T/t of choice for grade IV vesicoureteric reflux with recurrent UTI -
Ans is 'a' ie. Cotrimoxazale Don't get misled by this statement given in O.P. Ghai - "Operative correction of VUR is indicated in pts. with -persistent severe (grade IV or V) reflux". This 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 ceain 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 impoant 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 pelvis Grading of VUR : is based on the appearance of the urinary tract on Micturating Cystourethrograni reflux into a non-dilated ureter Grade I Grade II reflux into the upper collecting system without dilatation. Grade HI reflux into dilated ureter and /or blunting of calyceal fornices Grade IV reflux into a grossly dilated ureter Grade V Gross dilatation of the ureter, renal pelvis & calyces : calyces show loss of papillary impression. Complications of VUR Reflux predisposes to renal infection (pyelonephritis) by facilitating the transpo 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 hypeension, reflux nephropathy, renal insufficiency, end stage renal disease, reduced somatic growth and morbidity during pregnancy. Treatment The goals of t/t are to prevent pyelonephritis, renal injury, and other complication of reflux. Treatment modality is either medical or surgical. Medical therapy - is 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 ceain principles and parental, patient preferences. Below is given a cha listing the treatment recommendation for VUR. Before going through the cha lets see the basic principles on which this cha 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 whetner 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.
Cotrimoxazole
Bilateral reimplantation of ureter
Injection of Collegen in the ureter
Endoscopic resection of ureter