Reflux nephropathy is a common condition among children that leads to recurrent inflammation in the urinary tract (inflammation accompanied by fever in 30%-70% of children). In this type of reflux, urine flows back from the urinary bladder into the ureter, up to the collecting system of the kidney. This reverse flow sometimes causes a significant dilation of the urinary system. The backflow of urine from the ureter but within the bladder is caused by a defect in the valve of the ureterovesical junction - the sphincter located at the entrance of the ureter into the bladder.
Recurrent infections in the kidney accompanied by fever are the main cause of kidney damage that can lead in extreme cases to irreversible kidney damage and chronic kidney insufficiency requiring dialysis.
The goal of treating reflux, after identifying the disease at the earliest possible stage, is to try to prevent urinary infections in the urinary tract before renal damage occurs.
Diagnosis:
In the modern era, nearly every pregnant woman undergoes ultrasound examinations during the pregnancy period. In this examination, findings of kidney pelvis dilation are sometimes observed, with or without dilation of the ureter. Such findings might raise suspicion of reflux, and therefore there will be cases where based on these findings, a decision will be made to start preventative antibiotic treatment immediately after birth, and simultaneously perform an imaging test to confirm or rule out the suspicion of reflux. Even if the child is suffering from an acute urinary tract infection accompanied by fever, they should undergo imaging tests to confirm or rule out the presence of reflux. An ultrasound examination is a simple and essential test for every child suspected of having vesicoureteral reflux. This test is easy to perform, involves no radiation, and can detect structural abnormalities, identify the dilatation of the urinary system (hydronephrosis), and other issues. Besides the ultrasound examination, a child suspected of having vesicoureteral reflux will also undergo a voiding cystourethrogram (VCUG) as part of the diagnostic process. This test is performed in the radiology department. During the test, a catheter is inserted into the bladder, through which a contrast material is injected to see if the contrasted urine returns to the bladder, both during the catheter filling process and during its removal and independent voiding. The VCUG is an invasive test but generally causes no complications, and due to the skills of the medical staff, young patients usually tolerate it well. A urine culture should be performed 3-4 days before the test to ensure a sterile urine culture (without signs of infection), and antibiotic treatment should be administered in the morning of the test day and the evening of the test day, according to the treating doctor's recommendation, to prevent urinary tract infection before the test.
Treatment:
When diagnosed with reflux in children, the treatment approach depends on age, gender, and the severity of the disease (degree of reflux and whether there are recurrent infections in the urinary tract). In some cases, reflux disappears spontaneously without surgical intervention. The spontaneous disappearance of reflux depends on the natural development of the vesicoureteral junction, which causes spontaneous resolution of the disease in almost 80% of children with mild to moderate reflux. On the other hand, in children with bilateral disease, severe reflux, or abnormal behavior of the urinary bladder, there are fewer cases of spontaneous resolution of the disease. These children usually require surgical treatments.
Conservative Treatment (Follow-up and Prophylactic Antibiotics):
If it is decided to initiate conservative treatment (follow-up only), prophylactic antibiotic treatment should be started to prevent recurrent inflammation in the urinary tract. Since there is no consensus in the urology world regarding the continuation of antibiotic treatment in a child with reflux, prophylactic antibiotic treatment is given to all children with reflux up to the age of one year. After the age of one year, treatment is stopped for boys and continued for girls until they are toilet trained. In both genders, a repeat cystourethrogram is performed after the age of one year to check if the reflux has disappeared spontaneously.
Surgical Intervention:
The decision for surgical correction can be based on several factors, including recurrent inflammation in the urinary tract, lack of spontaneous resolution of the disease, and parental preference to avoid long-term antibiotic treatment. Until the mid-1980s, the accepted treatment for reflux was open surgery aimed at reimplanting the ureter into the bladder with reflux, to create a mechanism preventing urine from returning to the ureterovesical junction. After the surgery, the child would have to be hospitalized for 5-7 days. This surgery had high success rates (up to 95%), which slightly decreased in severe cases where children experienced ureteral contractions and prolonged pain after discharge. Moreover, open surgery left surgical scars on the lower abdomen. Today, endoscopic surgery is generally preferred. Open surgery is performed if endoscopic surgery fails or in complicated cases, such as ureteral diverticulum or very severe reflux.
Advantages of Endoscopic Correction:
In the mid-1980s, an endoscopic correction method for reflux was developed, involving the injection of various materials into the submucosa of the ureterovesical junction. This injection allows the narrowing of the ureterovesical junction and prevents the return of urine from the ureter to the bladder.
This procedure is performed as a day-care procedure under general anesthesia and takes about 10-15 minutes. The child is discharged after voiding and can return to regular activities on the same day. An endoscopic ureterovesical junction injection procedure does not leave any abdominal scars. The procedure does not cause significant pain after surgery, except for a mild burning sensation during voiding. The success rates of endoscopic surgery are close to those of open surgery. In cases where the initial injection did not correct the reflux, a second and third injection can be administered.
The Department of Pediatric Urology at Shaare Zedek Medical Center is a pioneer in the endoscopic approach to reflux correction and has accumulated over 25 years of experience in this field. Prof. Chartin, the head of the Pediatric Urology Department, is one of the leading experts in this field worldwide. For the past three years, he has operated a European center for endoscopic reflux correction. Within this center, more than thirty physicians from various European countries have received training in various aspects of reflux and especially endoscopic correction.
In cases where a patient is not suitable for an endoscopic procedure and requires ureteral reimplantation to prevent reflux, a minimally invasive procedure with robotic assistance can be performed, based on a technique that imitates the blockage of the ureteral orifice (Obstructive Megaureter).