Management of paediatric vesicoureteric reflux

Introduction
Vesicoureteral reflux is a condition in which, when the bladder is full of urine or during urination, urine abnormally flows back from the bladder into the upper urinary tract, such as the ureters and kidneys.This condition is observed in 1 to 21 TP3T children and in 20 to 501 TP3T children with recurrent urinary tract infections.

Governance
The majority of patients can be managed conservatively or with medication, but a small number of patients may require surgery to resolve reflux problems. Whether surgery is needed will depend on several factors, some of which will require detailed examination to determine.

Surgical options available

1. Endoscopic injection (Deflux)
2. Ureteric reimplantation
3. Endoscopic injection (Deflux)

This procedure involves injecting a bulking agent into the opening of the refluxing ureter using an endoscope. The doctor first inserts the endoscope into the bladder via the urethra (cystoscopy), then injects the bulking agent at or below the ureteric opening to make the area bulge. The injected implant causes fibrosis in the nearby tissue, thereby preventing urine from flowing back from the bladder into the ureter and kidney. This surgery does not require any external incisions but is performed under general anaesthetic.

Various bulking agents have been used in the past, but the most widely used bulking agent at present is called Deflux, which is a dextranomer/hyaluronic acid copolymer and the first bulking agent to be approved by the US Food and Drug Administration (FDA).

Indications

Treatment of vesicoureteral reflux.

Pre-operative preparation

• Patients must fast before undergoing general anaesthesia
• An enema may be needed to relieve constipation.
• Antibiotics need to be administered before the start of surgery.

Post-operative care

• No external wounds post-surgery
• Catheters are not usually required.
• If needed, take painkillers.
• Patients can usually be discharged after resuming a normal diet and urinating.
• Undergo an imaging examination at 3 months post-operation to diagnose post-operative reflux
• The patient needs to continue taking prophylactic antibiotics until their follow-up appointment.

Risks and complications

• Bleeding – such as blood in the urine or bleeding from the urethra
• Bleeding usually stops on its own.
• Urinary tract infection - Surgical procedures may cause urinary tract infections, and there may be recurrent urinary tract infections in the future.
• Urethral, bladder, or ureteral injury – caused by cystoscope insertion
• Urinary retention - inability to urinate after surgery
• Normally of a temporary nature, possibly due to post-operative pain
• Ureteric injection point obstruction
• Vesicoureteral reflux
• De novo contralateral vesicoureteral reflux
• If, during a cystoscopy, the patient's ureteric opening is found to be not in its normal position entering the bladder, it is not suitable

Endoscopic injection surgery
Some complications may require follow-up treatment or further surgery.

Effectiveness

Possible outcomes following surgery include: complete resolution of vesicoureteral reflux, worsening of the condition, or no change. In rare cases, reflux may develop in the contralateral ureter where none was previously present.The success rate of curing reflux with a single injection is approximately 60–90 per cent; however, high-grade reflux, congenital structural abnormalities and bladder dysfunction may all affect the success rate of treatment. If necessary, patients may undergo endoscopic injection or other surgical procedures.

1. Ureteric reimplantation

The principle of this surgery is to create a longer tunnel for the ureter to pass through before reaching the ureteric orifice in the bladder. This submucosal tunnel can act like a valve to prevent urine reflux. This surgery can be performed using an intravesical or extravesical approach.

Traditional surgery is performed as an open procedure; however, with the development of minimally invasive techniques, this procedure can also be performed laparoscopically (i.e., minimally invasively), where appropriate.

Indications
For the treatment of vesicoureteral reflux, vesicoureteral junction obstruction, or may be performed concurrently with other ureteral or bladder surgery.

In some cases, laparoscopic surgery may present technical difficulties, surgical complications, or anaesthetic complications. Proceeding with laparoscopic surgery may be hazardous. In such circumstances, laparoscopic surgery may be converted immediately to open surgery. In these instances, post-operative care will differ from that listed below.

Pre-operative preparation

• Patients must fast before undergoing general anaesthesia
• To relieve constipation with an enema
• Antibiotics need to be administered before the start of surgery.

Post-operative care

• The abdominal wound dressing should remain intact until it is examined by medical staff.
• A urinary catheter will be placed at the bladder outlet during surgery. If laparoscopic surgery is performed, this tube will be removed 1-2 days after the operation. Following open surgery, the urinary catheter may need to remain in place for a longer period, and other tubes and drains may also be necessary.
• If necessary, take or inject painkillers.
• Discharge timing will depend on the patient's overall condition.
• Discharged patients can resume normal activities.
• Undergo an imaging examination at 3 months post-operation to diagnose post-operative reflux
• The patient needs to continue taking prophylactic antibiotics until their follow-up appointment.

Risks and complications

• Bleeding - Minor bleeding from wounds and blood in the urine will usually stop on their own, but severe bleeding may require further treatment.
• Wound infection – may cause the wound to split open, or require the wound to be cut open and cleaned
• Urethral injury – caused by surgical procedures or urinary catheters
• Internal organ damage
• Ureteral obstruction – occurring at the neo-ureteral orifice, further treatment may be required
• Anastomotic leakage can generally be managed with drain insertion, while severe anastomotic leakage may require further surgical treatment.
• Neurogenic bladder dysfunction — a rare but serious complication following bilateral extravesical ureteric reimplantation.
• Vesicoureteral reflux
• Recurrent urinary tract infection

Some complications may require follow-up treatment or further surgery.

Effectiveness
Possible outcomes following surgery include: complete resolution of vesicoureteral reflux, worsening of the condition, or no change. In rare cases, contralateral reflux may develop in a ureter that previously showed no reflux. The success rate of this surgery in resolving reflux is approximately 85–95 per cent, and is also influenced by bladder dysfunction.

After open surgery, the situation of reflux is usually reassessed several months post-operatively, once the bladder muscles have contracted and reduced.

Notes
This leaflet provides only basic information about the surgery. The risks or complications that may occur cannot be listed exhaustively. The degree of risk also differs in different patients. Please consult your doctor.

Source: https://www.ekg.org.hk/pilic/public/surgery_pilic/paedsurg_managementofvesicoureteralrefluxinchildren_0215_chi.pdf