indication for a gastric emptying procedure at the time of antireflux surgery.

Segmental “hypoplasia” of the kidney (Ask-Upmark)

Severe segmental renal atrophy with loss of parenchymal elements in small kidneys is commonly known as segmental hypoplasia. The scars are seen as cortical depressions overlying shrunken medullary pyramids and their dilated calyces, and are characterized histologically by colloid-filled tubular microcysts and a paucity or absence of glomeruli. This lesion has been identified in 17 patients, 11 female and 6 male, between 6 and 23 years of age. Eleven patients had hypertension, which developed in six while they were under observation. Thirteen had histories of urinary tract infection, and 16 had evidence of vesicoureteric reflux. Seven patients had impaired renal function (GFR less than 40 ml/minute/1.73 m2). Abnormal metanephric differentiation (dysplasia) in two specimens, one in association with posterior urethral valves, suggested an occasional intrauterine origin of the abnormality. Twelve patients had radiographic evidence of decreasing renal size over two to five years of observation, even after surgical correction of reflux, in four of them unaccompanied by infection. We conclude that segmental "hypoplasia" is an acquired lesion, although it sometimes has intrauterine origins, and that it is commonly associated with vesicoureteric reflux, even in the absence of demonstrable infection.

Surgical Correction of Reflux: An effective therapy for esophageal strictures

An effective antireflux operation, posterior gastropexy with cardiac calibration, was performed on 24 patients with well established peptic strictures of the esophagus. Without intraoperative or postoperative dilation, the diameter of the strictures went from a mean of 6.3 mm to a postoperative mean diameter of 13.0 mm. Significant increases in sphincter pressure were recorded and endoscopic evaluation showed a return to normal. Preoperative dysphagia was relieved. It is concluded that an adequate antireflux operation will obviate the need for postoperative dilations or more formidable operations such as interposition.

Coexistence of Urinary Calculi and Vesicoureteral Reflux

Coexistence of vesicoureteral reflux and urinary calculi was noted in 16 patients. This new observation suggests that a patient with urinary calculi and urinary tract infection of long duration should be examined for reflux. After the removal of the stone (or stones) and appropriate anti-microbial therapy, if infection persists and reflux is believed to be an important etiologic factor, surgical correction of reflux may be considered.

Coexistence of urinary calculi and vesicoureteral reflux

Coexistence of vesicoureteral reflux and urinary calculi was noted in 16 patients. This new observation suggests that a patient with urinary calculi and urinary tract infection of long duration should be examined for reflux. After the removal of the stone (or stones) and appropriate anti-microbial therapy, if infection persists and reflux is believed to be an important etiologic factor, surgical correction of reflux may be considered.