Vesicoureteral Reflux - Campbell-Walsh Urology, 11th Edition

Campbell-Walsh Urology, 11th Edition

PART XV

Pediatric Urology

SECTION D

Lower Urinary Tract Conditions

137 Vesicoureteral Reflux

Antoine E. Khoury; Darius J. Bägli

Questions

The estimated prevalence of vesicoureteral reflux in children with a urinary tract infection (UTI) is:
1%.
3%.
5%.
10%.
30%.
Which of the following statements regarding reflux is FALSE?
Antenatally detected reflux is associated with a male preponderance.
Antenatally detected reflux is usually low grade in boys when compared with that in girls.
Antenatally detected reflux is usually bilateral in boys when compared with that in girls.
When reflux is detected antenatally, renal impairment is frequently present at birth and is likely due to congenital dysplasia.
The majority of reflux detected later in life occurs in females.
Which of the following statements regarding vesicoureteral reflux in regard to patient’s race is TRUE?
The incidence of vesicoureteral reflux is equal in children of all races.
The disparity in the incidence of vesicoureteral reflux with respect to race becomes clearer in adulthood.
The frequency of detected vesicoureteral reflux is lower in female children of African descent.
African infants and white infants have a similar incidence of reflux, diagnosed on the basis of antenatal hydronephrosis.
There is a clear understanding regarding the predisposition of reflux, because many of the studies have included patients from different countries around the world.
Which of the following statements is FALSE in regard to the diagnosis and treatment of sibling vesicoureteral reflux?
On the basis of clinical judgment and the presence or absence of urinary tract infection (UTI), the patient’s age should be taken into account in regard to the decision to proceed with diagnostic intervention to diagnose sibling reflux.
It is reasonable to prescribe antibiotic prophylaxis while the decision to diagnose sibling reflux or not takes place.
Once sibling reflux is diagnosed, the indications for correction are different from the indications for treating reflux in the general pediatric population diagnosed after UTI.
Siblings who are younger than 5 years with normal imaging studies of the kidneys can be managed on the basis of clinical judgment, and it is not absolutely necessary to obtain a voiding cystogram.
Siblings younger than 5 years who present with cortical renal defects have the most to lose by febrile UTIs in the presence of vesicoureteral reflux.
Primary reflux is a congenital anomaly of the ureterovesical junction with which of the following characteristics? A deficiency of the:
longitudinal muscle of the extravesical ureter results in an inadequate valvular mechanism.
longitudinal muscle of the intravesical ureter results in an inadequate valvular mechanism.
circumferential muscle of the extravesical ureter results in an inadequate valvular mechanism.
circumferential muscle of the intravesical ureter results in an inadequate valvular mechanism.
longitudinal and circumferential muscles of the intravesical ureter results in an inadequate valvular mechanism.
What is the ratio of tunnel length to ureteral diameter found in normal children without reflux?
5:1
4:1
3:1
2:1
1:1
Which of the following statements is TRUE regarding children with non-neurogenic neurogenic bladders?
Constriction of the urinary sphincter occurs during voiding in a voluntary form of detrusor-sphincter dyssynergia.
Gradual bladder decompensation and myogenic failure result from incomplete emptying.
Gradual bladder decompensation and myogenic failure result from increasing amounts of residual urine.
All of the above.
None of the above.
Which of the following statements is TRUE in regard to secondary vesicoureteral reflux?
The most common cause of anatomic bladder obstruction in the pediatric population is posterior urethral valves, and vesicoureteral reflux is present in a great majority of these children.
Anatomic obstruction of the bladder is a common cause of secondary vesicoureteral reflux in female patients.
Patients with neurofunctional etiology for secondary vesicoureteral reflux benefit from immediate surgical intervention to try to correct vesicoureteral reflux.
A sacral dimple or hairy patch on the lower back is not a significant finding in regard to evaluation and treatment of vesicoureteral reflux.
The most common structural obstruction in male and female patients is the presence of a ureterocele at the bladder neck.
The complex anatomic relationships required of the ureterovesical junction may be gradually damaged by:
decreases in bladder wall compliance.
detrusor decompensation.
incomplete emptying.
all of the above.
none of the above.
What does the initial management of functional causes of reflux involve?
Surgical treatment
Medical treatment
Observation only
All of the above
None of the above
Signs or symptoms of bladder dysfunction include:
dribbling.
urgency.
incontinence.
“curtsying” behavior in girls.
all of the above.
Treatment of bladder dysfunction and detrusor overactivity, regardless of its severity or cause, is directed at:
damping overactive detrusor contractions.
dilating the urethral sphincter.
lowering intravesical pressures.
all of the above.
a and c only.
There is a strong association between the presence of reflux in patients with neuropathic bladders and intravesical pressures of greater than:
10 cm H₂O.
20 cm H₂O.
40 cm H₂O.
60 cm H₂O.
80 cm H₂O.
Bladder infections and their accompanying inflammation can also cause reflux by:
lessening compliance.
elevating intravesical pressures.
distorting and weakening the ureterovesical junction.
all of the above.
none of the above.
Which system provides the current standard for grading reflux on the basis of the appearance of contrast in the ureter and upper collecting system during voiding cystourethrography?
The Heikel and Parkkulainen System
The International Classification system
The Dwoskin and Perlmutter system
The National Classification System
The Dwoskin and Parkkulainen system
Which of the following is TRUE regarding accurately grading reflux with coexistent ipsilateral ureteropelvic junction (UPJ) obstruction?
It is not possible.
It is facilitated by obtaining a renal scan.
It is facilitated by obtaining an ultrasonographic scan.
It is facilitated by obtaining a computed tomographic (CT) urogram.
It is facilitated by obtaining a radionuclide cystogram.
Which of the following is TRUE regarding the presence of fever?
It may be an indicator of upper urinary tract involvement.
It may not always be a reliable sign of upper urinary tract involvement.
It increases the likelihood of discovering vesicoureteral reflux.
All of the above.
None of the above.
Complete evaluation including a voiding cystourethrogram (VCUG) and ultrasound are required for which of the following patients?
An uncircumcised male infant with a febrile illness and a positive urine culture obtained through a bagged specimen
A 3-year-old girl admitted to the hospital with pneumonia and found to have Escherichia colion a urine culture without pyuria detected by microscopic analysis
A female patient with recurrent culture and urinalysis proven to have afebrile UTIs and later found to have scarring on a dimercaptosuccinic acid (DMSA) scan
Any child older than 5 years with documented UTIs
None of the above
Which of the following statements is TRUE regarding screening of older children who present with asymptomatic bacteriuria. They can be screened initially with:
ultrasonography.
cystography.
CT urogram.
renal scan.
nothing because they do not require any screening studies.
Which of the following is TRUE regarding cystography?
Cystography performed with a Foley catheter or while the patient is under anesthesia produces static studies that inaccurately screen for reflux or sometimes exaggerate its degree because of bladder overfilling.
Cystography performed in the presence of excessive hydration may mask low grades of reflux because diuresis can blunt the retrograde flow of urine.
Cystograms may show reflux only during active infections when cystitis weakens the ureterovesical junction with edema or by increasing intravesical pressures.
Cystograms obtained during active infections can overestimate the grade of reflux because the endotoxins produced by some gram-negative organisms can paralyze ureteral smooth muscle and exaggerate ureteral dilatation.
All of the above.
Which of the following statements is TRUE regarding radionuclide cystography?
It provides similar anatomic detail to that obtained with fluoroscopic cystography.
It is an accurate method for detecting and following reflux.
It is associated with more radiation exposure than is fluoroscopic cystography.
It is a less sensitive test than fluoroscopic cystography.
It provides more anatomic detail than fluoroscopic cystography.
Which of the following statements is TRUE regarding ultrasonography?
It is the diagnostic study of choice to initially evaluate the upper urinary tracts of patients with suspected or proven vesicoureteral reflux.
It can effectively rule out reflux.
It should be performed every 2 to 3 years in patients with reflux who are medically managed.
It is the study of choice for assessing renal function.
An ultrasonogram showing intermittent dilatation of the renal pelvis or ureter confirms the presence of reflux.
What is the best study for the detection of pyelonephritis and cortical renal scarring?
Diethylenetriaminepentaacetic acid (DTPA) renal scan
DMSA renal scan
Mercaptoacetyltriglycine (MAG3) renal scan
CT urogram
Renal ultrasonographic scan
Which of the following is TRUE regarding urodynamic studies?
They may be indicated in any child suspected of having a secondary cause for reflux (valves, neurogenic bladder, non-neurogenic neurogenic bladder, voiding dysfunction).
They should be performed without the use of prophylactic antibiotics in children with secondary reflux.
They help direct therapy in patients with secondary reflux.
All of the above.
Only a and c are true.
Which of the following is TRUE in regard to the evaluation of vesicoureteral reflux?
Routine cystoscopy is indicated in the workup of patients with vesicoureteral reflux.
The radiation doses with modern digital techniques have improved the anatomic detail, but the radiation dose with VCUG remains significantly higher than that of a radionuclide cystogram.
Grading of reflux by VCUG and radionuclide cystogram is similar and comparable between the two imaging modalities.
Ultrasonography provides an alternative means to evaluate the presence or absence of vesicoureteral reflux.
Uroflowmetry is a valuable tool in the workup of a patient with vesicoureteral reflux.
Which of the following accurately describes what happens during ureteral development? A ureteral bud that:
is medially (caudally) positioned from a normal takeoff at the trigone offers an embryologic explanation for primary reflux.
is laterally (cranially) positioned from a normal takeoff at the trigone offers an embryologic explanation for primary reflux.
fails to meet with the renal blastema offers an embryologic explanation for primary reflux.
is laterally (cranially) positioned is often obstructed.
fails to meet with the renal blastema is often obstructed.
In regard to the diagnosis of renal scars based on renal scintigraphy, which of the following is TRUE?
An area of photopenia detected during an acute episode of pyelonephritis always represents renal scar.
Photopenic areas may result from postinfection renal scarring and some renal dysplasia.
Ultrasound is a sensitive and accurate diagnostic modality for renal scarring.
Areas for photopenia detected during an acute episode of pyelonephritis that later resolve on a subsequent renal scan represent resolution of renal scarring.
All of the above.
Which of the following is TRUE regarding hypertension?
In children and young adults, it is most commonly caused by reflux nephropathy.
It is not related to the grade of reflux or severity of scarring.
It is not associated with abnormalities of Na⁺,K⁺-ATPase activity.
All of the above.
None of the above.
Which of the following factors might contribute to the effects of reflux on renal growth?
The congenital dysmorphism often associated with, but not caused by, reflux?
The number and type of urinary infections and their resultant nephropathy
The quality of the contralateral kidney and its implications for compensatory hypertrophy
The grade of reflux in the affected kidney
All of the above
Which of the following statements is FALSE in regard to bladder and bowel dysfunction (BBD) and vesicoureteral reflux (VUR)?
BBD lowers VUR resolution rates.
BBD is associated with higher recurrence rates of VUR after successful endoscopic correction.
BBD reduces the success rate of endoscopic implantation of dextranomer/hyaluronic copolymer (Dx/HA) and open surgical correction of VUR.
BBD is associated with higher breakthrough infection rates.
BBD is associated with increased incidence of UTI after surgery.
The anatomy of patients with ureteral duplication typically follows the Weigert-Meyer rule, in which the upper pole ureter enters the bladder:
distally and medially, and the lower pole ureter enters the bladder proximally and laterally.
proximally and medially, and the lower pole ureter enters the bladder distally and laterally.
distally and laterally, and the lower pole ureter enters the bladder proximally and medially.
proximally and laterally, and the lower pole ureter enters the bladder distally and medially.
superior to the lower pole ureter.
Which of the following is not found to be associated with higher success rate of endoscopic correction of VUR?
Volume of Dx/HA used
Surgeon experience
Volcano-shaped mound with no hydrodistention
Negative intraoperative cystogram
Utilization of the double hydrodistention-implantation technique
Which of the following accurately describes the state of the bladder during pregnancy?
Urine volume decreases in the upper collecting system while the physiologic dilatation of pregnancy evolves.
Bladder tone increases because of edema and hyperemia.
Bladder changes predispose the patient to bacteriuria.
All of the above.
None of the above.
During pregnancy, the presence of vesicoureteral reflux in a system already prone to bacteriuria may lead to increased morbidity. What is an additional risk factor?
Renal scarring
Tendency toward urinary infections
Hypertension
Renal insufficiency
All of the above
Which of the following statements is considered to be FALSE regarding reflux management?
Spontaneous resolution of vesicoureteral reflux is common.
Higher grades of vesicoureteral reflux are less likely to resolve than lower grades.
Reflux of sterile urine is a benign process that does not lead to significant renal damage.
The 2014 New England Journal of MedicineRandomized Intervention for Children with Vesicoureteral Reflux (RIVUR) study reported a 0.5% incidence of adverse reaction to prophylactic antibiotics and a 2% incidence of adverse reaction to the placebo.
All of the above.
Regarding surgical correction of vesicoureteral reflux, which of the following is currently accepted?
Extravesical ureteral reimplantation
Intravesical ureteral reimplantation
Endoscopic injection of bulking agent
All of the above
None of the above
Common to each type of open surgical repair for reflux is the creation of:
a valvular mechanism that enables ureteral compression with bladder filling and contraction.
a mucosal tunnel for reimplantation having adequate muscular backing.
a tunnel length of three times the ureteral diameter.
all of the above.
none of the above.
Complete ureteral duplications with reflux can be best managed surgically by:
separating the ureters and reimplanting them separately.
a common sheath repair in which both ureters are mobilized with one mucosal cuff.
performing an upper to lower ureteroureterostomy and reimplanting the lower ureter.
performing a lower to upper ureteroureterostomy and reimplanting the upper ureter.
none of the above.
Early postoperative obstruction can occur after a ureteral reimplant due to:
edema.
subtrigonal bleeding.
twist or angulation of the ureter.
blood clots.
all of the above.
If early postoperative obstruction occurs after a ureteral reimplant, the next step is:
immediate nephrostomy tube placement.
immediate placement of a ureteral stent.
initial observation and diversion for unabating symptoms.
placement of both a nephrostomy tube and a ureteral stent.
reoperation.
Which of the following is TRUE regarding persistent reflux after ureteral reimplantation?
It may be due to unrecognized secondary causes of reflux such as neuropathic bladder and severe voiding dysfunction.
It seldom results from a failure to provide adequate muscular backing for the ureter within its tunnel.
It may be repaired surgically by using minor submucosal advancements.
All of the above.
None of the above.
Which of the following is TRUE regarding the treatment of vesicoureteral reflux?
Since the widespread acceptance of endoscopic treatment, the indications for surgical correction differ between the open endoscopic and laparoscopic approaches.
Long-term follow-up data support the durability of endoscopic injection therapy.
All injection materials provide a similar success rate and are just as easily injected under similar circumstances.
The accuracy of the needle entry point during endoscopic injection, as well as the needle placement, are important components for the success of the surgical procedure.
The learning curve for endoscopic injection is similar to the learning curve for open surgical reimplantation.
Which of the following is TRUE regarding the laparoscopic approach for ureteral reimplantation?
The advantages of this approach versus open surgery include smaller incisions, less discomfort, and quicker convalescence.
As with other laparoscopic procedures, experience is essential to the success of this approach.
Costs may be increased because of lengthier surgery and the expense of disposable equipment.
All of the above.
None of the above.
After discontinuation of continuous antibiotic prophylaxis (CAP) in toilet-trained children: who is likely to develop recurrent UTI?
Patients with higher grades of VUR
Uncircumcised male children
Children with BBD
All of the above
a and c only
Which patients were more likely to have febrile or symptomatic recurrences in the RIVUR Trial?
Children with grade III or IV reflux at baseline
Patients presenting with febrile index infection
The presence of BBD at baseline
All of the above
a and c only
The 2011 American Academy of Pediatrics guidelines for management of the initial UTI in febrile infants and children age 2 to 24 months recommend obtaining:
A renal and bladder ultrasound and a VCUG during the febrile episode
A renal and bladder ultrasound and a VCUG 3 weeks after the febrile episode has resolved
A DMSA renal scan and, if positive, a VCUG
A renal and bladder ultrasound after confirmation of UTI by a properly collected urine specimen for culture and analysis
Wait for the second infection before performing any radiological testing

Answers

e. 30%.A meta-analysis of studies of children undergoing cystography for various indications has indicated that the prevalence of vesicoureteral reflux is estimated to be 30% for children with UTIs and approximately 17% in children without infection.
b. Antenatally detected reflux is usually low grade in boys when compared with that in girls.The reflux is usually high grade and bilateral in boys when compared with reflux in girls.
c. The frequency of detected vesicoureteral reflux is lower in female children of African descent. One of the clear differences that has been established with several studies is the relative tenfold lower frequency of vesicoureteral reflux in female children of African descent.
c. Once sibling reflux is diagnosed, the indications for correction are different from the indications for treating reflux in the general pediatric population diagnosed after UTI.By taking into account the imaging of the kidneys first, as well as the patient’s age and history of UTI, a rational top-down approach to sibling reflux screening emerges. In any sibling, however, in whom reflux is diagnosed, the indications for treatment remain the same as for general reflux in the pediatric population.
b. Longitudinal muscle of the intravesical ureter results in an inadequate valvular mechanism.Primary reflux is a congenital anomaly of the ureterovesical junction in which a deficiency of the longitudinal muscle of the intravesical ureter results in an inadequate valvular mechanism.
a. 5:1. In Paquin’s novel study, a 5:1 tunnel length–ureteral diameter ratio was found in normal children without reflux.
d. All of the above.On the far end of this spectrum are children with non-neurogenic neurogenic bladders. Here, constriction of the urinary sphincter occurs during voiding in a voluntary form of detrusor-sphincter dyssynergia. Gradual bladder decompensation and myogenic failure result from incomplete emptying and increasing amounts of residual urine.
a. The most common cause of anatomic bladder obstruction in the pediatric population is posterior urethral valves, and vesicoureteral reflux is present in a great majority of these children.This diagnosis is obviously limited to male patients; consequently, female patients have a lower incidence of anatomic bladder obstruction. The most common structural obstruction in female patients is the presence of a ureterocele that prolapses and obstructs the bladder neck. Between 48% and 70% of patients with posterior urethral valves have vesicoureteral reflux, and relief of obstruction appears to be responsible for resolution of the reflux in a good number of those patients. The presence of a neurologic disorder should prompt the clinician to treat based on the primary etiology as opposed to proceeding with immediate surgical correction. One important aspect of the physical examination in children who present with vesicoureteral reflux is detection of potential occult spinal dysraphism, and this includes a thorough physical examination looking for sacral dimples, hairy patches, or gluteal cleft abnormalities.
d. All of the above.Decreases in bladder wall compliance, detrusor decompensation, and incomplete emptying gradually damage the complex anatomic relationships required of the ureterovesical junction.
b. Medical treatment.The initial management of functional causes of reflux is medical. It is imperative that clinicians inquire about, and determine, the voiding patterns of children with reflux.
e. All of the above.In addition to a careful physical examination, signs or symptoms of bladder dysfunction include dribbling, urgency, and incontinence. Girls often exhibit curtsying behavior, and boys will squeeze the penis in an attempt to suppress bladder contractions.
e. a and c only.Treatment of bladder dysfunction and detrusor overactivity, regardless of its severity or cause, is directed at dampening overactive detrusor contractions and lowering intravesical pressures.
c. 40 cm H₂O.There is a strong association between intravesical pressures of greater than 40 cm H₂O and the presence of reflux in patients with myelodysplasia and neuropathic bladders.
d. All of the above. Bladder infections (UTIs) and their accompanying inflammation can also cause reflux by lessening compliance, elevating intravesical pressures, and distorting and weakening the ureterovesical junction.
b. The International Classification System.The Heikel and Parkkulainen system gained popularity in Europe a few years before the Dwoskin and Perlmutter system became widely accepted in the United States. The International Classification System, devised in 1981 by the International Reflux Study, represents a melding of the two. It provides the current standard for grading reflux on the basis of the appearance of contrast in the ureter and upper collecting system during voiding cystourethrography.
a. It is not possible.Accurately grading reflux is impossible with coexistent ipsilateral obstruction.
d. All of the above.The presence of fever may be an indicator of upper urinary tract involvement but is not always a reliable sign. However, if fever (and presumably pyelonephritis) is present, the likelihood of discovering vesicoureteral reflux is significantly increased.
c. A female patient with recurrent culture and urinalysis proven to have afebrile UTIs and later found to have scarring on a dimercaptosuccinic acid (DMSA) scan.The presence of culture-proven UTIs in the setting of an abnormal renal scan should raise the question of vesicoureteral reflux, and it is reasonable to proceed with a VCUG and ultrasound in those patients. The other clinical scenarios include a patient without pyuria and a clear alternative source for her fever, as well as an infant diagnosed with UTI with a specimen obtained through a bagged collection. In those children the diagnosis of UTI should be questioned before proceeding with evaluation through cystogram and renal ultrasonography. Patients older than 5 years should not undergo immediate VCUG just on the basis of the presence of a UTI.
a. Ultrasonography.Older children who present with asymptomatic bacteriuria or UTIs that manifest solely with lower tract symptoms can be screened initially with ultrasonography alone, reserving cystography for those with abnormal upper tracts or recalcitrant infections.
e. All of the above.Excessive hydration may mask low grades of reflux because diuresis can blunt the retrograde flow of urine. Some reflux is demonstrated only during active infections when cystitis weakens the ureterovesical junction with edema or by increasing intravesical pressures. In addition, cystograms obtained during active infections can overestimate the grade of reflux because the endotoxins produced by some gram-negative organisms can paralyze ureteral smooth muscle and exaggerate ureteral dilatation.
b. It is an accurate method for detecting and following reflux.Nuclear cystography is the scintigraphic equivalent of conventional cystography. Although the technique does not provide the anatomic detail of fluoroscopic studies, it is an accurate method for detecting and following reflux.
a. It is the diagnostic study of choice to initially evaluate the upper urinary tracts of patients with suspected or proven vesicoureteral reflux.Ultrasonography is the diagnostic study of choice to initially evaluate the upper urinary tracts of patients with suspected or proven vesicoureteral reflux. However, the appearance of the kidneys on ultrasound does not correlate with the absence or presence of reflux, or with its grade.
b. DMSA renal scan.Renal scintigraphy with technetium-99 m–labeled DMSA is the best study for detection of pyelonephritis and the cortical renal scarring that sometimes results.
e. Only a and c are true.Urodynamic studies may be indicated in any child suspected of having a secondary cause for reflux (e.g., valves, neurogenic bladder, non-neurogenic neurogenic bladder, voiding dysfunction), and they help direct therapy.
e. Uroflowmetry is a valuable tool in the workup of a patient with vesicoureteral reflux.Evaluation of the lower urinary tract cannot solely rely on imaging studies because reflux is considered to be a dynamic phenomenon. Uroflowmetry provides valuable information in the clinical assessment of these patients. Modern management of reflux does not include the routine evaluation through cystoscopy.The radionuclide cystogram has historically been described as a technique that requires a significantly lower dose of radiation than a regular VCUG, but the advances with modern digital techniques have significantly narrowed the difference between these two imaging modalities. Unfortunately, ultrasound cannot reliably detect the presence or absence of vesicoureteral reflux.
b. Is laterally (cranially) positioned from a normal takeoff at the trigone offers an embryologic explanation for primary reflux.As Mackie and Stevens have suggested, a ureteral bud that is laterally (cranially) positioned from a normal takeoff at the trigone offers an embryologic explanation for primary reflux, whereas those inferiorly (caudally) positioned are often obstructed.
b. Photopenic areas may result from postinfection renal scarring and some renal dysplasia. Vesicoureteral reflux, particularly reflux of higher grades, may result in renal dysplasia, which often appears scintigraphically identical to postinfection pyelonephritic scars.During an episode of active pyelonephritis, the renal scan may show an area of photopenia that later, if it persists, represents renal scarring secondary to the infection. Neither renal scan nor ultrasonography can differentiate accurately between renal dysplasia and renal scarring.
a. In children and young adults it is most commonly caused by reflux nephropathy. Reflux nephropathy is the most common cause of severe hypertension in children and young adults, although the actual incidence is unknown.
e. All of the above.Factors that might contribute to the effects of reflux on renal growth include the congenital dysmorphism often associated with (30% of cases), but not caused by, reflux; the number and type of urinary infections and their resultant nephropathy; the quality of the contralateral kidney and its implications for compensatory hypertrophy; and the grade of reflux in the affected kidney.
c. BBD reduces the success rate of endoscopic implantation of dextranomer/hyaluronic copolymer (Dx/HA) and open surgical correction of VUR.However, BBD is associated with increased incidence of UTI after surgery.
a. Distally and medially, and the lower pole ureter enters the bladder proximally and laterally.The anatomy of patients with ureteral duplication typically follows the Weigert-Meyer rule wherein the upper pole ureter enters the bladder distally and medially and the lower pole ureter enters the bladder proximally and laterally.

32 d. Negative intraoperative cystogram.

c. Bladder changes predispose the patient to bacteriuria.Bladder tone decreases because of edema and hyperemia, which are changes that predispose the patient to bacteriuria. In addition, urine volume increases in the upper collecting system as the physiologic dilatation of pregnancy evolves.
e. All of the above.It seems logical to assume that during pregnancy, the presence of vesicoureteral reflux in a system already prone to bacteriuria would lead to increased morbidity. Maternal history also becomes a factor if past reflux, renal scarring, and a tendency to get urinary infections are included. Women with hypertension and an element of renal failure are particularly at risk.
d. The 2014 New England Journal of MedicineRIVUR study reported a 0.5% incidence of adverse reaction to prophylactic antibiotics and a 2% incidence of adverse reaction to the placebo. Adverse reactions to antibiotics were reported in 2% of both the antibiotic prophylaxis and placebo groups.
d. All of the above.Extravesical and intravesical ureteral reimplantation are all options for treatment of vesicoureteral reflux. In the past decade there has been widespread enthusiasm for endoscopic treatment, and different bulking agents have been used to correct vesicoureteral reflux by using minimally invasive techniques.
a. A valvular mechanism that enables ureteral compression with bladder filling and contraction.Common to each technique is the creation of a valvular mechanism that enables ureteral compression with bladder filling and contraction, thus reenacting normal anatomy and function. A successful ureteroneocystostomy provides a submucosal tunnel for reimplantation having sufficient length and adequate muscular backing. A tunnel length of five times the ureteral diameter is cited as necessary for eliminating reflux.
b. A common sheath repair in which both ureters are mobilized with one mucosal cuff.Approximately 10% of children undergoing antireflux surgery have an element of ureteral duplication. The most common configuration is a complete duplication that results in two separate orifices. This is best managed by preserving a cuff of bladder mucosa that encompasses both orifices. Because the pair typically share blood supply along their adjoining wall, mobilization as one unit with a “common sheath” preserves vascularity and minimizes trauma.
e. All of the above.Early after surgery, various degrees of obstruction can be expected of the reimplanted ureter. Edema, subtrigonal bleeding, and bladder spasms all possibly contribute. Mucus plugs and blood clots are other causes. Most postoperative obstructions are mild and asymptomatic and resolve spontaneously. More significant obstructions are usually symptomatic. Affected children typically present 1 to 2 weeks after surgery with acute abdominal pain, nausea, and vomiting.
c. Initial observation and diversion for unabating symptoms.The large majority of perioperative obstructions subside spontaneously, but placement of a nephrostomy tube or ureteral stent sometimes becomes necessary for unabating symptoms.
a. It may be due to unrecognized secondary causes of reflux such as neuropathic bladder and severe voiding dysfunction. Other than technical errors, failure to identify and treat secondary causes of reflux is a common cause of the reappearance of reflux. Foremost among these secondary causes are unrecognized neuropathic bladder and severe voiding dysfunction.
d. The accuracy of the needle entry point during endoscopic injection, as well as the needle placement, are important components for the success of the surgical procedure.The learning curve for endoscopic injection is believed to be different from that of open surgical reimplantation, but studies have not been carried out comparing these two surgical approaches for correction of vesicoureteral reflux. Treatment is currently based on the same indications, and these indications do not differ between the different types of intervention.
d. All of the above.The advantages of this approach versus open surgery include smaller incisions, less discomfort, brief hospitalizations (although many centers now perform open reimplants on an outpatient basis), and quicker convalescence. As with other laparoscopic procedures, a learning curve needs to be climbed and experience is essential to the success of this approach. Laparoscopic reimplantation requires a team with at least two surgeons; the repair is converted from an extraperitoneal to an intraperitoneal approach; operative time is longer than with open techniques (although with experience it is now becoming gradually shorter); and cost is increased because of lengthier surgery and the expense of disposable equipment.
e. a and c only.Uncircumcised male children older than 1 year do not appear to be at higher risk for development of recurrent UTI after discontinuation of CAP.
d. All of the above.Children with grade III or IV reflux at baseline, patients presenting with febrile index infection and the presence of BBD at baseline were considered event modifiers in the RIVUR trial and appear to benefit from CAP.
d. A renal and bladder ultrasound after confirmation of UTI by a properly collected urine specimen for culture and analysis.A VCUG is recommended only if the renal and bladder ultrasound is abnormal or if the child develops a second infection.

Chapter review

In patients with reflux, approximately one third of their siblings will have reflux.
Reflux that is inherited is thought to be due to an autosomal dominant pattern.
There is a frequent association of constipation and encopresis with reflux and UTIs.
If both the ureteropelvic junction (UPJ) and ureterovesical junction (UVJ) require operative repair, the UPJ should be repaired first.
There is an association of renal maldevelopment with high grades of reflux.
The cardinal renal anomalies associated with reflux are multicystic dysplastic kidney and renal agenesis.
Women with UTIs and reflux who have undergone a reimplantation will still be at significant risk for UTIs during pregnancy and should be monitored.
Almost 80% of low-grade and half of grade III reflux will resolve spontaneously.
Sterile reflux is benign.
Cohen’s cross-trigonal technique of ureteral reimplantation is particularly well suited for small bladders and thick-walled bladders.
There is a 10% to 15% incidence of contralateral reflux after unilateral reflux is repaired.
Prophylactic bilateral reimplantation for unilateral reflux is not indicated.
Reflux is unlikely to be of any clinical significance in the absence of infection in a patient with normal bladder function.
The greatest risk for postinfection renal scarring is in the first year of life.
Reflux associated with a paraureteral diverticulum resolves at a similar rate to primary reflux.
There is a tenfold lower frequency of vesicoureteral reflux in female children of African descent.
The endoscopic repair of reflux is less invasive and less durable than the open surgical repair.
A 5:1 tunnel length–ureteral diameter ratio should be achieved in antireflux surgery for best results.
Bladder infections (UTIs) and their accompanying inflammation can also cause reflux by lessening compliance, elevating intravesical pressures, and distorting and weakening the ureterovesical junction.
Modern management of reflux does not include routine evaluation through cystoscopy.
Vesicoureteral reflux, particularly reflux of higher grades, may be associated with renal dysplasia, which often appears scintigraphically identical to postinfection pyelonephritic scars.
Reflux nephropathy is the most common cause of severe hypertension in children and young adults.
In a duplex system where one ureter refluxes and surgical reconstruction is indicated, both ureters should have a common sheath reimplantation because the paired ureters typically share blood supply along their adjoining wall, and mobilization as one unit with a “common sheath” preserves vascularity and minimizes trauma.
Failure to identify and treat secondary causes of reflux is a common cause of the reappearance of reflux following correction. Foremost among these secondary causes are unrecognized neuropathic bladder and severe voiding dysfunction.

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