VUR Treatment in Singapore

• Children diagnosed with vesicoureteral reflux grades I-V
• Patients experiencing recurrent UTIs despite antibiotic prophylaxis
• Children with high-grade reflux (grades IV-V) unlikely to resolve spontaneously
• Patients showing evidence of kidney scarring or reduced kidney function
• Children with persistent reflux beyond expected age of resolution
• Patients with breakthrough UTIs while on prophylactic antibiotics
• Those with bladder dysfunction contributing to reflux
• Children whose parents prefer definitive treatment over long-term antibiotics

• Active urinary tract infection (must be treated before intervention)
• Severe systemic illness preventing safe anaesthesia
• Uncorrected bladder outlet obstruction
• Neurogenic bladder without proper management
• Blood clotting disorders (for surgical options)
• Severe kidney disease requiring different management approach

The decision for VUR treatment requires careful evaluation by a paediatric urologist. Factors including the child’s age, reflux grade, kidney function, and response to conservative management all influence the treatment approach. A thorough assessment ensures the appropriate treatment strategy for each individual case.

Conservative management remains the first-line approach for low to moderate grade VUR (grades I-III). This involves continuous antibiotic prophylaxis to prevent UTIs while allowing time for the reflux to resolve naturally as the child grows. Regular monitoring with urine cultures and periodic imaging helps track progress. Bladder and bowel dysfunction management forms an integral part of conservative treatment, including timed voiding, treatment of constipation, and behavioural modifications.

Endoscopic injection therapy offers a minimally invasive option for VUR treatment. This procedure involves injecting a bulking agent at the ureteral opening to create a valve mechanism that prevents reflux. The procedure is performed through a cystoscope under general anaesthesia and typically takes 15-30 minutes. Various injection materials are available, including dextranomer/hyaluronic acid copolymer, which has shown good safety profiles and effectiveness.

Open ureteral reimplantation remains the gold standard for surgical VUR treatment, particularly for high-grade reflux. The procedure involves repositioning the ureter within the bladder wall to create an effective anti-reflux mechanism. Several surgical techniques exist, including the Cohen cross-trigonal technique and the Leadbetter-Politano method. The choice of technique depends on anatomy and surgeon preference.

Modern VUR treatment utilises various technologies to enhance outcomes. Voiding cystourethrography (VCUG) and nuclear cystography provide accurate diagnosis and grading. During endoscopic procedures, paediatric cystoscopes with specialised injection needles ensure precise placement of bulking agents. For surgical repairs, operating microscopes may be used for precise tissue handling. Postoperative monitoring includes ultrasound technology to assess kidney health and detect any complications.

Before VUR treatment, comprehensive evaluation ensures optimal outcomes. This includes urine culture to confirm absence of active infection, blood tests to assess kidney function, and imaging studies to document reflux grade. For surgical interventions, pre-operative assessment includes anaesthesia evaluation and necessary blood work. Parents receive detailed instructions about fasting requirements and what to bring for hospital admission. Antibiotic prophylaxis continues until the day of procedure.

For endoscopic injection, the child receives general anaesthesia before the urologist inserts a paediatric cystoscope through the urethra. The procedure involves identifying the ureteral openings and carefully injecting bulking agent to create a mound that prevents reflux. The injection process takes approximately 15-30 minutes for both ureters.

Open surgical repair requires a lower abdominal incision to access the bladder. The surgeon carefully mobilises the ureter and creates a new tunnel through the bladder muscle, repositioning it to prevent reflux. The procedure typically takes 2-3 hours, depending on whether one or both ureters require repair.

Following endoscopic injection, children recover in the post-anaesthesia care unit for 1-2 hours. A temporary urinary catheter may be placed but is often removed before discharge. Pain is usually minimal, managed with oral medications. Most children go home the same day.

After open surgery, children remain hospitalised for 1-3 days. A urinary catheter stays in place for 24-48 hours to allow bladder healing. Pain management includes both oral and intravenous medications as needed. Parents receive training on incision care and activity restrictions before discharge.

Following endoscopic injection, children may experience mild discomfort with urination and occasional blood-tinged urine. Encouraging frequent small voids helps minimise discomfort. Pain medication is rarely needed beyond the first day. Parents should monitor for signs of urinary retention or fever.

After open surgery, the first 48 hours focus on pain control and catheter care. Children gradually increase activity as tolerated. Clear liquids progress to regular diet as bowel function returns. The surgical dressing remains dry and intact until the first follow-up visit.

During the first week after endoscopic treatment, children can usually return to normal activities within 2-3 days. Antibiotic prophylaxis continues as prescribed. Parents should ensure adequate fluid intake and monitor urination patterns.

Following open surgery, activity remains restricted with no heavy lifting, strenuous exercise, or swimming. The incision requires daily inspection for signs of infection. Children may return to school after one week if comfortable, with activity modifications as needed.

Complete healing after endoscopic injection occurs within 4-6 weeks. Follow-up imaging at 3 months assesses treatment success. If reflux persists, repeat injection may be considered. Long-term success rates vary but generally range from 70-90% depending on initial reflux grade.

Open surgical repair shows success rates exceeding 95% for resolving reflux. Full recovery takes 4-6 weeks, with gradual return to all activities. Annual follow-up includes ultrasound to monitor kidney growth and ensure continued success. Most children require no further intervention after successful surgery.

Following endoscopic injection, temporary urinary symptoms occur in approximately 20-30% of children. These include urgency, frequency, and mild discomfort with voiding, typically resolving within days. Transient haematuria (blood in urine) is common but self-limited. Some children experience temporary urinary retention requiring catheterisation.

Open surgery side effects include typical post-operative discomfort, managed with appropriate pain medication. Temporary bladder spasms may occur while the catheter is in place. Minor wound complications such as superficial infection or delayed healing affect less than 5% of patients.

Serious complications from VUR treatment are uncommon when performed by experienced surgeons. Endoscopic injection rarely causes ureteral obstruction (less than 1%), which may require surgical intervention. Reflux recurrence occurs in 10-30% of cases, potentially necessitating repeat treatment.

Open surgery complications include ureteral obstruction or persistent reflux in less than 5% of cases. Bladder dysfunction is rare but may require additional management. Wound infections requiring antibiotics occur infrequently with proper surgical technique and post-operative care.

Our paediatric urologists employ meticulous surgical techniques and comprehensive pre-operative planning to minimise risks. Regular follow-up ensures early detection and management of any complications, contributing to positive long-term outcomes.