Frequent disease. In 35 % of cases, a sibling is affected, which justifies a systematic exploration of the siblings of an affected child. Vesicoureteral reflux predisposes to urinary tract infections and, in particular, pyelonephritis, its most severe form. Recurrent urinary infections are often the revealing sign of the disease and threaten the renal function. Performing a miction echography in case of urinary tract infection in the child allows to make the diagnosis without exposing the child to significant irradiation.

A distinction is made between:

• primary reflux

Congenital anomaly of the uretero-vesical junction associating at varying degrees the following 3 elements: a laxity of the trigone of the bladder, a deficiency of the muscle fibers of the terminal ureter and a too short submucosal path with a lateral implantation of the meatus.

• reflux secondary to anatomical injury following

• surgical destruction of the valve mechanism.
• sclerosis of the detrusor muscle.
• neurological bladder.
• congenital anomaly of ureter-bladder implantation (ectopic or supernumerary ureter).
• a cervico-urethral obstacle.

• reflux secondary to acute urinary tract infection

there are probably uretero-vesical junctions at the limit of competence for which an urinary tract infection (especially Gram- bacilli ) leads to persistant opening of the meatus and promotes a VUR.

The Duckett International Classification has described stages:

Type I: partial reflux in a thin pelvic ureter.

Type II : total reflux without ureteropyelic dilatation

Type III: moderate ureteropyelic dilation without caliceal involvement.

Type IV: ureteropyelocaliceal expansion with bulging and deformation of the renal papillae.

Type V: dilatation and major ureteral tortuosity, large pyelocaliceal dilatation with loss of vision of the papillae.

The presence of intrarenal reflux at stages IV and V has to be added to these 5 stages and appears to be a factor of severity.

The management of vesicourethral reflux is controversial as the medical management is associated with a high rate of arterial hypertension in adulthood. The initial treatment is medical and consists in antibio therapy: it is first curative first, followed with daily prophylaxis, as long as the child has not acquired sphincter control, to prevent infection. Regular echographic monitoring is performed, usually every 3 to 6 months. Later or in case of infectious recurrence, a miction cystography and/or isotopic examination is performed to determine the grade of reflux, its evolution and its impact on renal function.

There are 3 types of surgical procedures, the aim of which is to restore a sufficient muscular function at the level of the terminal portion of the ureter and to create or to prolong its submucosal path (it should be at least as long as 5 times the diameter of the ureter) so as to avoid any reflux of urine from the bladder into the ureter during micturition:

• endoscopic injection of macroplastic or other synthetic polymer around the opening of the ureters in the bladder: this is a simple, fast and non-invasive procedure but with a limited long-term success rate;
• the extravesical approach of the ureters;
• the intravesical approach of the ureters and their submucosal reimplantation.

Anesthetic implications:

1. The injection of macroplastic material is a relatively painless procedure, both intra and postoperatively, practically comparable to the realization of a simple cystoscopy. Conventional general anesthesia, in spontaneous or assisted ventilation, most often with a laryngeal mask, is quite appropriate.

In case of endoscopic examination of the urinary tract, care should be taken to use a warmed (37°C) solution (to avoid causing hypothermia that occurs quickly in the youngest children) and to use NaCl 0.9 % to avoid hyponatremia by resorption or extravasation. H2O should only be used in cases where an electric cautery is necessary for surgery (as for ureterocelectomy).

2. Open surgical approaches are invasive procedures. The incision is subumbilical (Pfannenstial type). They are performed under general anesthesia, with tracheal intubation or use of a laryngeal mask, and analgesia is ideally provided by an epidural block, either caudal or lumbar, with local anesthetics and adjuvants in order to prolong the analgesia for at least 24 hours (clonidine or morphine). The placement of a catheter allows for continuous administration of a local anesthetic mixture to continue for 48 to 72 hours. One can also perform a transverse block of the abdomen (TAP block) under ultrasound guidance.

One of the problems of intravesical surgery is the occurrence of postoperative bladder spasms: their suppression requires an extended sympathetic block (T9  to L2  nerve roots but also of the afferents of sacral origin (S2-S4)). It seems that these spasms are caused by the reactivation by local inflammation of the C fibers directly connected to the detrusor muscle. A study has shown that the use of a caudal catheter is more effective than a lumbar epidural catheter in preventing these spasms. In addition, a too cephalad position of the catheter could lead to more spasms.

In the absence of contraindications to the administration of a NSAID (renal function, hydration, nephrotoxic antibiotics), routine administration of ketorolac 0.5 mg/kg IV 3 to 4 times a day during the first two postoperative days usually controls these pains by reducing the intravesical production of prostaglandins. In case of contraindication to NSAIDs, an anticholinergic such as oral oxybutinin may be tried.

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Urinary tract infections and vesicoureteral reflux in infants and children.
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Updated: October 2021