Treatment of vesicoureteral reflux

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

If the inflammatory process in the bladder was the cause of the development of the disease, most often (this primarily affects the girls) in patients with minor renal dysfunction and grade I-II disease. In this case, with the help of cystoscopy, the patients reveal characteristic signs of chronic cystitis, the mouth is located in the usual place and has a slit or conical shape according to Lyons. It is necessary to evaluate the effectiveness of previously conservative treatment in patients: in the case of irregular use of drugs or the absence of complex pathogenetic treatment, conservative therapy is prescribed. If the previously performed (for 6-8 months) therapy did not have an effect and the kidney function deteriorated, then it does not make sense to continue it: in these cases, an operative correction is shown. In determining the positive dynamics continue conservative treatment. In most patients in this group, cystoscopy is diagnosed with chronic cystitis, and it is also determined that the anatomical ureteral orifices are located in normal positions in the vesicle triangle.

Medication for vesicoureteral reflux

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

• beta-lactam semisynthetic aminopenicillins: 
• Amoxicillin with clavulanic acid - 40 mg / kg per day, inside 7-10 days; 
• cephalosporins of the second generation: cefuroxime 20-40 mg / kg per day (in 2 doses) 7-10 days: cefaclor 20-40 mg / kg per day, (3 times a day) 7-10 days;
• cephalosporins of the third generation: 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:
• phosphomycin 1.0-3.0 g / day.

After the use of bactericidal drugs (antibiotics), a long course is indicated for uroseptic treatment of vesicoureteral reflux:

• nitrofuran derivatives: nitrofurantoin 5-7 mg / kg per day inside 3-4 weeks;
• quinolone derivatives (non-fluorinated): nalidixic acid 60 mg / kg per day within 3-4 weeks: pipemidic acid 400-800 mg / kg per day within 3-4 weeks; Nitroxoline 10 mg / kg per day inside 3-4 weeks:
• sulfanilamide preparations: co-trimoxazole 240-480 mg / day inside 3-4 weeks,

To improve the effectiveness of cystitis treatment in older children, local therapy is used - intravesical installations that should be used with caution in patients with high degrees of 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 on 5-10 installations, with bullous cystitis repeat 2-3 courses. The effectiveness of treatment is positively influenced by the addition of local therapy with physiotherapy.

If the cause of the disease is neurogenic dysfunction of the bladder, then the treatment should be aimed at eliminating the detrusor function. When detrusor detrusor detrusor detrusor detrusor and detrusor sphincter dissection with a large amount of residual urine are often resorted to drainage of the bladder with a urethral catheter, against which a conservative etiologic treatment of vesicoureteral reflux is performed.

Eliminating functional disorders of the urinary tract is a difficult task and requires a long time.

When hyporeflective detrusor is recommended:

• a mode of compulsory urination (in 2-3 hours);
• bath with sea salt;
• glycine 10 mg / kg per day within 3-4 weeks;
• electrophoresis with neostigmine methylsulfate, calcium chloride; ultrasound effect on the bladder area; electrostimulation;
• sterile intermittent catheterization of the bladder.

With detrusor hyperactivity, it is recommended:

• tolterodine 2 mg / day inside 3-4 weeks;
• oxybutynin 10 mg / day inside 3-4 weeks;
• trospium chloride 5 mg / day inside 3-4 weeks;
• picamilon 5 mg / kg per day within 3-4 weeks;
• Imipramine 25 mg / day inside 4 weeks;
• desmopressin (enuresis) 0.2 mg / day inside Z-4 weeks
• physiotherapeutic treatment of vesicoureteral reflux: electrophoresis with atropine, papaverine; ultrasound effect on the bladder area; electrostimulation of the bladder by a relaxing technique; magnetotherapy;
• biological feedback.

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

The most common cause of IBI in patients is the congenital valve of the back of the urethra. Treatment consists in TOUR of the urethra with a valve.

Operative treatment of vesicoureteral reflux

Operative treatment of vesicoureteral reflux is performed with ineffectiveness of conservative therapy, III-V degree of the disease, a decrease in kidney function of more than 30% or progressive loss of function, with persistent infection of the urinary system and recurrent pyelonephritis, vicious ureteral orifices (yawning, lateral dystopia, paraureteral diverticulum, ureterocele, doubling of VMP, etc.).

The moderate degree of decrease in kidney function in combination with the I-II degree of the disease is an indication for endoscopic treatment, which consists of a minimally invasive transurethral submucosal injection of bioimplants (Teflon paste, silicone, bovine collagen, hyaluronic acid, polyacrylamide hydrogel, plasma clot, cultures of autogenic fibroblasts and chondrocytes etc.) under the mouth of the ureter. As a rule, up to 0.5-2 ml of gel is injected. The method has a low invasiveness. In connection with which the manipulation is often performed in a hospital of one day, it is possible to re-insert the implant. This operation does not require an endotracheal anesthesia. It should be noted that endoscopic correction is ineffective or even ineffective with the location of the ureteral outlet outside the zone of the Lieto triangle, the stable mouth gap, the acute inflammatory process in the bladder.

Decreased kidney function by more than 30% in combination with any degree of disease, dystopia of the ureter's mouth, persistent gap in the mouth, presence of a diverticulum of the bladder in the refluxing estuary zone, repeated operations on vesicoureteral anastomosis, inefficiency of endoscopic correction of the mouth are indications for ureterocystoanastomosis ureterocystoneontomy).

In the literature, more than 200 methods for correcting vesicoureteral anastomosis have been described. Operative treatment of vesicoureteral reflux is performed under endotracheal anesthesia extraperitoneally from incisions in the iliac regions along Pirogov or from access via Pfannenstil.

The main pathogenetic sense of modern antireflux surgery is the lengthening of the intravesical part of the ureter, which is achieved by creating a submucosal tunnel, through which the ureter passes. Conditionally reconstructive operations on the vesicoureteral junction can be divided into two large groups. The first group of surgical interventions - operations performed with the opening of the bladder (intra- or transvesical technique). This group includes interventions by Cohen, Politano-Ledbetter, Glenn-Anderson, Gilles-Vernet, and others. The second group (extra-vesic technique) includes operations involving Leach-Paeguar, Barry, and others.

Ureterocystoanastomosis according to Cohen is performed through the incision of the anterior wall of the bladder and is based on the principle of lengthening the intravesical part of the ureter by reimplantation into the newly formed submucosal tunnel. Specific complications of this method are hemorrhage from the bladder triangle (Lieto) and the juxtavezical ureter, development of postoperative cystitis. Postoperative bleeding from the Lieto triangle is associated with the formation of a submucosal tunnel in the most blood supply zone of the bladder, which is due to anatomical features. Postoperative bleeding from the juxtavezikalnogo department of the ureter arises from the rupture of regional arterial and venous plexuses during his blind traction for conducting through a submucosal tunnel. Both variants of bleeding require a second revision of the operating wound, haemostasis and worsen the result of reconstructive-plastic surgery. Because of the esophageal access, the peculiarity and the weak side of the ureterocystoanastomosis according to Cohen is the impossibility of straightening the bends of the enlarged ureter, performing its modeling before reimplantation. The need for which arises in the IV and V degrees of the disease.

At the heart of ureterocystoanastomosis according to Politano-Lidbetter is the creation of a submucosal tunnel of the bladder. A special feature 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, with the ureter being cut off from the outside of the bladder, since this method involves resection of the enlarged ureter. Specific complications of the Politano-Lidbetter operation are the development of angulation of the pre-tubular ureter due to the technique of anastomosing and the formation of strictures of the vesicoureteral anastomosis that do not lend themselves to endoscopic correction. A characteristic radiologic symptom of ureteral angulation is its transformation in the form of a fish hook. In practice, this significantly reduces the possibility of catheterization of the kidneys when there is a need (for example, with urolithiasis ).

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

The extravesical method of ureterocystoanastomosis is the most effective surgical treatment of vesicoureteral reflux in children. The tasks of ureterocystoanastomosis include the creation of a reliable valve mechanism of the vesicoureteral anastomosis, the formation of an adequate ureteral lumen that does not interfere with the free passage of urine. The extravesical technique of ureterocystoanastomosis fully meets the requirements. The use of extra-vesic technique allows to avoid opening the bladder (wide detrusor dissection) and at the same time makes it possible to form a submucous tunnel on any part of the wall of the bladder, choosing an avascular zone. The length of the tunnel can also be chosen arbitrarily by the operator.

Doubling VMP is one of the most frequent abnormalities 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 predominance of vesicoureteral reflux in the lower half with a full doubling of the kidney is explained by the Weigert-Meyer law. By which the ureter from the lower half opens lateral to the urinary bladder triangle and has a short intravesical department. When diagnosing the disease in one or both halves of the doubled kidney, an antireflux surgery is performed on one or both ureters, according to rare indications uretero-ureteral anastomosis.

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

In the postoperative period, prophylactic antibacterial therapy is mandatory for all patients for 3-4 days, with a subsequent transition to uroantiseptic therapy within 3-6 months.  

With a positive result of treatment of vesicoureteral reflux, the patient should be on dispensary observation for the next 5 years. During this time, the patient undergoes follow-up examinations every 6 months for the first 2 years, then once a year. Ambulatory monitoring of urinalysis is carried out at a frequency of once every 3 months. During the follow-up examination, the patient undergoes ultrasound of the urinary system organs, cystography, radioisotope investigation of kidney function. When urinary infection is detected, a long uroantiseptic treatment of vesicoureteral reflux with low doses of uroantiseptics is performed once a night. Particular attention should be paid to the state of the urinary system in pregnant women who previously had vesicoureteral reflux; treatment of the disease in this group of patients is important because they have an increased risk of developing nephropathy and complications of pregnancy.