Vesicoureteral Reflux Surgery in Turkey

Vesicoureteral reflux surgery is a surgical treatment method applied to prevent the backward flow of urine from the bladder to the ureters and kidneys. This procedure is planned to prevent kidney damage and reduce recurrent urinary tract infections.

Vesicoureteral reflux surgery methods include open surgery, laparoscopic techniques, and endoscopic injection applications. Each method is selected according to the grade of reflux and the age of the patient. Surgical planning is determined through imaging findings and clinical evaluation.

Vesicoureteral reflux surgery in children is important in preserving kidney functions during growth and development. Proper surgical intervention performed at an early stage reduces the risk of permanent renal damage and helps prevent long-term complications.

The recovery process after vesicoureteral reflux surgery varies depending on the patient’s general condition and the technique applied. During the follow-up process, success is evaluated with urine tests and imaging methods, while infection control and kidney functions are monitored regularly.

What Is Vesicoureteral Reflux (VUR) and How Does It Develop?

We can liken the urinary system in the human body to a perfectly functioning plumbing network in our home. Our kidneys are the main filters that clean the blood, the thin long structures called ureters are the pipes that carry the filtered fluid, and the bladder is the flexible reservoir where this fluid accumulates. In normal anatomy, the ureters do not enter the bladder in a straight line. They pass at a certain angle beneath the inner lining of the bladder, forming a long tunnel. As the bladder fills with urine and expands, the internal pressure increases and compresses this submucosal tunnel, effectively closing it. Thanks to this perfect design, a one-way valve mechanism is formed, making backward flow of urine physically impossible.

However, in some cases, this system malfunctions and urine begins to flow backward. The underlying causes of this problem can generally be divided into structural or acquired issues.

The main underlying mechanisms are as follows:

• Anatomical insufficiency
• High bladder pressure
• Obstructions
• Neurogenic voiding disorders

Anatomical insufficiency is usually congenital. During development in the womb, the submucosal tunnel where the ureter connects to the bladder remains shorter than it should be. When the tunnel is short, the pressure generated as the bladder fills is not sufficient to close the channel, and the system remains open. In acquired cases, the valve is initially completely normal. However, due to obstruction at the bladder outlet or excessive contraction of the bladder due to neurological causes, the pressure inside the bladder rises to abnormally high levels. This excessive pressure overwhelms and disrupts the healthy valve mechanism.

How Common Is Vesicoureteral Reflux in Children?

In the general population of healthy children, the incidence of this condition ranges between one and two percent. At first glance, this may seem like a low probability. However, when a febrile urinary tract infection is present, the situation changes completely. It is observed that in nearly half of children who have experienced at least one febrile urinary tract infection, the underlying cause is this backward flow of urine.

Gender and age distribution also show a remarkable pattern. During the neonatal period and especially in prenatal ultrasound examinations, kidney enlargements are more commonly detected in male infants. However, after the child reaches one year of age, the pattern begins to change, and the incidence becomes significantly higher in girls compared to boys. Especially in infants within the first year of life who experience unexplained febrile infections, the likelihood of this reflux problem is very high.

Should Individuals with a Family History of Vesicoureteral Reflux Be Screened?

One of the most important characteristics of this condition is its strong genetic predisposition. The genetic codes that determine our body structure also influence how our organs develop. The angle at which the urinary channels enter the bladder and the anatomical structure of that region are largely hereditary. Therefore, children with family members diagnosed with this condition have a significantly higher risk compared to the general population.

Family members at risk include:

• Siblings
• Identical twins
• Fraternal twins
• Mother
• Father

The probability of this condition occurring in siblings of a diagnosed child is approximately one in three. If the case involves identical twins, this risk can rise to as high as eighty percent. Similarly, in newborns whose parents had this condition during childhood, similar anatomical differences are frequently observed. Due to this strong familial connection, if there is a history of the disease in the family, it is extremely important to evaluate children early with ultrasonography even if they have no symptoms. Early detection allows preventive measures to be taken before any damage occurs to the kidneys.

How Does Vesicoureteral Reflux Cause Kidney Damage?

The main danger of this urine reflux is not just the backward movement of urine toward the kidneys, but the damage this reverse flow causes in the kidneys. In a healthy individual, even if bacteria are present in the lower urinary tract, such as the bladder, the system works in one direction, so these bacteria are expelled with urine. Only a simple bladder infection occurs, and this does not threaten the kidneys.

However, if urine flows backward, the bacteria-laden urine in the bladder is directly transported to the inner collecting system of the kidneys. Kidney tissue is extremely sensitive to infections. When bacteria reach the kidney, severe inflammation begins, which manifests as high fever. While the body fights this infection, the kidney tissue essentially becomes a battlefield. When the inflammation heals, what remains is not healthy tissue but stiff scar tissue that has lost its flexibility and filtering ability. These scars, referred to as “renal scars,” are permanent. With each new infection episode, the kidney suffers further damage, shrinks, and over time loses its function, paving the way for hypertension and kidney failure.

Why Is Vesicoureteral Reflux Grading Important?

The most important criterion in determining how the treatment process will proceed is the severity, or grade, of the reflux. The course of the disease, the likelihood of spontaneous resolution, and the extent of the threat to the kidneys all depend on this grading. The classification is based on how far the urine reflux reaches and how much structural damage it causes in the kidney.

The grades of reflux are as follows:

• Grade I
• Grade II
• Grade III
• Grade IV
• Grade V

In Grade I, urine refluxes slightly into the lower part of the ureter but does not reach the kidney. In Grade II, urine reaches the renal pelvis but does not cause any dilation or pressure effect. In Grade III, mild to moderate dilation begins in the renal pelvis, indicating that the anatomy is under stress. In Grade IV, the ureters become tortuous, and the kidney becomes clearly enlarged. Grade V is the most severe stage; the ureters are massively dilated and twisted, and the delicate filtering structures of the kidney are flattened and severely damaged due to high pressure. While low-grade reflux has a high chance of resolving spontaneously as the child grows, this likelihood is very low in Grades IV and V.

Which Methods Are Used to Diagnose Vesicoureteral Reflux?

The diagnostic phase is one of the most critical parts of the process. The goal is not only to confirm the backward flow of urine but also to evaluate the bladder structure, the current functional capacity of the kidneys, and whether any previous damage has occurred in a comprehensive manner. Families may often be concerned about the tests performed on their children, but with today’s technology, these tests are carried out very safely.

The main diagnostic tools used are:

• Ultrasonography
• Voiding cystourethrography
• Static renal scintigraphy
• Radionuclide cystography

Ultrasonography is the first step, using sound waves without radiation. It shows kidney size, tissue thickness, and whether there is swelling. However, it cannot demonstrate reflux on its own. Voiding cystourethrography, also known as a contrast voiding study, is the gold standard for definitive diagnosis. A very thin catheter is inserted through the urinary opening into the bladder, contrast fluid is administered, and images are taken while the child urinates. This clearly shows the degree of reflux. Static renal scintigraphy evaluates kidney function. With a low-dose injected substance, it precisely measures whether permanent scarring has occurred in the kidney tissue and the percentage of function each kidney contributes.

Is Medical Follow-up Possible in the Treatment of Vesicoureteral Reflux?

The fundamental approach in treatment planning is always to first evaluate non-surgical methods. Children’s bodies are in a constant state of growth and development. As the bladder grows in volume and its wall thickness changes, the previously short and insufficient tunnel may lengthen. In other words, the body has the capacity to correct this anatomical issue on its own up to a certain age. This maturation process generally continues until the child reaches around five years of age.

During this waiting period, the primary goal is to protect the kidneys from new infections and potential damage. For this purpose, prophylactic antibiotic treatments are often used. The aim is not to treat an existing infection but to keep the urinary tract sterile and prevent bacterial colonization. The medication is usually given once daily in a low dose, often before bedtime. This is because urine remains in the bladder for a long time during sleep, creating an ideal environment for bacterial growth. In low-grade reflux cases and in older children who have not experienced serious kidney infections, close clinical follow-up without medication may sometimes be preferred.

Do Bladder and Bowel Problems Affect Vesicoureteral Reflux Treatment?

There is a very critical issue that deeply affects the success of the treatment process but is often overlooked: the child’s toileting habits. In human anatomy, the bladder and the final part of the large intestine are neighboring organs positioned back-to-back. The physical and neurological interaction between these two organs directly influences the healing process.

Associated problems that should be considered include:

• Constipation
• Urinary retention habits
• Interrupted voiding
• Urgency

If a child has chronic constipation, the hardened stool mass accumulated in the rectum exerts constant physical pressure on the bladder. This pressure prevents the bladder from expanding comfortably. Additionally, children who delay urination until the last moment or do not fully relax their muscles during voiding experience increased bladder pressure. This elevated pressure continuously strains the already weakened valve mechanism. Without addressing these toileting issues, simply administering medication or performing surgery often leads to failure. Proper nutrition, adequate hydration, scheduled toileting habits, and, if necessary, pelvic floor exercises should be included in the treatment process.

What Are the Minimally Invasive Surgical Methods for Vesicoureteral Reflux?

If the child’s anatomy does not correct itself during growth or if febrile infections threatening the kidneys continue despite prophylactic medication, the treatment strategy changes. At this stage, the first surgical option that comes to mind is usually endoscopic methods performed without any incision on the body. This approach is highly comfortable due to its ease of application and the patient’s ability to return to normal life on the same day.

During the procedure, very thin instruments with a light and camera are inserted through the urinary passage into the bladder. The problematic and short tunnel opening where the ureter connects to the bladder is identified. With the help of a special needle, biocompatible bulking agents are injected just beneath or around this opening. This injection creates a supportive tissue at that region, narrows the tunnel opening, and forms an artificial valve mechanism to prevent urine reflux.

Some of the materials used include:

• Dextranomer hyaluronic acid
• Polyacrylate polyalcohol copolymer
• Polydimethylsiloxane

These materials are safe biomaterials that are not rejected by the body. Some integrate with tissue over time, while others provide more permanent volume. The biggest advantage of this procedure is that it is completed in a very short time without requiring hospitalization. However, the success of this minimally invasive method is inversely related to the severity of the disease. In very high-grade reflux, the anatomical defect may be too extensive, and the injected material alone may not provide sufficient resistance, requiring repeat procedures.

When Is Open Surgery Performed in Vesicoureteral Reflux Treatment?

In advanced structural abnormalities where minimally invasive methods are insufficient or in cases where previous endoscopic interventions have failed, open surgical intervention provides the most definitive and permanent solution. These procedures, known medically as ureteral reimplantation, have success rates exceeding ninety-five percent and represent the most reliable and final treatment method for this condition. The main principle of the surgery is to eliminate the short and insufficient tunnel and create a new, sufficiently long, and strong one-way tunnel system within the bladder wall.

Common open surgical techniques include:

• Cohen technique
• Politano-Leadbetter method
• Lich-Gregoir procedure

Among these, techniques that allow the ureter to traverse a longer path along the bladder base are frequently preferred. As a result, when the bladder fills, the increased pressure effectively closes this newly created tunnel. Although the term “open surgery” may cause concern among families, it is performed in children with very small incisions and excellent cosmetic outcomes. While the recovery process requires a few days of hospital observation, it provides a lifelong permanent solution.

Is Robotic Surgery an Option for Vesicoureteral Reflux?

With advancements in medical technology, the pursuit of achieving the high success rates of open surgery with less pain and smaller incisions has brought robotic and laparoscopic surgery to the forefront. The excellent results obtained with traditional open surgery can now also be achieved with high-tech robotic systems.

The abdominal and pelvic cavities of children are much smaller than those of adults. Performing extremely delicate suturing and tissue manipulation in such a confined space requires great skill. Robotic systems provide surgeons with a three-dimensional, high-resolution, magnified view. With robotic instruments that eliminate natural hand tremors and can rotate beyond the capability of the human wrist, a new urinary tunnel can be constructed inside the bladder with millimetric precision. Thanks to this minimally invasive approach, children experience less postoperative pain, are discharged earlier, and are left with only a few barely visible millimetric scars.

In Which Cases Is Surgery Absolutely Necessary in Patients with Vesicoureteral Reflux?

There are critical turning points where, despite ongoing medical follow-up or observation, the situation changes, and surgery becomes a necessity rather than an option. Although waiting and medical management are the first choices, once it is understood that kidney tissue is at risk, more aggressive steps must be taken. The patient’s age, overall kidney condition, and family compliance with treatment are all carefully evaluated in the decision-making process.

Conditions that necessitate surgery include:

• Resistant infections
• New kidney damage
• Medication side effects
• Anatomical abnormalities
• High-grade reflux

If a child continues to develop kidney infections despite taking daily prophylactic antibiotics, this clearly indicates that preventive measures are insufficient, and further waiting will harm the kidney. Similarly, if new scars are detected on follow-up scintigraphy, it means that damage is ongoing and urgent repair is required. Additionally, in cases where there are anatomical abnormalities such as duplication of the ureter or congenital bladder diverticula, spontaneous correction is not possible, and direct surgical planning is the most appropriate approach. In adolescent girls, persistent reflux also poses significant risks for future pregnancies, both for themselves and their babies, and is therefore usually corrected surgically.