7.3.1 Secondary reflux

Diagnosis and treatment of the underlying disease are, of course, primary aspects in secondary acquired reflux. If reflux persists after successful treatment of the underlying condition, therapy of reflux is oriented with respect to clinical conditions. In order to diagnose a secondary reflux, it has to be ensured that VCUG was carried out in a non-inflammatory interval and, if necessary, repeated after clearing up the infection. Further diagnosis then proceeds according to the same rules as primary reflux.

7.4 Treatment

The objective of treatment is the avoidance of late complications, such as reflux nephropathy. Therapeutic options consist of conservative medical treatment and endoscopic or open surgical procedures. The choice is influenced by the age of the patient, the grade of reflux, the position or configuration of the ureteral orifices and the clinical course.

Table 10: Treatment of reflux I

1 year		Conservative
1-5 year(s)	Grade I - III	Conservative
	Grade IV - V	Surgery
> 5 years	Boys	Indication for surgery is rare
	Girls	Surgery (due to higher rate of infections,
		esp. during pregnancy)

Table 11: Treatment of reflux II

Recurrent febrile infections despite antibiotic prophylaxis

surgery

(not before the age of 6 months)

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.

7.4.2 Surgical therapy

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

7.4.3 Endoscopic therapy

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

7.4.4 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.