Treatment of vesicoureteral reflux

Modern treatment of vesicoureteral reflux includes a set of measures (therapeutic and surgical) aimed at eliminating the cause of reflux and eliminating its consequences. Treatment of vesicoureteral reflux is certainly determined by its cause and form.

If the cause of the disease development was an inflammatory process in the bladder, then most often (this primarily concerns girls) minor renal dysfunction and stage I-II disease are detected in patients. In this case, cystoscopy reveals characteristic signs of chronic cystitis in patients, the orifice is located in the usual place and has a slit-like or conical shape according to Lyon. It is necessary to evaluate the effectiveness of the conservative treatment previously carried out by the patient: in case of irregular use of drugs or the absence of complex pathogenetic treatment, conservative therapy is prescribed. If the previously carried out (over 6-8 months) therapy did not give an effect and deterioration of renal function is detected, then there is no point in continuing it: in these cases, surgical correction is indicated. If positive dynamics are determined, conservative treatment is continued. In most patients of this group, chronic cystitis is diagnosed during cystoscopy, and it is also determined that the anatomical orifices of the ureters are located in normal positions in the urinary bladder triangle.

Drug treatment of vesicoureteral reflux

Conservative tactics are aimed at eliminating the inflammatory process and restoring the function of the detrusor. Complex therapy in girls is carried out jointly with a pediatric gynecologist. When planning therapeutic measures, the nature of the course of chronic cystitis is taken into account, especially in girls and women. Elimination of infection of the genitourinary system is the main link in the treatment of secondary vesicoureteral reflux. Scheme of modern antibacterial treatment:

• beta-lactam semisynthetic aminopenicillins:
• amoxicillin with clavulanic acid - 40 mg/kg per day, orally for 7-10 days;
• 2nd generation cephalosporins: cefuroxime 20-40 mg/kg per day (in 2 doses) 7-10 days: cefaclor 20-40 mg/kg per day (in 3 doses) 7-10 days;
• 3rd generation cephalosporins: cefixime 8 mg/kg per day (in 1 or 2 doses) 7-10 days: ceftibuten 7-14 mg/kg per day (in 1 or 2 doses) 7-10 days:
• fosfomycin 1.0-3.0 g/day.

After using bactericidal drugs (antibiotics), a long course of uroseptic treatment of vesicoureteral reflux is prescribed:

• nitrofuran derivatives: nitrofurantoin 5-7 mg/kg per day orally for 3-4 weeks;
• quinolone derivatives (non-fluorinated): nalidixic acid 60 mg/kg per day orally for 3-4 weeks: pipemidic acid 400-800 mg/kg per day orally for 3-4 weeks; nitroxoline 10 mg/kg per day orally for 3-4 weeks:
• sulfonamides: co-trimoxazole 240-480 mg/day orally for 3-4 weeks,

To increase the effectiveness of cystitis treatment in older children, local therapy is used - intravesical installations, which should be used with caution in patients with high degrees of the disease. It is important to remember that the volume of solutions should not exceed 20-50 ml.

Solutions for intravesical installations:

• silver proteinate
• solcoseryl;
• hydrocortisone;
• chlorhexidine;
• nitrofural.

The course of treatment is calculated for 5-10 installations, with bullous cystitis, 2-3 courses are repeated. The effectiveness of treatment is positively affected by the addition of local therapy with physiotherapy.

If the cause of the disease is neurogenic dysfunction of the bladder, then treatment should be aimed at eliminating the dysfunction of the detrusor. In case of detrusor hyporeflexia and detrusor-sphincter dysinergia with a large amount of residual urine, drainage of the bladder with a urethral catheter is often used, against the background of which conservative etiologic treatment of vesicoureteral reflux is carried out.

Elimination of functional disorders of the urinary tract is a complex task and requires a long time.

In case of hyporeflexive detrusor it is recommended:

• forced urination regime (every 2-3 hours);
• baths with sea salt;
• glycine 10 mg/kg per day orally for 3-4 weeks;
• electrophoresis with neostigmine methyl sulfate, calcium chloride; ultrasound exposure to the bladder area; electrical stimulation;
• sterile intermittent catheterization of the bladder.

For detrusor overactivity, it is recommended:

• tolterodine 2 mg/day orally for 3-4 weeks;
• oxybutynin 10 mg/day orally for 3-4 weeks;
• trospium chloride 5 mg/day orally for 3-4 weeks;
• picamilon 5 mg/kg per day orally for 3-4 weeks;
• imipramine 25 mg/day orally for 4 weeks;
• desmopressin (enuresis) 0.2 mg/day orally 3-4 weeks
• Physiotherapeutic treatment of vesicoureteral reflux: electrophoresis with atropine, papaverine; ultrasound exposure to the bladder area; electrical stimulation of the bladder using a relaxing technique; magnetic therapy;
• biofeedback.

Physiotherapeutic treatment of vesicoureteral reflux is of an auxiliary nature, but plays an important role in increasing the effectiveness of therapy; it is used both for neurogenic dysfunction of the bladder and for inflammatory diseases of the urinary tract.

The most common cause of IBO in patients is a congenital valve of the posterior urethra. Treatment consists of TUR of the urethra with valve.

Surgical treatment of vesicoureteral reflux

Surgical treatment of vesicoureteral reflux is performed when conservative therapy is ineffective, the disease is of stage III-V, renal function is reduced by more than 30% or there is progressive loss of function, persistent infection of the urinary system and recurrent pyelonephritis, and a defective ureteral orifice (gaping, lateral dystopia, paraureteral diverticulum, ureterocele, doubling of the upper urinary tract, etc.).

Moderate degree of renal function impairment in combination with stage I-II of the disease is an indication for endoscopic treatment, which consists of minimally invasive transurethral submucosal injection of bioimplants (Teflon paste, silicone, bovine collagen, hyaluronic acid, polyacrylamide hydrogel, plasma clot, autogenous fibroblast and chondrocyte cultures, etc.) under the ureteral orifice. As a rule, up to 0.5-2 ml of gel is injected. The method is minimally invasive. Therefore, the manipulation is often performed in a one-day hospital, and repeated implantation is possible. This operation does not require endotracheal anesthesia. It should be noted that endoscopic correction is ineffective or even ineffective when the ureteral orifice is located outside the Lieto triangle, the orifice is persistently gaping, or there is an acute inflammatory process in the bladder.

A decrease in renal function by more than 30% in combination with any degree of the disease, dystopia of the ureteral orifice, persistent gaping of the orifice, the presence of a bladder diverticulum in the area of the refluxing orifice, repeated operations on the vesicoureteral junction, and the ineffectiveness of endoscopic correction of the orifice are indications for performing ureterocystoanastomosis (ureterocystoneostomy).

More than 200 methods of correction of vesicoureteral anastomosis are described in the literature. Surgical treatment of vesicoureteral reflux is performed under endotracheal anesthesia extraperitoneally from incisions in the iliac regions according to Pirogov or from the Pfannenstiel approach.

The main pathogenetic meaning of modern antireflux operations is the lengthening of the intravesical part of the ureter, which is achieved by creating a submucous tunnel through which the ureter is passed. Conventionally, reconstructive operations on the vesicoureteral junction can be divided into two large groups. The first group of surgical interventions are operations performed with opening of the bladder (intra- or transvesical technique). This group includes interventions according to Cohen, Politano-Leadbetter, Glenn-Anderson, Gilles-Vernet, etc. The second group (extravesical technique) includes operations according to Leach-Paeguar, Barry, etc.

Cohen ureterocystostomy is performed through an incision in the anterior wall of the bladder and is based on the principle of lengthening the intravesical portion of the ureter by reimplanting it into a newly formed submucous tunnel. Specific complications of this method include bleeding from the bladder triangle (Lieto) and the juxtavesical portion of the ureter, and the development of postoperative cystitis. Postoperative bleeding from the Lieto triangle is associated with the formation of a submucous tunnel in the most blood-supplied area of the bladder, which is due to anatomical features. Postoperative bleeding from the juxtavesical portion of the ureter occurs due to rupture of regional arterial and venous plexuses during its blind traction to pass through the submucous tunnel. Both types of bleeding require repeated revision of the surgical wound, hemostasis, and worsen the result of reconstructive plastic surgery. Due to the transvesical access, the peculiarity and weakness of the Cohen ureterocystoanastomosis is the impossibility of straightening the kinks of the dilated ureter and performing its modeling before reimplantation, the need for which arises in stages IV and V of the disease.

The basis of the Politano-Lidbetter ureterocystoanastomosis is the creation of a submucous tunnel of the bladder. The peculiarity of the technique is a wide opening of the bladder and opening of the mucous membrane of the bladder in three places to create a tunnel, while the ureter is cut off from the outside of the bladder, since this method involves resection of the dilated ureter. Specific complications of the Politano-Lidbetter operation are the development of angulation of the prevesical part of the ureter due to the anastomosis technique and the formation of strictures of the vesicoureteral anastomosis that are not amenable to endoscopic correction. A characteristic radiographic symptom of angulation of the ureter is its transformation into a fish hook. In practice, this significantly reduces the possibility of renal catheterization if necessary (for example, in case of urolithiasis ).

At any age, open surgical treatment of vesicoureteral reflux is performed under endotracheal anesthesia. The duration of surgical intervention in case of bilateral pathological process, regardless of the surgeon's experience, is at least one and a half hours.

Extravesical ureterocystoanastomosis is the most effective surgical treatment for vesicoureteral reflux in children. The objectives of ureterocystoanastomosis include creating a reliable valve mechanism of the vesicoureteral junction, forming an adequate lumen of the ureter that does not interfere with the free passage of urine. The extravesical technique of ureterocystoanastomosis fully meets the requirements. The use of the extravesical technique allows avoiding opening the bladder (wide dissection of the detrusor) and at the same time makes it possible to form a submucosal tunnel on any part of the bladder wall, choosing an avascular zone. The length of the tunnel can also be chosen arbitrarily by the operator.

Duplication of the UUT is one of the most common anomalies of the urinary system. In 72% of cases, it affects the lower half of the doubled kidney, in 20% - both halves, in 8% - the upper half. The prevalence of vesicoureteral reflux in the lower half with complete duplication of the kidney is explained by the Weigert-Meyer law, according to which the ureter from the lower half opens lateral to the ureteral triangle and has a short intravesical section. When diagnosing the disease in one or both halves of the doubled kidney, antireflux surgery is performed on one or both ureters, and in rare cases, uretero-ureteral anastomosis.

According to the combined data of various authors, after surgical treatment of vesicoureteral reflux, the latter is eliminated in 93-98% of cases, kidney function improves in 30%, and stabilization of indicators is observed in 55% of patients. A higher frequency of positive results is noted in children.

In the postoperative period, all patients are required to undergo prophylactic antibacterial therapy for 3-4 days, followed by a transition to uroantiseptic therapy for 3-6 months.

If the treatment of vesicoureteral reflux is successful, the patient must be monitored for the next 5 years. During this time, the patient undergoes control examinations every 6 months for the first 2 years, then once a year. Outpatient monitoring of urine tests is performed once every 3 months. During the follow-up examination, the patient undergoes ultrasound of the urinary system, cystography, and radioisotope examination of renal function. If a urinary infection is detected, long-term uroantiseptic treatment of vesicoureteral reflux is carried out with low doses of uroantiseptics once at night. Particular attention should be paid to the condition of the urinary system in pregnant women who previously had vesicoureteral reflux; treatment of the disease in this group of patients is important, since they have an increased risk of developing nephropathy and pregnancy complications.