T/t of choice for grade IV vesicoureteric reflux with recurrent UTI
Ans. is 'a' ie. Cotrimoxazole (Ref. Nelson, 18/e p2233 (16/e, p 1628))Don't get misled by this statement given in O.P. Ghai - "Operative correction of VUR is indicated inpts. with - persistent severe (grade IV or V) refluxThis statement does not mean that any pt. with grade IV & V reflux will be given surgical management and rest medical management. Treatment is not so clear-cut.The choice b/w medical or surgical modality is based on certain principles (go through the following text to understand it).The below given explanation is a bit lengthy. Bear with me for giving such a long text, as it is one of the most important but less read topic (UG books do not give sufficient information on its treatment).This explanation will help you to tackle any future question on t/t of VUR with different patient profile (as t/t changes with grades as well as age of the patient)Vesicoureteral reflux (VUR)is the retrograde flow of urine from the bladder to the ureter and the renal pelvisGrading of VUR : is based on the appearance of the urinary tract on Micturating Cystourethrogram (MCU).Grade 1reflux into a non-dilated ureterGrade IIreflux into the upper collecting system without dilatation.Grade IIIreflux into dilated ureter and /or blunting of calyceal fornicesGrade IVreflux into a grossly dilated ureterGrade VGross dilatation of the ureter, renal pelvis & calyces : calyces show loss of papillary impression. Complications of VURReflux predisposes to renal infection (pyelonephritis) by facilitating the transport of bacteria from the bladder to the upper urinary tract.The inflammatory reaction caused by a pyelonephritic infection may result in renal injury or scarring.Extensive renal scarring impair renal function and may result in renin mediated hypertension, reflux nephropathy, renal insufficiency, end stage renal disease, reduced somatic growth and morbidity during pregnancy.* TreatmentThe goals of t/t are to prevent pyelonephritis, renal injury, and other complication of reflux.Treatment modality is either medical or surgical.Medical therapyis based on the principle that reflux often resolves over time and the antibiotics maintain urine sterility and prevent infection and complication while awaiting spontaneous resolution.Surgical therapy :the basis for surgical therapy is that in selected children, ongoing reflux has caused or has significant potential for causing renal injury.The decision to do medical or surgical t/t is based on certain principles and parental, patient preferences.Below is given a chart listing the treatment recommendation for VUR.Before going through the chart lets see the basic principles on which this chart is based -With bladder growth and maturation, there is tendency for reflux to resolve or improve over time.Lower grades of reflux are much more likely to resolve than are higher grades.For grades I & II reflux, the likelihood of resolution is similar irrespective of age at diagnosis and whether if it unilateral or bilateral.For grade III & IV a younger age at diagnosis and unilateral reflux generally are associated with a higher rate of spontaneous resolution.Grade V reflux rarely resolves.The mean age for reflux resolution is 6 - 7 yrs.Reflux is unlikely to cause any renal injury in the absence of infection.Treatment Recommendation for VUR diagnosed following a UTI.GradeAge (yrs)ScarringInitial t/tFollow-upI-iiAny-Antibiotic prophylaxis-III - IV0-5-Antibiotic prophylaxisSurgeryIII - IV6- 10-U/L: Antibiotic prophylaxisSurgeryIII - IV6 - 10-B/L: Surgery V<1-Antibiotic prophylaxisSurgeryV1 - 5NoU/L: Antibiotic prophylaxisSurgeryV1 - 5NoB/L: Surgery V1 - 5YesSurgery V6- 10-Surgery * ThusMedical Management is the initial t/t in almost all children except for -Grade III & IV (Bilateral)Grade V (Mostly)Medical management (antibiotic prophylaxis) is continued till the reflux resolves.Pt. is shifted from medical to surgical management, in children withbreakthrough UTI (Recurrent UTI despite prophylaxis)Development of new renal scarsFailure of reflux to resolve.Thus in this question we will begin with medical management ie cotrimoxazole. This pt is having recurrent UTI. This will not alter our t/t. If the pt. had recurrent UTI despite prophylaxis, we would have done a surgical management.If you have a close look at the statement of O.P. Ghai, you will note that he is not stating that grades IV & V will be t/t surgically. It is persistent grades IV & V that are t/t surgically (persistent means VUR that are not resolving over time).
Cotrimox azole
Bilateral reimplantation of ureter
Injection of Collegen in the ureter
Endoscopic resection of ureter
Urinary Tract