“In the past, we were very aggressive at correcting urinary reflux in children because we were concerned that reflux would cause damage to the kidney,” says Dix P. Poppas, MD, FACS, Chief of Pediatric Urology at NewYork-Presbyterian/Weill Cornell Medicine. “Over the last 10 years, we have come to learn that urinary reflux, simple reflux by itself, is much less likely to cause kidney damage long-term. However, when reflux is associated with a urinary tract infection that is in the bladder, it then has a direct route to infect the kidney leading to pyelonephritis. If not caught early and corrected with antibiotic treatment, reflux with infected urine can cause scarring and permanent damage to the kidneys.”
Dix P. Poppas, MD, FACS
Dr. Poppas has extensive experience in minimally invasive surgery and pediatric laparoscopy, with focused expertise in vesicoureteral reflux, genital reconstruction, and intersex disorders. In addition to seeing patients at NewYork-Presbyterian Komansky Children’s Hospital, Dr. Poppas serves as Co-Director of the Laboratory for Minimally Invasive Urologic Surgery and pursues research in developing advanced surgical techniques for tissue reconstruction using novel tissue sealants to replace sutures and staples during surgery.
Vesicoureteral reflux is estimated to affect 1 to 3 percent of all children. Girls are more likely to develop urinary tract infections, and boys who are uncircumcised have a higher risk of developing urinary tract infections compared to those who are circumcised.
The diagnosis of vesicoureteral reflux is often made through two separate pathways. If a prenatal sonogram shows dilation in the kidney and the ureter, then the newborn is evaluated with a sonogram and a voiding cystourethrogram (VCUG), which documents reflux. They are then placed on a prophylactic antibiotic to lower the risk of developing a urinary tract infection. The typical long-term management for these patients would be to keep them on a prophylactic antibiotic, which reduces the risk of a urinary tract infection by 50 percent. If vesicoureteral reflux is not picked up prenatally, then it is usually diagnosed when a child develops their first or second urinary tract infection that is associated with a fever.
“Once a child is placed on a protective prophylactic antibiotic, our team monitors them with a renal sonogram every six months to gauge renal growth and dilation,” says Dr. Poppas. “Once a year, we would perform a VCUG to document whether the reflux is improving or changing in any way. If the patient develops breakthrough urinary tract infection, indicated by a fever, despite being on prophylactic antibiotic, we will treat that infection but also talk to the family about continuing the antibiotics or moving to correct the reflux in some way. It is important to understand whether the patient has any evidence of voiding dysfunction or history of constipation, both of which will need to be addressed.”
“If the child has ongoing breakthrough infections or, after toilet training, continues to have stable or worsening reflux, we begin to discuss correcting the reflux,” continues Dr. Poppas. “Many parents do not want to have their child on long-term prophylactic antibiotics, although very little data shows that there is any negative impact. I do recommend that our patients be placed on a probiotic during treatment and that their genital hygiene is optimized, and they stay well hydrated.”
Considering Treatment Options
The first step in management for any patient who presents with a documented urinary tract infection with a fever is to treat the infection and obtain a renal/bladder sonogram. If this sonogram is normal, no further management is required. “Boys have a higher chance of outgrowing the reflux spontaneously over time than girls,” says Dr. Poppas. “If medical management fails, the child has multiple breakthrough infections, or the family wants the child to be taken off the prophylactic antibiotics, the question then becomes how do we correct the reflux?”
The grade of reflux – grades 1 through 5, with 5 being the most serious –helps to dictate management. “Grade 3 and higher tend to be more concerning than grades 1 and 2,” notes Dr. Poppas. “Some doctors feel that correcting reflux is not necessary, but I don’t think the majority of those in our field hold that view. Most pediatric urologists would proceed with some correcting maneuver to eliminate the reflux, discontinue prophylactic antibiotics and, at the same time, protect the kidneys from becoming infected.”
The average age for correcting reflux at NewYork-Presbyterian/Weill Cornell is three to four years. Dr. Poppas and his colleagues prefer to perform the procedure after a child is toilet trained. If they haven’t outgrown the reflux following toilet training and the reflux remains grade 3 or higher, they will offer correction at that time.
Deflux® (Hyaluronic Acid/Dextranome) Injection
“If the reflux is of low grades 1, 2, and maybe 3, some doctors would recommend Deflux® injection,” says Dr. Poppas. “Deflux is an injectable material administered through a cystoscope at the ureterovesical junction to bulk up that space and eliminate reflux. It’s a very simple, minimally invasive approach to correcting low grade reflux, and the success rates are in the 70 to 80 percent range depending on the grade of reflux. These patients require a postoperative VCUG at 6 to 12 months to make sure that the injection was successful. Many parents avoid a VCUG because it’s a traumatic procedure in most children. Personally, I only use Deflux for a very low grade, 1 to 2, reflux.”
Open Bladder Surgery
There are two commonly used open bladder surgical techniques: Cohen cross-trigonal and Politano-Leadbetter ureteral reimplantation, in which the ureter is detached from the bladder and then re-implanted with a longer tunnel to prevent reflux. These techniques are performed by making a Pfannenstiel incision of 4 to 6 centimeters just above the pubic bone. The bladder is identified and then opened to expose the inside of the bladder. In the Cohen cross-trigonal approach, the ureter is brought across the bladder horizontally. With the Politano-Leadbetter method, the ureter is placed vertically in a more natural position.
“Personally, I have stopped using the Cohen cross-trigonal approach because once that procedure is performed you cannot gain access to the ureter from below without significant difficulty,” notes Dr. Poppas. “If the patient develops a kidney stone or a ureteral tumor later in life it’s very difficult to access that area. Therefore, when I perform an open bladder re-implant, my preference is the Politano-Leadbetter approach as I will always have access to the upper tracts from below.”
The open bladder approach takes at least an hour to an hour and a half and requires a catheter. In some institutions, patients will spend the night in the hospital and have the catheter removed the next day. There is also hematuria that can be significant.
Extravesical Approach
Another option, notes Dr. Poppas, is an extravesical approach for correcting the reflux from outside of the bladder. “I have been using this technique for 30 years and was a very early adopter due to its minimally invasive aspects,” he says. “In my opinion, if the goal of correcting simple primary reflux is to make the tunnel longer, approaching from outside of the bladder makes the most sense. In this operation, the same 4-to-6-centimeter Pfannenstiel incision is made, but the bladder is never opened, and the ureter is mobilized down to where it begins to enter the bladder. The ureter is not detached.”
“Once I have identified that junction, an incision is made into the detrusor muscle without entering the bladder epithelium,” Dr. Poppas continues. “The ureter is then laid down over the bladder epithelium and the detrusorotomy is closed over the ureter, thereby lengthening the tunnel. The advantage of this approach over an open surgery is that you don’t open the bladder, you don’t detach the ureter, and you don’t have to leave in a catheter or a drain for unilateral procedures. A small suprapubic drain is place in patients with bilateral repair. We have found that a small SPT is superior to a urethral catheter as it can be clamped and reopened if needed without having the patient come to the hospital or have a urethral catheter replaced. The open extravesical procedure is an extraperitoneal procedure so there is also no risk for bowel injury or adhesions. Additionally, the total anesthesia time is about 45 minutes from the point the child goes to sleep until the child wakes up. The procedure is always performed as an outpatient and the child can go home without a catheter and without a drain. This procedure has a 99 percent success rate, and because the success rates are so high, we do not recommend a post-surgical VCUG unless the child develops a urinary tract infection with a fever. For these reasons, the extravesical approach is my preferred method of correcting reflux.”
Dr. Poppas schedules a follow-up visit one week postop. “Most parents tell me that their child is up and running around the next day. I follow them with a sonogram at one month and at 12 months after the procedure. I then discharge them from my service if they’re doing well clinically and do not repeat a VCUG unless the patient presents with a urinary tract infection and a fever or if I see progressive dilation on the post-surgical sonograms.”
Some pediatric urologists will perform the extravesical correction procedure robotically.
With this approach, three trocars through three incisions are placed into the abdominal cavity to reach the surgical site. “Compared to the robotic extravesical approach, open extravesical is less invasive, less painful, and offers a faster recovery without an overnight stay in the hospital,” says Dr. Poppas. “A study is now underway at Weill Cornell Medicine as part of a national consortium of robotic surgeons to compare the two procedures and their respective risks and benefits.”
“I try to be a very thoughtful surgeon and to treat my patients the way I would treat my children or my grandchildren,” adds Dr. Poppas. “In any management approach we recommend, our overriding goal is to provide the best treatment with the best outcome, lowest complication rates, and quickest return to normal function.”
