A total of 165 patients with VUR from PUV and following reconstruction of exstrophy bladder were treated at our center from March 2005 to April 2019. Out of 165 patients, 135 patients (170 renal units; n = 146 from PUV and n = 24 from exstrophy bladder) had adequate data regarding control/correction of obstruction and urodynamic studies, etc. The mean patient's age was 2.8 years (range 1 day–14 years).
The diagnosis of VUR was made with cystogram following fulguration in PUV patients and at follow-up in patients with repaired continent bladder exstrophy. We did MCB (Mitra, Chatterjee, Basu) cystograms not MCU following USG showing dilated ureter/s as mentioned by some authors.[5 (link)] In MCB cystogram, as mentioned, we introduced contrast in the bladder. Absence of VUR following MCB cystogram indicates uretero vesical junction obstruction (UVJO). On the other hand, following the presence of VUR, we released catheter to empty the contrast from bladder and ureters. We labeled VUR as “rise and fall” VUR (raf_VUR) if we had found no residual in ureter/s after 30 min [Flow chart 1]. That was an “innocent VUR” i.e., without obstruction [Figure 2]. In another group, we had found stasis of post-void residual in ureter/s for more than 30–180 or more minutes. We labeled those VUR as “rise and stasis” VUR (ras_VUR); which means combination of VUR with UVJO. Combination VUR with UVJO confirmed post void residual of contrast in ureters persisting [Figure 3] following MCB and their progression or regression was monitored with the diameter of calyx, ureters, and cortical thickness by USG Renometry (USGR) during follow-up as mentioned by some authors.[5 (link)] All 19 patients with exstrophy bladder were continent, either with CIC or natural Void or with both. However, had VUR in 24 renal units. Superficial bladder neck incision (BNI) was done in two continent patients with repaired exstrophy.
All patients were followed up with albumin creatinine ratio (ACR), CCr to monitor USCKD, USGR, DTPA renal scan, and uroflowmetry. All patients were advised for UDS, particularly for Pdet, Pdet Qmax, and DLPP to exclude or confirm increased bladder pressure from outlet obstruction. Repeat cystoscopy, if necessary, was done following UDS for secondary BNI or to repeat BNI if necessary. Following BNI in patients with suspected UVJO were kept on anticholinergics for few months and monitored with USGR, ACR and CCr. We did DJ stenting [Figure 4] or re-implantations if the deterioration of renal function was found to be >10% from the previous level even with anticholinergics. During the reimplantation of ureters, caliber of ureters was thicker due to muscular hypertrophy. Hence, those ureters were not tapered, unlike the thinner wall of ureter with raf_VUR and minimal tunnels through thicker bladder wall were created to avoid re-obstruction.