白袍恐懼症

Vesicoureteral reflux (VUR)

1.      Epidemiology: 1% of newborns; 30~45% in children with UTI

2.      Classification:

Primary VUR: inadequate closure of UVJ, shortening of intravesical ureter

Secondary VUR: posterior urethral valves, neurogenic bladder

3.      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

Severity of reflux is classified as follows:

Mild     — Grades I and II (no dilation, 藥物治療)

Moderate — Grade III (mild dilation)

Severe   — Grades IV and V(grossly dilation)

4.      Surgery indications

-breakthrough UTI (fever despite medication)

 -progressive renal function impairment

 -association with other congenital anomalies

 -grade V reflux with scarring in children > 1 year

 -grade V reflux in children > 6 years

 -grade IV reflux with either bilateral reflux or renal scarring in children > 6 years

 -children who fail medical therapy

5.      Treatment

Open surgical reimplantation (correction rates: 95~99%)

 -intravesical approach(bilateral): open bladder, tunneling ureteral segment through detrusor, creating submucosal tunnel

 -extravesical approach(unilateral): without opening bladder,延長ureter 進入submucosa, 易切到nerve造成urinary retention

Endoscopic correction

 -subureteric transurethral injection of dextranomer/hyaluronic acid (Dx/HA)

  copolymer (Deflux)

ps. Deflux的成分為dextranomer+hyaluronic acid(玻尿酸)