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Vesicoureteral reflux
Urological Science xxx (2014) 1e3
Contents lists available at ScienceDirect
Urological Science journal homepage: www.urol-sci.com
Practical uroradiology
Vesicoureteral refluxq
CME Credits
Jia-Hwia Wang a, b, c, * a
Department of Radiology, Cheng Hsin General Hospital, Taipei, Taiwan Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan c School of Medicine, National Yang-Ming University, Taipei, Taiwan b
a r t i c l e i n f o Article history: Received 9 January 2014 Accepted 13 January 2014 Available online xxx Keywords: vesicoureteral reflux voiding vesicourethrography
examination revealed nothing particular except mild dyspnea. Urine routine examination showed pyuria. Urine culture revealed the growth of Escherichia coli, which was sensitive to the first generation of cephalosporin. After admission, cephradine (200 mg/ Q, 6 hours/day) was administered intravenously. During hospitalization, voiding cystourethrography (VCUG) revealed Grade III left vesicoureteral reflux (VUR; Fig. 1A). The antibiotic treatment was continued for 1 week, following which the patient’s body temperature returned to normal. The patient was discharged in a stable condition. Outpatient department follow-up was recommended. Follow-up VCUG 3 months later revealed no left VUR (Fig. 1B). 3. Discussion
1. Introduction Vesicoureteral reflux (VUR) is the retrograde flow of urine from the bladder into the ureter. It may potentially cause pyelonephritis, renal scarring, hypertension, and renal failure. The main goal in the management of patients with VUR is the preservation of kidney function by minimizing the risk of pyelonephritis, and in this regard early diagnosis is crucial. Diagnosis is usually made by imaging studies. Voiding cystourethrography (VCUG) remains the gold standard because it provides a better demonstration of the grade of VUR. Treatment for VUR includes conservative management and surgical treatment. 2. Case report An 8-month-old baby was brought to the emergency room (ER) of our hospital with a complaint of intermittent high fever for the past 2 days. The patient’s body temperature in the ER was 38.4 C. Laboratory data showed leukocytosis, elevated C-reactive protein, and pyuria. He was admitted to the general ward with suspected urinary tract infection. The patient had a history of laryngomalacia after undergoing laser treatment twice. After admission, physical
* Department of Radiology, Cheng Hsin General Hospital, Number 45, Cheng Hsin Street, Beitou, Taipei 112, Taiwan. E-mail address: [email protected]. q There are 3 CME questions based on this article.
VUR is the retrograde flow of urine from the bladder into the ureter. It may potentially cause pyelonephritis, renal scarring, hypertension, and renal failure. The exact prevalence of VUR is unknown. However, the prevalence of VUR in normal children has been estimated at 0.4e1.8%.1 Among infants prenatally identified by ultrasonography to have hydronephrosis who were screened for VUR, the prevalence was 16.2% (range: 7e35%).2 The incidence of VUR is much higher among children with urinary tract infection. The main goal in the management of patients with VUR is the preservation of kidney function by minimizing the risk of pyelonephritis. Early diagnosis in such patients is crucial. Diagnosis and further management are usually made by imaging studies. The imaging studies include VCUG, ultrasonography, and dimercaptosuccinic acid renal scanning. The grading system for VUR on VCUG was well established by the International Reflux Study CommitteedTable 13 and Figs. 1e5. The VCUG remains the gold standard investigation because it provides better demonstration of the grade of VUR. Patients with higher grades of VUR present with higher rates of renal scarring. Treatment for VUR includes conservative management and surgical treatment. The conservative treatment includes watchful waiting, intermittent antibiotic prophylaxis or continuous antibiotic prophylaxis, and bladder rehabilitation in patients with lower urinary tract dysfunction. Surgical management includes injection of bulking agents and ureteral reimplantation. Ureteral reimplantation can involve an open surgical technique,4 or a conventional or robot-assisted laparoscopic approach.5e8
http://dx.doi.org/10.1016/j.urols.2014.01.003 1879-5226/Copyright Ó 2014, Taiwan Urological Association. Published by Elsevier Taiwan LLC. All rights reserved.
Please cite this article in press as: Wang J-H, Vesicoureteral reflux, Urological Science (2014), http://dx.doi.org/10.1016/j.urols.2014.01.003
2
J.-H. Wang / Urological Science xxx (2014) 1e3
Fig. 1. (A) Grade III left vesicoureteral reflux. (B) No left vesicoureteral reflux after antibiotic treatment.
Table 1 Grading system for vesicoureteral reflux on voiding cystourethrography, according to the International Reflux Study Committee.3 Grade I Reflux does not reach the renal pelvis Grade II Reflux reaches the renal pelvis; no dilatation of the collecting system Grade III Mild or moderate dilatation of the ureter; moderate dilatation of the collecting system Grade IV Moderate dilatation of the ureter; moderate dilatation of the collecting system Grade V Gross dilatation and kinking of the ureter; marked dilatation of the collecting system
Fig. 4. Grade IV left vesicoureteral reflux.
Fig. 2. Grade I right vesicoureteral reflux. Fig. 5. Grade V left vesicoureteral reflux and chronic cystitis.
Conflicts of interest The author declares that he has no financial or nonfinancial conflicts of interest related to the subject matter or materials discussed in the manuscript. Appendix A. Supplementary data Supplementary data related to this article can be found at http:// dx.doi.org/10.1016/j.urols.2014.01.003 References
Fig. 3. Grade II bilateral vesicoureteral reflux.
1. Sargent MA. What is the normal prevalence of vesicoureteral reflux? Pediatr Radiol 2000;30:587e93. 2. Skoog SJ, Peters CA, Arant Jr BS, Copp HL, Elder JS, Hudson RG, et al. Pediatric Vesicoureteral Reflux Guidelines Panel summary report: clinical practice
Please cite this article in press as: Wang J-H, Vesicoureteral reflux, Urological Science (2014), http://dx.doi.org/10.1016/j.urols.2014.01.003
J.-H. Wang / Urological Science xxx (2014) 1e3 guidelines for screening siblings of children with vesicoureteral reflux and neonates/infants with prenatal hydronephrosis. J Urol 2010;184:1145e51. 3. Lebowitz RL, Olbing H, Parkkulainen KV, Smellie JM, Tamminen-Möbius TE. International system of radiographic grading of vesicoureteric reflux. International Reflux Study in Children. Pediatr Radiol 1985;15:105e9. 4. Duckett JW, Walker RD, Weiss R. Surgical results: International Reflux Study in ChildrendUnited States branch. J Urol 1992;148:1674e5. 5. Janetschek G, Radmayr C, Bartsch G. Laparoscopic ureteral anti-reflux plasty reimplantation. First clinical experience. Ann Urol (Paris) 1995;29:101e5.
3
6. Jayanthi V, Patel A. Vesicoscopic ureteral reimplantation: a minimally invasive technique for the definitive repair of vesicoureteral reflux. Adv Urol; 2008: 973616. 7. Riquelme M, Aranda A, Rodriguez C. Laparoscopic extravesical transperitoneal approach for vesicoureteral reflux. J Laparoendosc Adv Surg Tech A 2006;16:312e6. 8. Marchini GS, Hong YK, Minnillo BJ, Diamond DA, Houck CS, Meier PM, et al. Robotic assisted laparoscopic ureteral reimplantation in children: case matched comparative study with open surgical approach. J Urol 2011;185: 1870e5.
Please cite this article in press as: Wang J-H, Vesicoureteral reflux, Urological Science (2014), http://dx.doi.org/10.1016/j.urols.2014.01.003
Contents lists available at ScienceDirect
Urological Science journal homepage: www.urol-sci.com
Practical uroradiology
Vesicoureteral refluxq
CME Credits
Jia-Hwia Wang a, b, c, * a
Department of Radiology, Cheng Hsin General Hospital, Taipei, Taiwan Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan c School of Medicine, National Yang-Ming University, Taipei, Taiwan b
a r t i c l e i n f o Article history: Received 9 January 2014 Accepted 13 January 2014 Available online xxx Keywords: vesicoureteral reflux voiding vesicourethrography
examination revealed nothing particular except mild dyspnea. Urine routine examination showed pyuria. Urine culture revealed the growth of Escherichia coli, which was sensitive to the first generation of cephalosporin. After admission, cephradine (200 mg/ Q, 6 hours/day) was administered intravenously. During hospitalization, voiding cystourethrography (VCUG) revealed Grade III left vesicoureteral reflux (VUR; Fig. 1A). The antibiotic treatment was continued for 1 week, following which the patient’s body temperature returned to normal. The patient was discharged in a stable condition. Outpatient department follow-up was recommended. Follow-up VCUG 3 months later revealed no left VUR (Fig. 1B). 3. Discussion
1. Introduction Vesicoureteral reflux (VUR) is the retrograde flow of urine from the bladder into the ureter. It may potentially cause pyelonephritis, renal scarring, hypertension, and renal failure. The main goal in the management of patients with VUR is the preservation of kidney function by minimizing the risk of pyelonephritis, and in this regard early diagnosis is crucial. Diagnosis is usually made by imaging studies. Voiding cystourethrography (VCUG) remains the gold standard because it provides a better demonstration of the grade of VUR. Treatment for VUR includes conservative management and surgical treatment. 2. Case report An 8-month-old baby was brought to the emergency room (ER) of our hospital with a complaint of intermittent high fever for the past 2 days. The patient’s body temperature in the ER was 38.4 C. Laboratory data showed leukocytosis, elevated C-reactive protein, and pyuria. He was admitted to the general ward with suspected urinary tract infection. The patient had a history of laryngomalacia after undergoing laser treatment twice. After admission, physical
* Department of Radiology, Cheng Hsin General Hospital, Number 45, Cheng Hsin Street, Beitou, Taipei 112, Taiwan. E-mail address: [email protected]. q There are 3 CME questions based on this article.
VUR is the retrograde flow of urine from the bladder into the ureter. It may potentially cause pyelonephritis, renal scarring, hypertension, and renal failure. The exact prevalence of VUR is unknown. However, the prevalence of VUR in normal children has been estimated at 0.4e1.8%.1 Among infants prenatally identified by ultrasonography to have hydronephrosis who were screened for VUR, the prevalence was 16.2% (range: 7e35%).2 The incidence of VUR is much higher among children with urinary tract infection. The main goal in the management of patients with VUR is the preservation of kidney function by minimizing the risk of pyelonephritis. Early diagnosis in such patients is crucial. Diagnosis and further management are usually made by imaging studies. The imaging studies include VCUG, ultrasonography, and dimercaptosuccinic acid renal scanning. The grading system for VUR on VCUG was well established by the International Reflux Study CommitteedTable 13 and Figs. 1e5. The VCUG remains the gold standard investigation because it provides better demonstration of the grade of VUR. Patients with higher grades of VUR present with higher rates of renal scarring. Treatment for VUR includes conservative management and surgical treatment. The conservative treatment includes watchful waiting, intermittent antibiotic prophylaxis or continuous antibiotic prophylaxis, and bladder rehabilitation in patients with lower urinary tract dysfunction. Surgical management includes injection of bulking agents and ureteral reimplantation. Ureteral reimplantation can involve an open surgical technique,4 or a conventional or robot-assisted laparoscopic approach.5e8
http://dx.doi.org/10.1016/j.urols.2014.01.003 1879-5226/Copyright Ó 2014, Taiwan Urological Association. Published by Elsevier Taiwan LLC. All rights reserved.
Please cite this article in press as: Wang J-H, Vesicoureteral reflux, Urological Science (2014), http://dx.doi.org/10.1016/j.urols.2014.01.003
2
J.-H. Wang / Urological Science xxx (2014) 1e3
Fig. 1. (A) Grade III left vesicoureteral reflux. (B) No left vesicoureteral reflux after antibiotic treatment.
Table 1 Grading system for vesicoureteral reflux on voiding cystourethrography, according to the International Reflux Study Committee.3 Grade I Reflux does not reach the renal pelvis Grade II Reflux reaches the renal pelvis; no dilatation of the collecting system Grade III Mild or moderate dilatation of the ureter; moderate dilatation of the collecting system Grade IV Moderate dilatation of the ureter; moderate dilatation of the collecting system Grade V Gross dilatation and kinking of the ureter; marked dilatation of the collecting system
Fig. 4. Grade IV left vesicoureteral reflux.
Fig. 2. Grade I right vesicoureteral reflux. Fig. 5. Grade V left vesicoureteral reflux and chronic cystitis.
Conflicts of interest The author declares that he has no financial or nonfinancial conflicts of interest related to the subject matter or materials discussed in the manuscript. Appendix A. Supplementary data Supplementary data related to this article can be found at http:// dx.doi.org/10.1016/j.urols.2014.01.003 References
Fig. 3. Grade II bilateral vesicoureteral reflux.
1. Sargent MA. What is the normal prevalence of vesicoureteral reflux? Pediatr Radiol 2000;30:587e93. 2. Skoog SJ, Peters CA, Arant Jr BS, Copp HL, Elder JS, Hudson RG, et al. Pediatric Vesicoureteral Reflux Guidelines Panel summary report: clinical practice
Please cite this article in press as: Wang J-H, Vesicoureteral reflux, Urological Science (2014), http://dx.doi.org/10.1016/j.urols.2014.01.003
J.-H. Wang / Urological Science xxx (2014) 1e3 guidelines for screening siblings of children with vesicoureteral reflux and neonates/infants with prenatal hydronephrosis. J Urol 2010;184:1145e51. 3. Lebowitz RL, Olbing H, Parkkulainen KV, Smellie JM, Tamminen-Möbius TE. International system of radiographic grading of vesicoureteric reflux. International Reflux Study in Children. Pediatr Radiol 1985;15:105e9. 4. Duckett JW, Walker RD, Weiss R. Surgical results: International Reflux Study in ChildrendUnited States branch. J Urol 1992;148:1674e5. 5. Janetschek G, Radmayr C, Bartsch G. Laparoscopic ureteral anti-reflux plasty reimplantation. First clinical experience. Ann Urol (Paris) 1995;29:101e5.
3
6. Jayanthi V, Patel A. Vesicoscopic ureteral reimplantation: a minimally invasive technique for the definitive repair of vesicoureteral reflux. Adv Urol; 2008: 973616. 7. Riquelme M, Aranda A, Rodriguez C. Laparoscopic extravesical transperitoneal approach for vesicoureteral reflux. J Laparoendosc Adv Surg Tech A 2006;16:312e6. 8. Marchini GS, Hong YK, Minnillo BJ, Diamond DA, Houck CS, Meier PM, et al. Robotic assisted laparoscopic ureteral reimplantation in children: case matched comparative study with open surgical approach. J Urol 2011;185: 1870e5.
Please cite this article in press as: Wang J-H, Vesicoureteral reflux, Urological Science (2014), http://dx.doi.org/10.1016/j.urols.2014.01.003