Non-obstructive vesicoureteral reflux in adults: value of conservative treatment

Has the data efflux regarding the promising outcome following injection of deflux changed the management of adult vesicoureteral reflux?

Primary vesicoureteral reflux (VUR), traditionally considered a problem of childhood, can also be detected during adulthood. However, while the concept regarding the therapeutic management of VUR in children has undergone revolutionary changes, moving from surgical to conservative approach, the optimal therapeutic approach in adult reflux is poorly addressed and is still unknown. Herein, we review clinical and therapeutic approaches of VUR in pediatric population as published throughout the years. With the introduction of Deflux injection as a minimally invasive procedure, we identify a beginning of a new trend that further extends the indications for endoscopic injections, including its introduction to adult patients as well.

Conservative treatment and anti-reflux surgery in adults with vesico-ureteral reflux: effect on urinary-tract infections, renal function and loin pain in a long-term follow-up study

STUDY PURPOSE

To investigate the long-term effects in adults of conservative treatment and anti-reflux surgery for vesico-ureteral reflux on urinary-tract infections, renal function, and loin pain.

METHODS

Of 115 adult patients with vesico-ureteral reflux diagnosed between 1968 and 1984, conservative treatment was given to 46 patients (36 women) and anti-reflux surgery was performed in 57 patients (52 women). The remaining 12 patients underwent nephrectomy or heminephrectomy and were excluded from the study. The anti-reflux surgical methods used were the Politano-Leadbetter procedure in 44 patients (73 ureters) and the Hutch procedure in 19 patients (25 ureters). Six of these patients were operated on with both methods.

RESULTS

The frequency of acute pyelonephritis was significantly reduced after anti-reflux surgery (P < 0.0001) as well as after diagnosis of vesico-ureteral reflux in the group given conservative treatment (P or < 0.001). The frequency of lower-urinary-tract infections was not altered in either group. Surgery had no effect on significant albuminuria (Albustix > or = 2+) or on progressive renal functional deterioration. Forty-three patients reported recurrent loin pain at the time of diagnosis or anti-reflux surgery. Only one of the 12 patients in the conservative group, compared with 29 of the 31 patients in the anti-reflux surgery group, obtained relief from loin pain during the follow-up. Nine patients in the anti-reflux surgery group reported restitution of reduced general well-being after surgery. These patients had experienced weariness and/or headache before surgery. Vesico-ureteral reflux was eliminated more frequently (P < 0.01) in the patients operated on by the Politano-Leadbetter procedure (94%) than in those operated on by the Hutch procedure (68%).

CONCLUSIONS

Loin pain is common in adults with vesico-ureteral reflux and is effectively eliminated by anti-reflux surgery. Anti-reflux surgery should be considered in adults with vesico-ureteral reflux and very frequent acute pyelonephritic attacks only if conservative treatment has failed to alleviate these symptoms. Anti-reflux surgery is not indicated with the aim of arresting renal functional deterioration.

Vesicoureteric reflux in the adult male

The main prevalence of vesicoureteric reflux (VUR) is in the adult female population. Although recognised as a clinical entity in adult males, little detailed information is available on this subject. A retrospective analysis was carried out on the results of 1519 consecutive videocystometrograms performed on male patients. VUR had an overall incidence of 8.6% within this population, with a range of 5.1% in patients with normal urodynamics to 15.6% in those with detrusor-sphincter dyssynergia. The common denominator between VUR and urodynamic measurement appears to be the generation of high intravesical pressures. These findings suggest that VUR is not uncommon in the male population, is usually asymptomatic and should respond to the treatment of any underlying bladder abnormality.

Submeatal injection of polytetrafluoroethylene paste for the endoscopic treatment of vesicoureteric reflux in adults

The injection of submeatal Teflon paste is often used for the treatment of paediatric vesicoureteric reflux (VUR). We present our results using this treatment in 7 adults and 1 female child; 11 ureters were injected with a 73% success rate. The simplicity of the procedure and the encouraging results make this a desirable treatment for adult VUR.

Vesicoureteral reflux in the adult. IV. Medical versus surgical management

A group of 27 adults with bilateral primary vesicoureteral reflux diagnosed during a 10-year interval was managed medically for a mean of 87 months. Their outcome was compared to that of 67 adults with bilateral primary reflux treated surgically during the same interval. In both groups the presence of renal insufficiency and hypertension correlated with the severity of renal scarring. Furthermore, the fate of renal function was similar irrespective of the method of management and appeared to be determined by the severity of renal scarring, level of renal function at initial evaluation and presence of proteinuria. The 2 groups appeared to fare equally well during the followup of up to 13 years.

Vesicoureteral reflux in the adult. III. Surgical correction: risks and benefits

Antireflux surgery was successful in 97 per cent of 67 adults with primary bilateral vesicoureteral reflux. Mean followup was 43 months. Of the patients 93 per cent became free of acute pyelonephritis, although 50 per cent continued to experience occasional cystitis. Surgical correction of reflux had no beneficial effect on renal size, renal scars or significant proteinuria with impaired renal function. Antireflux surgery does not appear to be justified in cases of proteinuria unless recurrent symptomatic pyelonephritis becomes uncontrollable. Additionally, antireflux surgery did not appear to have any beneficial effect on hypertension or large bladder capacity. However, calculogenesis remained inactive with this and other adjunctive therapies.

Transureteroureterostomy in spinal cord injury patients for persistent vesicoureteral reflux: 6 to 14-year followup

We did a long-term followup for spinal cord injury patients who had undergone transureteroureterostomy for persistent reflux after failed vesicoureteroplasty. Particular attention was paid to the complications that are unique to these patients and include the trapping of ureteral calculi, recurrent vesicoureteral reflux and bladder hypertrophy with vesicoureteral junction obstruction. Caution is advised in using this procedure in the spinal cord injury patient because of these problems despite the over-all success in maintaining the patency of the anastomosis.

Chronic lower quadrant abdominal pain due to vesicoureteral reflux

Chronic lower abdominal pain or flank pain in adults may be associated with vesicoureteral reflux. Although it is well known that renal scarring may occur in adults with vesicoureteral reflux associated with urinary tract infection, renal function may vary significantly when these patients are found to have sterile vesicoureteral reflux. We report 2 cases of lifelong intermittent lower abdominal pain associated with vesicoureteral reflux without damage to the upper urinary tracts. A voiding cystourethrogram should be included in the evaluation of adults with chronic lower quadrant pain or flank pain even if excretory urography and cystoscopy are normal and the urine is sterile.

Vesico-ureteral reflux in non-paediatric patients

In the period 1968-1975 we treated 55 female and 19 male adolescent or adult patients for vesico-ureteral reflux (v. u. r.) to a total of 116 renal units. The reflux was primary in 69 units, secondary in 20 and or mixed type in 27 units. It was of moderate degree in 50 units, 31 (62%) of which showed radiologic nephropathy. Of the 18 units with gross reflux, 16 (89%) showed nephropathy. Re-implantation of 75 ureters in the bladder ad modum Politano-Leadbetter was followed by cessation of reflux in 66 units (88%), with cure of symptoms and bacteriuria in a corresponding number of patients. Infravesical surgery or antibacterial medication were less effective when used alone. Two patients with severely impaired renal function (serum creatinine greater than 440 mumol/l) failed to improve, despite technically successful surgery. Primary v. u. r. in adolescents and adults has often been present since childhood, and many of these patients show radiologic evidence of nephropathy. Effective antireflux treatment should be given early, in order to prevent progressive renal damage.

A plea for antireflux operations in adults: review of 50 cases

The results of antireflux operations in 41 cases of primary and 9 cases of secondary vesicoureteral reflux in adults are presented. Reflux was eliminated in all cases and there were no postoperative complications. Most patients had a long history of urinary tract infection preoperatively, which was eliminated in 64.1 per cent of the cases after surgical correction of the reflux. A relapse of infection occurred in 30.8 per cent of these cases. Chronic pyelonephritis remains active in 5.1 per cent of the cases. There were 6 patients with serum creatinine levels higher than 1.8 mg. per cent who underwent a successful antireflux procedure without an increase of serum creatinine levels. An antireflux operation should be preferred over long-term conservative management in most cases of symptomatic vesicoureteral reflux in adults less than 50 years old.

Followup study after conservative and surgical treatment of vesicoureteral reflux

Our series of 94 cases (145 ureters) of vesicoureteral reflux is reviewed. The occasional disappearance of reflux during conservative treatment should not be mistaken for cure because of its variable nature. To avoid such a mistake voiding cystography under fluoroscopic monitoring is repeated indefinitely. Those patients who were treated surgically were followed for at least 2 to 3 years before cure was established. Transient ureteral dilatation after reimplantation was eradicated within 3 months. Postoperative urinary infection was observed at various intervals, ranging from 1 week to 5 months, and the erythrocyte sedimentation rate was likely to be influenced by infection. Postoperative chemotherapy was continued until the erythrocyte sedimentation rate was normal and there was no infection and/or dilatation of the upper tract.