Medical versus Surgical Management of Vesico Ureteral Reflux

Vesico ureteral reflux is the abnormal retrograde flow of urine from the bladder into the ureter and possibly the kidney. There are 2 types of reflux: Primary reflux – which is caused by a congenital abnormality at the ureterovesical junction Secondary reflux – occurs when high pressure in the bladder causes a breakdown of the normal antireflux mechanism at the ureterovesical junction that occurs in children with posterior urethral valves or neurogenic bladders. This also happens in children who have complete ureteral duplication with or without a ureterocoele. T article focuses on primary vesico ureteral reflux and the approach to this entity. Primary vesico ureteral reflux can and should be treated conservatively (except Grade V bilateral reflux) with very selective indications for surgical intervention. The advantages and the disadvantages are discussed in detail together with details of both these modes in the treatment of reflux, and recommendations for therapy, follow up and the future. The choice for conservative or surgical therapy for vesico ureteral reflux (VUR) applies only to primary VUR. In order to understand the arguments for and against the type of therapy –one must understand the basics of what is VUR and its natural course, hence a brief summary of VUR follows and then the actual details of medical or surgical intervention. VUR refers to the retrograde flow of urine Paediatric Urologist and Paediatric Surgeon, Sir Hurkisondas Hospital, Breach Candy Hospital, Wockhardt Hospitals, Jupiter Hospital, B J Wadia Hospital for Children, Dr Sathe Road, Mumbai 400 004 from the bladder into the upper urinary tract. Reflux may be congenital or acquired. Reflux can be basically divided into 2 types – primary and secondary. The incidence of reflux in asymptomatic children is anywhere between 0.5% and 18.5%. In children who present with urinary tract infection, reflux has been found in 29 – 50% cases.1,2 Though VUR is more common in girls, boys with urinary infections have a higher incidence of VUR. The incidenc of VUR is also found to be inversely proportional to the age. Primary VUR is caused by a congenital inadequacy of the valvular mechanism at the uretero-vesical junction(UVJ), and secondary reflux is the result of anatomic abnormalities (posterior urethral valves(PUV), prune belly syndrome, ano rectal malformations(ARM); or due to functional obstructive phenomenon (myelodysplasia, dysfunctional voiding) Primary VUR : The main factors that keep the UVJ valve mechanism intact are: Oblique entry of ureter into the bladder and ratio of submucosal tunnel length to ureteral diameter of 4:1.3,4