Vesicoureteric reflux is defined as a permanent or intermittent intrusion of bladder urine into the upper urinary tract due to a defective ureterovesical junction1. The incidence of VUR is approximately 1% in normal children.2 The defect in the ureterovesical junction may be a primary disorder or may arise secondary to bladder dysfunction or bladder outlet obstruction (PUV, spinal dysraphism, urogenital anomalies like cloaca, exstrophy-epispadias).1,3 The refluxing urine can fill the upper excretory system during micturition. The intrarenal reflux of infected urine can cause renal damage (reflux nephropathy).4 VCUG is a diagnostic investigation for VUR. USG, renal scan, cystoscopy and urodynamic study are necessary investigations to guide management for VUR.5 Management of VUR is based on the age of the patient, grade of VUR, breakthrough UTI, renal scarring, and deterioration of renal function. The primary VUR is managed with uroprophylaxis and closed follow-up.6 The secondary VUR is managed by treating bladder dysfunction and relieving bladder outlet obstruction. Surgical intervention is required in cases of failed medical management.6

Study Design and duration: This was a prospective study of Vesicoureteric reflux in children from October 2013 to July 2016. Study Participants: The VUR was diagnosed by VCUG. VCUG was performed in the patients who had antenatally detected hydronephrosis, congenital urinary tract abnormality, dilatation of the upper tract on ultrasound, male patients having ≥ 2 episodes of documented UTI and female patients with febrile UTI. Patients with congenital anomalies of ano-rectal malformation, spinal dysraphism and exstrophy- epispadias complex were also screened for VUR. Data collection: Age, gender, demographic data, grade of reflux, type of reflux (primary or secondary), correlation with urinary tract infection, incidence of renal scarring at diagnosis, type of management, surgical procedure, complications, and resolution of reflux were recorded. Detailed history of acute episodes, previous episodes of UTI, antenatal hydronephrosis, reflux in siblings, voiding dysfunction (dribbling, incontinence) and bowel dysfunction (constipation or encopresis) were noted. Management of VUR: An acute urinary tract infection episode was managed with medication and supportive care. Examination of the external genitalia, perineum, back, and spine was performed in all patients. USG KUB, VCUG, and DMSA scans were performed in all patients. Urodynamic studies, cystoscopy, and CT IVP were performed as and when required. Patients were managed based on patient age, grade of VUR, number of UTI episodes, and scarring or deterioration of renal function on DMSA scan. Regular timed complete voiding, perineal hygiene and constipation management were advised. Monthly follow-up with routine urine analysis and microscopy was performed for 3 months, then every 3 months thereafter. USG KUB was done every six months. VCUG and DMSA scans were repeated 1 year later. If reflux resolved, uroprophylaxis was continued for 3 months and then stopped. Uroprophylaxis was continued in all patients with persistent VUR. Management of secondary VUR was based on its aetiolog.

This was a prospective study of Vesicoureteral reflux conducted in children from the neonatal period to 12 years of age. It was done from October 2013 to August 2016. VCUG was performed in 855 patients to detect VUR for various indications. VUR was detected in 250 patients. VUR was diagnosed in 129 (51.6%) infants: 85 (34%) patients aged 1- 5 years and 36 (14.4%) patients aged more than 5 years. There were 110(44 %) male and 140(56 %) female patients. Grade I, II, III, IV, and V were found in 28 (11.2%), 89 (35.6%), 65 (26%), 43 (17.2%), and 25 (10%) patients, respectively. Unilateral reflux was found in 131 (52.5%) patients, while 119 (47.5%) had bilateral reflux. Renal scarring was seen in 65 (26%) at the time of diagnosis. Causes of VUR are explained in Table 1. VUR was present in 66.6% of patients with recurrent UTI. Initially, medical management was started in all patients for VUR. Of these, 5 (2%) patients were lost to follow-up. So, the remaining 245 patients were continued on medical management. Breakthrough UTI occurred in 43 patients (17.5%). Recurrent UTI and development of new renal scars were seen in 29(11.83%) patients, so they underwent ureteric reimplantation. Five patients with ectopic ureter underwent ureteric reimplantation after investigation at the proper age. Thus, 211 patients received medical management, while 34 received surgical management. Table 1: Causes of Vesicoureteric reflux (n=855) Causes Number of VCUG VUR Male Female Total Presenting with UTI(Primary) 180 44 (36.66%) 76 (63.33%) 120(66.6%) Antenatal Hydronephrosis (Primary) 35 6(60%) 4(40%) 10(28.5%) Anorectal Malformation (Secondary) 378 18 (33.33%) 36 (66.66%) 54(14.2%) Posterior urethral valve (Secondary) 30 16 (100%) - 16(53.3%) Exstrophy-epispadias complex (Secondary) 27 16 (61.53%) 10(38.46%) 26(96.2%) Neurogenic bladder (Secondary) 200 6 (31.57%) 13 (68.42%) 19(9.5%) Ectopic ureter (Secondary) 5 4(80%) 1(20%) 5(100%) Total 855 110 140 250 Figure 1 Vesicocystourethrography The techniques used for ureteric reimplantation were Cohen cross-trigonal in 16 (53.4 %), Leadbetter-Politano in 9 (30 %), Lich-Gregor in 1 (3.3 %), and Cephalo-trigonal in 4 (13.3 %) patients, respectively. Injection deflux was given in 4 patients. In the operative group of 34 patients, four patients had UTI at follow-up. Two of them had multiple episodes. VCUG showed persistent reflux, so redo-reimplantation was done. Figure 2: Ureteric reimplantation Haematuria, bladder spasm, breakthrough UTI, and persistent reflux were found in 10, 2, 4, and 2 patients, respectively, postoperatively in our study. Complete resolution of reflux was found in 76% (19/25), 27% (20/74), 18% (10/55), and 2.8% (1/37) of patients in grades I, II, III, and IV, respectively. None of the patients had resolution of reflux in grade V. They were all on medical management.

This was a prospective study of Vesicoureteral reflux conducted in children from the neonatal period to 12 years of age. It was done from October 2013 to August 2016. We have detected 250 (29.23%) cases of VUR in a VCUG study performed on 855 patients. Sargent et al.5 performed VCUG in 309 patients with UTI. VUR was detected in 91 (29%) patients. In our study, 129 patients (51.6%) had VUR detected less than 1 year. In the remaining half, 85 (34%) patients were 1 to 5 years old, and 36 (14.4%) were more than 5 years old. Sargent et al.5 study found 48 (36%) patients less than 2 years, 26 (32%) patients aged 2-5 years, and 17 (18%) patients aged more than 5 years. Mei-Ju Chen et al.7 reported results similar to ours, detecting VUR in 92 (53.2%) patients aged less than 1 year, 49 (28.3%) patients aged 1-5 years, and 32 (18.5%) patients aged more than 5 years. The natural history of reflux involves spontaneous resolution over time; thus, its prevalence is lower in older children. VUR was more common in male patients in the < 1-year age group due to routine screening for VUR in male anorectal anomalies in our study. In our study, there was a female preponderance of 110 (44%) compared to males of 140 (56%). Sargent et al.5 had 35 (30%) male and 56 (30%) female patients with VUR, while Meri Ju Chen et al.7 had 82 (47%) male and 91 (53%) female patients with VUR. Both studies include only primary VUR patients. Unilateral VUR was detected in 131 (52.5%) patients, while bilateral VUR was found in 119 (47.5%) patients in our study. Mei-Ju Chen et al.7 reported unilateral and bilateral VUR in 87 (50.28%) and 86 (49.71%) patients, respectively. There were 68 (44.73%) patients with unilateral VUR and 84 (55.26%) patients with bilateral VUR in the Hamid et al.8 We included primary and secondary VUR in our study, whereas most studies in the literature included only primary VUR. We found VUR in 120 patients with UTI, 10 with antenatal hydronephrosis, 54 with anorectal malformation, 16 with posterior urethral valve, 26 with exstrophy-epispadias complex, 19 with neurogenic bladder, and 5 with ectopic ureter. Kari et al.9 reported that primary vesicoureteral reflux (VUR) occurred in 20 patients (20.2%), whereas secondary VUR was identified in 79 patients (79.8%). Among those with secondary VUR, 37 patients (46.8%) presented with posterior urethral valves, 20 patients (25.3%) exhibited neurogenic bladder associated with meningomyelocele, 5 patients (6.3%) demonstrated neurogenic bladder secondary to prune-belly syndrome, and 17 patients (21.5%) were diagnosed with non-neurogenic neurogenic bladder. VUR was detected in 18% of patients with anorectal malformation in the Goossens et al.10 study, which was comparable to our study (14%). In the Sabrina et al.11 study, VUR was detected in 31% of patients with anorectal malformation, which was much higher than in our study. Almost half of patients with posterior urethral valve had VUR in our study (53%), which was comparable to Kari et al9 (47%) and Hassan JM et al.12 (48%) study. Incidence of VUR was reported in 12% (36/277) of patients with antenatal hydronephrosis in the Murat Kangin et al.13 We had 28.5% of patients with VUR in antenatally detected hydronephrosis. In neurogenic bladder patients due to congenital spinal dysraphism, VUR was detected in 31.04% (199/641) and 25.3% (20/99) of patients in the E. Merlini et al.14 and Kari et al.9 studies, respectively. VUR was detected in 9% (19/200) of patients with neurogenic bladder in our research. In 27 operated cases for bladder exstrophy and epispadiasis complex, 26 had reflux (96%). This was expected, given that reflux occurs in 100% of cases after exstrophy closure due to the abnormal course of the lower ureter and high vesical pressure. The one patient without reflux underwent ureteric reimplantation primarily during CPRE. Recently, we have started doing this to reduce the risk of UTI and upper tract deterioration. Its long-term role in preventing upper tract damage and outcomes needs to be evaluated. Grades I, II, III, IV, and V VUR were found in 28 (11.2%), 89 (35.6%), 65 (26%), 43 (17.2%), and 25 (10%) patients, respectively, in our study. The study by Sharifian M et al.15 detected grades I, II, III, IV, and V VUR in 18%, 37%, 26%, 11%, and 8% of patients, respectively. VUR with grades I, II, III and IV were detected in 3(1%), 29(14.5%), 29(14.5 %) and 2(1%) renal units in Hadi Sorkhi et al study.16 Complete resolution of reflux was observed in 76% (19/25), 27% (20/74), 18% (10/55), and 2.8% (1/37) of grade I, II, III, and IV patients, respectively, who were on medical management. None of the patients had resolution of reflux in the grade V category. Sharifian M et al.15 found 63%, 57%, 27%, 22%, and 10% resolution of VUR in grade I, II, III, and IV patients, respectively. Renal scaring was present in 7% (2/28) in grade I, 7% (6/89) in grade II, 19% (12/65) in grade III, 60% (25/42) in grade IV and 80% (20/25) in grade V at the time of diagnosis in our study. There were 10% who had developed renal scar at the time of the diagnosis in Mattoo et al study.17 We had 87% (211/250) of patients managed with medical measures, four patients were given endoscopic injections of Deflux, and 30 have undergone ureteric reimplantation. 79% (7498/9496) of patients were managed conservatively (medical management) in the study by Caleb P et al.18 The remaining 21% (1998/9496) patients were managed surgically. The survey conducted by Sharifian M et al.15 found that 90% (252/279) of patients were managed conservatively, and the remaining 10% (27/279) underwent surgical correction. The techniques used for ureteric reimplantation were Cohen cross-trigonal in 16 (53.4 %), Leadbetter-Politano in 9 (30 %), Lich-Gregor in 1 (3.3 %), and Cephalo-trigonal in 4 (13.3 %) patients, respectively, in our study. Grossklaus et al.19 performed the Cohen cross-trigonal technique in 120 renal units (45 %), the Leadbetter-Politano technique in 55 renal units (20 %), and the Glenn-Anderson technique in 92 renal units (35 %), respectively. Breakthrough UTI was found in 33 (15%) patients in the medical management group and 4 patients in the surgical group. Mei-Ju Chen et al.7 reported results similar to ours for breakthrough UTI in the medical (18%) and surgical (21%) groups. Haematuria, bladder spasm, breakthrough UTI, and persistent reflux were found in 10, 2, 4, and 2 patients, respectively, postoperatively in our study. The study by Hubert et al.20 found persistent reflux in 6% (59/965) of patients, and breakthrough UTI in 37% (22/59) of those with persistent reflux postoperatively. The low rate of complications makes the option of ureteric reimplantation an attractive one for the management of VUR.

VUR is the most common urinary tract abnormality in children. The incidence is higher in infants. Incidence is higher in males than in females in the infant age group. VUR is more prevalent in girls > 1year. VCUG is a diagnostic test for VUR. Ultrasound KUB is useful for assessing the status of the upper tracts. If the upper tracts are dilated, a VCUG is performed, followed by a DMSA scan. VUR leads to reflux nephropathy, hypertension and renal failure. Renal scarring is common at the time of diagnosis. This shows the need for prompt, early detection and aggressive management of VUR. Low-grade reflux is more common. Scarring is more common in high-grade reflux. Most patients with primary VUR can be managed conservatively with chemoprophylaxis. Patients required surgical intervention for a breakthrough UTI. Endoscopic injection of Deflux solution and Surgical management are indicated for high-grade reflux with scar at diagnosis, appearance of new scar on follow-up and recurrent breakthrough UTI. The anatomical causes of secondary VUR, like ectopic ureter, bladder diverticula or ureterocele, were managed by surgical intervention. Conflict of interest: There is no conflict of interest. Abbreviations: VUR- Vesicoureteric reflux VCUG- Vesicocystourography UTI- Urinary tract infection USG- Ultrasonography CIC- clean intermittent catheterisation DMSA- Diamercapto succinic acid CPRE- Complete Primary repair

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