–Persistent bleeding or clots indicate inadequate hemostasis at the time of operation.

–Hematuria is often self-limited and does not require operative intervention.

–Continue prolonged catheterization is important until hematuria resolves.

–Patients rarely need transurethral fulguration or reoperation.

•Persistent, transient, contralateral reflux:

–Persistent reflux of the reimplanted ureter and development of de novo reflux of the contralateral side are usually temporary and resolve spontaneously.

–Transient postoperative reflux is usually caused by detrusor instability of the healing bladder.

–Persistent reflux of the ipsilateral ureter in the absence of secondary causes (e.g. a poorly compliant bladder) is usually caused by a technical error.

–Some technical problems associated with ureteral reimplantation include:

•Inadequate ureteral mobilization

•Short intramural tunnel

•Inadequate anchoring of the ureter

•Inappropriate placement of the ureteral orifice

–These technical errors are treated by reoperation or endoscopic injection if the reflux is grade III or less.

–Most contralateral reflux is caused by recurrent or previously undiagnosed reflux.

–Contralateral reflux may become evident when the contralateral refluxing ureter is no longer refluxing. These can managed conservatively, and usually subside spontaneously.

–If a patient experiences persistent or severe VUR following repair, perform a thorough workup, including urodynamics, imaging, and cystoscopy.

•Postsurgical obstruction after open antireflux surgery:

–Most cases of postoperative upper tract obstruction are mild, produce no symptoms, and spontaneously resolve.

–These cases are due to:

•Edema at the ureteroneocystostomy site

•Intraureteral blood clots

•Intraureteral mucous

•Bladder spasms

•Submucosal bladder hematoma

–Rarely, the obstruction is severe and present late, 1–2 weeks postoperatively.

–This is usually secondary to ischemia of the distal reimplanted segment of the ureter leading to fibrosis and stricture, an incorrect tunnel construction or too tight ureteral hiatus.

–These patients present with flank or abdominal pain, nausea, and vomiting.

–Obtain a renal ultrasonography, intravenous pyelography, or nuclear renography to confirm diagnosis.

–Ultrasonography can be difficult to assess in patients who had significant dilation preoperatively.

–Rarely, the obstruction is intermittent due to kinking or angulation of the reimplanted ureter with bladder filling.

–Most postoperative ureteral obstructions resolve spontaneously; however, temporary ureteral stenting may be necessary.

–Cystoscopy, ureteroscopic dilation and stent placement may correct mild obstruction or stenosis.

–Percutaneous placement of a nephrostomy tune may be necessary if a transvesical approach is not achievable.

–Treatment for high-grade obstruction is surgical revision of the obstructed system.

8.9Mortality/Morbidity

•Modern series consistently report success rates greater than 95 % for antireflux surgery.

•In cases in which reflux persists postoperatively, initial observation with continued antibiotic prophylaxis is indicated.

•A substantial number of patients with reflux at the first postoperative study have complete resolution at the 1-year follow-up point.

•Reoperation is generally reserved for patients with persisted febrile UTI despite prophylaxis.

•A very high percentage of patients in whom surgery has failed have voiding dysfunction, thus urodynamic evaluation should be considered in these patients, especially if reoperation is considered.

•New contralateral vesicoureteral reflux after unilateral antireflux surgery:

–New onset of vesicoureteral reflux in a renal unit that had no vesicoureteral reflux on preoperative imaging occurs in 10–32 % of patients after open correction and 7–14 % of patients after endoscopic correction.

–In general, the new vesicoureteral reflux is usually of low grade and more likely to spontaneously resolve.

•Outcome and morbidity of VUR:

–The success rate of ureteral reimplantation is higher than 95 %.

–The success rate of endoscopic treatment is lower than open surgical treatment but offers an alternative to either medical treatment or open surgical treatment.

–Following surgical repair, the incidence of pyelonephritis significantly decreases in comparison to medical management with long-term antibiotic therapy.

–The incidence of cystitis or renal scarring is the same following both medical and surgical management of VUR.

•Morbidity associated with vesicoureteral reflux:

–Acute urinary tract infection

–Reflux nephropathy

–Changes in renal function:

•Decrease in urine-concentrating ability

•Decrease in glomerular filtration rate

–Decreased renal and somatic growth

–Hypertension

•Reflux nephropathy may be the most common cause of childhood hypertension.

•This is secondary to elevated renin levels produced by scarred renal tissue

•The presence of hypertension correlates well with the degree of renal scarring.

–Renal failure

•The most devastating outcome of reflux nephropathy is renal failure.

•It is estimated that 15–30 % of renal failure in children and young adults is attributed to chronic pyelonephritis and reflux nephropathy.

•Although renal failure is a devastating complication of vesicoureteral reflux, it actually affects only a small minority of children with VUR.

Further Reading

1. Asgari SA, Asl AS, Safarinejad MR, Ghanaei MM. High success rate with new modified endoscopic treatment for high-grade VUR: a pilot study with preliminary report. J Pediatr Urol. 2015;12(2):100.e1–4.

2. Beetz R, Mannhardt W, Fisch M, Stein R, Thüroff JW. Long-term followup of 158 young adults surgically treated for vesicoureteral reflux in childhood: the ongoing risk of urinary tract infections. J Urol. 2002;168(2):704–7; discussion 707.

3. Belman AB. Vesicoureteral reflux. Pediatr Clin North Am. 1997;44(5):1171–90.

4. Canning DA. Five-year study of medical or surgical treatment in children with severe vesico-ureteral reflux. Dimercaptosuccinic acid findings. J Urol. 2000;163(1):380.

5. Cooper CS, Chung BI, Kirsch AJ. The outcome of stopping prophylactic antibiotics in older children with vesicoureteral reflux. J Urol. 2000;163(1):269–72.

6. Elder JS, Diaz M, Caldamone AA, Cendron M, Greenfield S, Hurwitz R. Endoscopic therapy for vesicoureteral reflux: a meta-analysis. I. Reflux resolution and urinary tract infection. J Urol. 2006;175(2): 716–22.

7. Elder JS, Diaz M, Caldamone AA, et al. Endoscopic therapy for vesicoureteral reflux: a meta-analysis. I. Reflux resolution and urinary tract infection. J Urol. 2006;175(2):716–22.

8. Hayn MH, Smaldone MC, Ost MC, Docimo SG. Minimally invasive treatment of vesicoureteral reflux. Urol Clin North Am. 2008;35(3):477–88, ix.

9. Hoberman A, Charron M, Hickey RW, et al. Imaging studies after a first febrile urinary tract infection in young children. N Engl J Med. 2003;348:195.

10.Hoberman A, Greenfield SP, Mattoo TK, Keren R, Mathews R, Pohl HG, et al. Antimicrobial prophylaxis for children with vesicoureteral reflux. N Engl J Med. 2014;370(25):2367–76.

11. Keren R, Shaikh N, Pohl H, et al. Risk factors for recurrent urinary tract infection and renal scarring. Pediatrics. 2015;136:e13.

12.Kirsch AJ, Perez-Brayfield M, Smith EA, Scherz HC. The modified sting procedure to correct vesicoureteral reflux: improved results with submucosal implantation within the intramural ureter. J Urol. 2004;171(6 Pt 1):2413–6.

13. Lee YJ, Lee JH, Park YS. Risk factors for renal scar formation in infants with first episode of acute pyelonephritis: a prospective clinical study. J Urol. 2012;187(3):1032–6.

14.Mattoo TK, Chesney RW, Greenfield SP, Hoberman A, Keren R, Mathews R, et al. Renal scarring in the Randomized Intervention for Children with Vesicoureteral Reflux (RIVUR) trial. Clin J Am Soc Nephrol. 2015;11:54.

15.Mattoo TK, Chesney RW, Greenfield SP, et al. Renal scarring in the Randomized Intervention for Children with Vesicoureteral Reflux (RIVUR) trial. Clin J Am Soc Nephrol. 2016;11:54.

16.Metcalfe CB, Macneily AE, Afshar K. Reliability

assessment of international grading system for vesicoureteral reflux. J Urol. 2012;188:1490.

17. Nagler EV, Williams G, Hodson EM, Craig JC. Interventions for primary vesicoureteric reflux. Cochrane Database Syst Rev. 2011;(6):CD001532.

18.Nelson CP, Johnson EK, Logvinenko T, Chow JS. Ultrasound as a screening test for genitourinary anomalies in children with UTI. Pediatrics. 2014; 133:e394.

19.Nelson CP, Johnson EK, Logvinenko T, Chow JS. Ultrasound as a screening test for genitourinary anomalies in children with UTI. Pediatrics. 2014; 133(3):e394–403.

20. Peters CA, Skoog SJ, Arant Jr BS, et al. Summary of the AUA guideline on management of primary vesicoureteral reflux in children. J Urol. 2010;184:1134.

21. RIVUR Trial Investigators, Hoberman A, Greenfield SP, et al. Antimicrobial prophylaxis for children with vesicoureteral reflux. N Engl J Med. 2014;370: 370–2367.

22. Shaikh N, Ewing AL, Bhatnagar S, Hoberman A. Risk of renal scarring in children with a first urinary tract infection: a systematic review. Pediatrics. 2010; 126:1084.

23. Sjöström S, Sillén U, Jodal U, et al. Predictive factors for resolution of congenital high grade vesicoureteral reflux in infants: results of univariate and multivariate analyses. J Urol. 2010;183:1177.

24. Smellie JM, Prescod NP, Shaw PJ, et al. Childhood reflux and urinary infection: a follow-up of 10–41 years in 226 adults. Pediatr Nephrol. 1998;12(9):727–36.

25. Tekgül S, Riedmiller H, Hoebeke P, et al. EAU guidelines on vesicoureteral reflux in children. Eur Urol. 2012;62:534.

26.Weiss R, Duckett J, Spitzer A. Results of a randomized clinical trial of medical versus surgical management of infants and children with grades III and IV primary vesicoureteral reflux (United States). The International Reflux Study in Children. J Urol. 1992;148(5 Pt 2):1667–73.