Vesicorenal reflux
| Classification according to ICD-10 | |
|---|---|
| N13.7 | Uropathy related to vesicoureteral reflux
Vesicoureteral reflux: |
| ICD-10 online (WHO version 2019) | |
The vesicorenal reflux (synonyms: vesicoureteral reflux , vesico-uretero-renal reflux , VRR , VUR , English vesicorenal reflux ) is a non-physiological reflux of urine from the bladder through the urethra (ureters) into the renal pelvis .
to form
The vesicorenal reflux is divided into a primary , congenital and a secondary , acquired form.
If the urine backflow already begins in the filling phase of the urinary bladder, one speaks of a low-pressure VUR . If the reflux can only be detected in the emptying phase of the bladder, one speaks of a high pressure VUR .
Primary reflux
The congenital reflux based on a malformation of the ureteral orifice in the bladder wall. The submucosal course of the ureter is shortened. As a result, the urinary bladder cannot be adequately sealed in the event of an intravesical pressure increase caused by the bladder muscles.
Secondary reflux
The acquired form of vesicorenal reflux is caused by direct damage to the previously intact ureteral ostium (ureter opening).
The following causes are possible:
- specific and unspecific urinary bladder inflammation
- neurogenic bladder dysfunction
- infravesical urinary tract obstruction , e.g. B. urethral valves , urethral strictures
Classification of reflux
In 1985, the International Reflux Study Committee developed a generally applicable classification of the severity of vesicorenal reflux:
- Grade I : reflux in the ureter, not reaching the renal pelvis
- Grade II : The reflux reaches the renal pelvis, the calyx system is not blocked
- Grade III : The renal pelvis is slightly dilated, the calyx system is unchanged or slightly plumped
- Grade IV : Moderate dilatation of the renal pelvis, the fornices of the renal calyx are plumped, the impressions of the renal papillae are still visible
- Grade V : The ureter is greatly dilated with kinking ( kinking ), the void system is greatly extended, the papillary impressions are no longer visible in the majority.
Epidemiology
The incidence in childhood is 1%. The ratio of boys to girls over 1 year olds is 1: 5–6. Fair-skinned people are 10 times more likely to be affected than dark-skinned people. Red-haired children are at higher risk. In a diagnosed patient, the risk for siblings is over 30% of also having reflux. Of the children with urinary tract infections , 30–40% show vesicoureteral reflux. 20–30% of children already have kidney scars at the time of diagnosis.
60% of newborns have reflux, whereas only 5% of those under 5 years of age have reflux; this can be attributed to the maturation of the vesicoureteral junction.
Symptoms
Early symptoms:
- asymptomatic per se
- High-grade reflux leads to second micturition due to the refluxate flowing back into the bladder after the first micturition, with the development of renewed filling pressure
- Primarily no kidney affection
The unphysiological backlog of the urine paves the way for bacterial ascension and infections. This manifests itself in recurrent urinary tract infections up to high-fever pyelonephritis with flank pain.
Late symptoms can be:
- arterial hypertension
- Renal failure
- renal growth retardation
- unclear failure to thrive in childhood
- childhood urinary incontinence
Diagnosis
After a detailed medical history is taken, the following examinations are usually carried out:
- Determination of creatinine
- Urine status
- Urine culture
- Sonography
- Micturition cystoureterogram or micturition urosonography in the infection-free interval
- Urodynamics
- possibly kidney scintigraphy
therapy
The therapy depends on the type of vesicorenal reflux.
Conservative therapy
Depending on the degree of reflux and the age of the patient, there is a spontaneous healing rate between 4% (grade 5) and 87% (grade 1) (so-called maturation ). Infection prophylaxis should be carried out, as the occurrence of urinary tract infections reduces the chance of spontaneous healing.
Endoscopic Therapy
Injection of material (e.g. stabilized hyaluronic acid ) by means of cystoscopy into the mouth of the ureter to cushion it. The success rate is between 50 and 90% depending on the material and experience. The procedure can be repeated several times.
Operative therapy
Perform open or endoscopic reflux surgery . The success rate with this standardized method is about 95%.
Transvesical antireflux according to Politano-Leadbetter: excision of the ostium from the bladder wall and mobilization of the same. A further cranial and lateral passage is created for the ureter, thus creating a longer submucosal course of the ureter. This is followed by reimplantation of the ureteral ostium near the previous opening.
Cohen transvesical antireflux surgery: excision of the ostium from the bladder wall with reimplantation on the contralateral side.
Extravesical antireflux according to Lich-Gregoir: Lateral and cranial splitting of the detrusor muscle at the ostium while protecting the mucosa. Then the closure takes place over the ureter.
Therapy of secondary reflux
In secondary reflux, the focus is always on eliminating the cause of the reflux. The above-mentioned therapy procedures may also be carried out.
Web links
- AWMF guidelines ( Memento from December 25, 2004 in the Internet Archive )
Individual evidence
- ↑ www.emedicine.com
- ↑ M. Zerati Filho, AA Calado, U. Barroso, Jr, J. Amaro: Spontaneous resolution of vesicoureteral reflux rates in Brazilian children: a 30-year experience. In: Int Braz J Urol. 33 (2), Mar-Apr 2007, pp. 204-212.
- ^ VA Politano, WF Leadbetter: Operative technique for correction of vesicoureteral reflux. In: J Urol. 79, 1958, pp. 932-941.
- ^ SJ Cohen: Ureterocystoneostomy. An antireflux technique. In: Current Urol. 6, 1975, pp. 1-8.
- ↑ W. Gregoir: Le reflux vesico-ureteral congenital. In: Acta Urol Belg. 30, 1962, pp. 286-300.
