Matt Kulzer, MSIV 12/4/2008

The Case

 2 wk old infant born at term via CS 2/2 maternal hypertension/GDM  On prenatal ultrasound a “renal abnormality” was noted  No other complications with pregnancy/delivery

Findings – Renal ultrasound

 Normal right kidney without dilation  Left kidney with complete duplex system (small upper pole with dilated ureter)  Upper pole with ureterocele at the bladder base  Mild fullness of lower pole collecting system

Findings - VCUG

 Left sided grade 4/5 VUR  Right sided grade 2 VUR  Normal bladder/urethra

Duplicated collecting system

 Key points:  Weigert-Meyer rule: 85% of the time, an ectopic upper pole ureter will insert inferior and medial to the lower pole ureter; upper pole ureter will frequently obstruct  Drooping lily sign – seen on VCUG or IVP   Obstructed upper pole pelvis becomes hydronephrotic and compresses lower pole pelvis, pushing it down Makes lower pole pelvis resemble a drooping flower

Vesicoureteral Reflux (VUR)

  What is it?

  Retrograde passage of urine from the bladder into the upper urinary tract Most common urologic abnormality affecting 1% of newborns and 30-45% of young children with a UTI So What?

  Popular thinking is that VUR predisposes patients to pyelonephritis which may lead to renal scarring and eventually to HTN, ESRD, etc.

However, this popularly held belief is coming into question (outcomes related more to the degree of reflux rather than number of infections)

    

VUR Grading

Grade I — Reflux only fills the ureter without dilation.

Grade II — Reflux fills the ureter and the collecting system without dilation.

Grade III — Reflux fills and mildly dilates the ureter and the collecting system with mild blunting of the calyces.

Grade IV — Reflux fills and grossly dilates the ureter and the collecting system with blunting of the calyces. Some tortuosity of the ureter is also present.

Grade V — Massive reflux grossly dilates the collecting system. All the calyces are blunted with a loss of papillary impression and intrarenal reflux may be present . There is significant ureteral dilation and tortuosity.

Management

 Medical  Daily prophylactic Abx (TMP-SMX, TMP alone, nitrofurantoin, amoxicillin or cephalosporins if under 2 mos of age)  Dose ½ to ¼ the usual therapeutic dose to treat  Surgical  Open vs. endoscopic reimplantation of the ureter  Similar outcomes for both  With age, intravesicular ureter will lengthen and may improve reflux

Prognosis

 Prenatal Dx – J Pediatr 2006 Feb;148(2):222-227  43 pts followed prospectively for 2 years with VCUG before 6 mos, after 1 yr of age, and if VUR persisted after 2 yrs of age:   VUR resolved in 91% with grade I-III VUR resolved in 2/11 with grade IV-V  Postnatal Dx – J Urol 1997 May;157(5):1846-1851  Review of 26 studies (1987 pts)   Resolution dependent on severity of VUR, unilat vs. bilat Grade V rarely resolved