Matt Kulzer, MSIV12/4/2008

The Case2 wk old infant born at term via CS 2/2

maternal hypertension/GDMOn prenatal ultrasound a “renal abnormality”

was notedNo other complications with

pregnancy/delivery

Findings – Renal ultrasoundNormal right kidney without dilationLeft kidney with complete duplex system

(small upper pole with dilated ureter)Upper pole with ureterocele at the bladder

baseMild fullness of lower pole collecting system

Findings - VCUGLeft sided grade 4/5 VURRight sided grade 2 VURNormal bladder/urethra

Duplicated collecting systemKey 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.

ManagementMedical

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 treatSurgical

Open vs. endoscopic reimplantation of the ureterSimilar outcomes for bothWith age, intravesicular ureter will lengthen

and may improve reflux

PrognosisPrenatal 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):1846-1851Review of 26 studies (1987 pts)

Resolution dependent on severity of VUR, unilat vs. bilat Grade V rarely resolved