Additional malformation (double kidney, Hutch diverticulum, ectopic ureter)

7.4.1 Conservative therapy

The objective of conservative therapy is prevention of febrile UTIs. Along with an ample supply of liquid and regular complete voidance of the bladder (if necessary with double micturition), a good hygiene and a low dosage of prophylactic long-term antibiotics are central aspects of conservative therapy.

The assumption that in some patients VRR disappears without surgical intervention justifies a conservative approach. The chance of a spontaneous improvement only exists, however, for young patients with a low-grade reflux and without serious pathology of the ureteral orifices. If reflux persists up to an age in which spontaneous disappearance can no longer be expected, then girls should be submitted to operative reconstruction. In boys > 5 years, antibiotic prophylaxis may be stopped as the indication for reflux correction is rare. If febrile UTIs occur under antibiotic prophylaxis, the conservative strategy should be omitted and surgical intervention should be planned.

Surgical therapy

Surgery should not be performed before the age of 6 months.

Endoscopic therapy

Currently, experience with endoscopic treatment as an operative option is limited.

Open surgery

Various techniques for reflux correction have been described (e.g. Lich-Gregoir, Politano-Leadbetter, Cohen, Psoas-Hitch), the principle being to lengthen the intramural part of the ureter by submucosal embedding of the ureter. A high success rate of over 95%, with only a small rate of complications, is shared by all surgical procedures.

As a rule, prior to extravesical procedures an endoscopy should be performed, whereas the ureteral orifices can be directly visualized with intravesical operations. Other important technical details are an absolutely tension free ureteral anastomosis, as well as meticulous preservation of the blood supply of the distal ureter. In addition, a sufficient length and width of the tunnel is mandatory.

In case of a bilateral reflux the Lich-Gregoir as well as the Psoas-Hitch procedure should be performed in two stages to prevent bladder dysfunction.

Follow-up

After surgical reflux correction, patients require peri-operative antibiotic therapy, this being continued as prophylaxis for 6 weeks post-operatively. Optionally, a VCUG is carried out 3 months post-operatively in order to prove successful reflux correction. Obstruction of the upper urinary tract is ruled out by sonography on patients' discharge and this should be repeated after 4-6 weeks if any sign of obstruction is present. In all other cases, a routine ultrasound is carried out 3 months post-operatively.

All patients with parenchymal damage at the time of reflux correction should receive a control scintigraphy 12 months post-surgery. The follow-up examination should include blood pressure controls for early detection of renal hypertension.

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