CHANGES IN THE TREATMENT OF VESICO-URETERAL REFLUX

1. CHANGES IN THE TREATMENT OFVESICO-URETERAL REFLUX Sarel Halachmi MD. Rambam Medical Center Haifa

2. 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

3. 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.

4. 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.

5. Pathogenesis of reflux– the simple explanation NON REFLUXING REFLUXING

6. Surgical correction of refluxunderstanding the pathogenesis gave rise to many surgical correction techniques. Art of reconstructive surgery

7. 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

8. 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

9. Historical milestones • Ransley and Risdon – 1978 Sterile reflux does not cause renal scarring

10. alternative to surgical treatmenta pill a day keeps the surgery away Medical VS. Surgical

11. Medical treatment for reflux:is it as efficient as surgical treatment ?

12. 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

13. 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

14. Medical treatment is effective as surgical treatment. • Most of the new scars were formed till the age of 5 years.

15. 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%.

16. Reflux has high spontaneous resolution rate

17. 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.

18. Dilemmas in Medical treatment for reflux

19. Persistent asymptomatic refluxShould we continue treat?Should we continue to observe?Until when? Should we operate?Whom, and when? VCUG - ROOM

20. 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.

21. 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.

22. 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.

23. 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.

24. 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

25. Persistent reflux • We still need more studies in order to have accurate guidelines for management.

26. And while we are dealing with those complex issues there is a “new” player is on the field ENDOSCOPIC TREATMENT

27. 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.

28. 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.

29. VUR Medical vs. surgical treatment

30. 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.

31. Thank you