Definition
The reflux of urine called vesicorenal reflux or vesicoureteral reflux. The situation is one in which the urine go from the bladder backwards to the kidneys normally prohibited.
General
The union of the ureters to the bladder is made from nature so that it is not possible of urine from the bladder to go back to the kidneys. Urine is stored in the bladder and normally during void leave the bladder through the urethra to the outside.
If there is a fetal formation defect in the union of the ureters to the bladder, urine can come back to the kidneys (there is reflux of urine).
Pathology
The reflux of urine causes urinary tract infection (UTI) which is mostly accompanied by high fever. A fever indicates that there is inflammationof the renal cellsand that can lead to permanent kidney damage. Rarely, UTI by reflux of urine nay not be accompanied by fever.
Diagnosis
The reflux of urine may be diagnosed prenatally several times. If the prenatal ultrasound of the fetus saws urinary retention in the kidneys (hydronephrosis) it may correspond to a 10% of cases at prenatal diagnosis of reflux. In these cases the newborn enters a daily prophylactic small dose of antibiotic therapy to prevent UTI. Very often reflux is not diagnosed prenatally, resulting in the child at an early age to make a febrile UTI, which will lead to investigations, which will show the reflux of urine. The younger the child, makes febrile urinary tract infection, the greater are the chances of being found of reflux of urine. Girls often find reflux after a febrile urinary tract infection than boys.
The diagnosis is made through an X-ray examination called voiding cystogram. The voiding cystogram will also show the degree of reflux. Refluxes are classified into five stages, from stage I to stage V.
Treatment
When diagnosed with reflux of urine in a child, the child goes into a protocol of daily antibiotic treatment in order to prevent new UTI and protect the kidneys. A large proportion of refluxes can regress spontaniously and can be cured by itselves, with the development of the child. Growing up the child can be fined the union of the ureter to the bladder and thus the regression may cease to exist by itself without any external surgical assistance. This can happen until the age of 6-7 years.
Previously, when not left alone is regression or when the child has sustained UTIs despite receiving antibiotics, we went to a big open surgery (reimplantations of the ureters). This procedure required 6 days stay in hospital with catheter. Despite its severity, the response has been excellent in experienced hands with success rates of 99%.
Endoscopic Therapy Of Urine Reflux
By now, the majority of surgeries for reflux of urine has been replaced by endoscopic surgery.
The endoscopic surgery is performed with a light general anesthesia, lasts 15-20 minutes and the child leaves the hospital 2 hours later, without catheter and without pain.
The aim of the surgery is to reduce the width of ureteric orifice by which the ureter enter into the bladder.
We enter into the bladder of children with special optical systems and through our video-monitoring we inject through a needle 1 gr of hyaluronic acid.
Hyaluronic acid is a normal constituent of human cells which replaces the materials we used the past years. With this material, there is no reaction of the human body and hence there are no complications. The only thing that can happen is the persistance of reflux, where the success rate of endoscopic interventions in these experienced hands amounts to 85-88%.
PHOTOS AND VIDEOS
Figure 1: Endoscopic appearance of a wide refluxing ureteral orifice.
Figure 2: At the bottom of the image appears metallic needle through which we inject the matterial (hyaluronic acid).
Figure 3: The injection has started and shows the progressive closure of the ureteric orifice.
Figure 4: The injection has been completed and the orifice has taken a very good closed morphology.
Video of endoscopic surgery for vesicorenal reflux (from our personal collection).
