VESICO URETERIC REFLUX, VUR: What The Trials Are Telling Us

VESICO URETERIC REFLUX, VUR: What The Trials Are Telling Us

Clarence Lei Chang Moh

Normah Medical Specialist Centre, Kuching

Introduction and Objectives:

About 40% of children with febrile UTI have been found to have vesico ureteric reflux. The international reflux study in children, first established in 1981, reported on 250 children for 10 years.  The conclusion is that antibiotic prophylaxis is as good as ureteric re-implantation.  Prophylactic antibiotics are associated with problems of compliance, side effects and the induction of antibiotic resistance.  The objective is to review the current evidence.

Materials and Methods:

The recent relevant publications in the English literature are reviewed, especially with regards to the use of antibiotic prophylaxis for vesico ureteric reflux.

Results:

Many RCTs, randomized controlled trials, do not show efficacy in preventing UTI and renal scarring.  Among the trials are:  The Swedish Reflux Trial In Children, published in J Urol 2010 and the RIVUR (Randomized Intervention For Children With Vesico Ureteral Reflux) published in the New England Journal of Medicine in 2014. The RIVUR study represents a collaboration of 15 clinical trial centres throughout North America, recruiting 607 children, followed up for 2 years, with the end points being febrile UTI, VCUG and DMSA scans. There has also been an increased use of injection of the ureteric orifice, namely, STING (sub-trigonal injection) or HIT (hydrodistension technique) as these are simple endoscopic therapy. Results published (e.g. by Puri in Urol 2007 and by Elder JS et al in J Urol 2006) indicated good success rate, 53% resolution after first injection, even for Grade 5 vesico ureteric reflux. However, Deflux is rather costly. There may therefore be a return to ureteric re-implantation for patients with recurrent febrile UTI  not responsive to antibiotic prophylaxis.  There has also been a change in the imaging techniques with more reliance on high quality and focussed ultrasound of the urinary tract.  Ultrasound should include:  bipolar length, anterior  posterior diameter of the pelvis, parenchymal thickness,  scars, ureteric dilation, bladder volume pre and post micturition and bladder wall thickness.  MCUG can be avoided in most patients especially those with mild hydronephrosis.  However, it should be done in males with bilateral hydronephrosis and a abnormal bladder and in patients with severe bilateral hydroureter.  Neonates and young children should not be exposed to radiation, especially that of CT. MRU is occasionally indicated if more detailed anatomy study is required.   Circumcision reduces the risk of recurrent UTI for patients with high grade VUR.  Antibiotic prophylaxis in neuropathic bladders, in patients on clean intermittent catheterisation  confer little benefit. 

Conclusion:

A detailed ultrasound of the urinary tract is usually sufficient as the investigation of the child with UTI.  Radio isotope scan, if available, can be useful looking for scars and excretion.  Most cases do not require antibiotic prophylaxis but rather a vigorous and immediate 5 days’ course of antibiotics, if they develop a febrile UTI.  Antibiotic prophylaxis would be indicated for patients with a history of recurrent febrile UTI, usually in patients with higher grade reflux. When prophylactic antibiotic fails, ureteric   re-implantation may be considered. 

Keywords:

Vesico ureteric reflux, MCUG, antibiotic prophylaxis, Deflux, ureteric re-implantation.

Presented at 25th Malaysian Urological Conference KL 25 Nov 2016

MALAYSIAN PERSPECTIVE IN FUTURE TRAINING

MALAYSIAN PERSPECTIVE IN FUTURE TRAINING

Clarence Lei Chang Moh

Chairman, National Specialist Registry in Urology 2006 – 2015

Honorary Secretary, Federation Association Urological Associations, 2014-2017

Introduction and Objectives:

The Institute of Urology and Nephrology at General Hospital Kuala Lumpur was established with 2 urologists in 1974.  The training then was by apprenticeship, over 4 years; certification was by government gazette. In 2016, the Malaysian population is 32 million with 100 urologists. With ASEAN established on 14.6.1997 (now expanded to 10 countries in South East Asia) and globalisation, there is an urgent need to increase the number of Malaysian urologists.  The MRA (Mutual Recognition Arrangement) among ASEAN countries was signed on 26.2.2009 and was supposed to be implemented on 1.6.2010! To meet the target of 1 urologist to 100,000 population, Malaysia  will need at least 200 urologists! 

Materials and Methods:

Data available with the MUA, Malaysian Urological Association archives were analysed.  Current information is available on the internet, e.g. http://www.nsr.org.my.  There has also been a sharing of information at the yearly urological conferences of ASEAN and UAA, Urological Association of Asia. 

Results:

The MBU, Malaysian Board of Urology was established by the Malaysian Urological Association with the first Board examination held in 2000.  Since 2014, the FEBU in-service exam was used as the Part I exam in Malaysia.  The MBU certificate was benchmarked with the FRCS Urology from the Royal College of Physicians and Surgeons of Glasgow, since 2008, with formal MOUs signed on 23.11.2012 and 21.11.2015.  The training programme is 3 years locally and 1 year overseas, usually in Australia or the United Kingdom.  Benchmarking with an international established college encourages mutual recognition and training programmes, especially among Commonwealth countries, e.g. Singapore, Hongkong, Brunei, India, Myanmar, Pakistan, Australia and Sudan.  Indeed, Malaysian urology graduates also gain limited GMC recognition for training in the United Kingdom. 

Trainees are  from candidates who has been  been certified as general surgeons. The output is therefore limited, about 5 urologists per year. A decision was made on 28.3.2015 by the  MUA Board of Urology to start a direct intake programme.  This was presented to the examiners’ team from the Royal College of Physicians and Surgeons of Glasgow in Kuala Lumpur on 16.11.2015. 

The Ministry of Health of Malaysia is facing a chronic shortage of specialists although there has been  an over production of medical graduates.  Following the MUA’s presentation to the Director General of Health of Malaysia on 29.1.2016,  government circulars were issued on 16.2.2016 and 5.5.2016 to expedite the intake of potential urology trainees as soon as they have passed the MRCS Part I.  The first interview for direct intake Malaysian urology trainees was held on 1.5.2016.  Of the 18 applicants, 7 started urological training with the Ministry of Health with effect from 1.7.2016.  The trainees remain as government servants, rotating among the 10 training centres as required and on a comfortable government salary.

This milestone in Malaysian urological training will hopefully improve urological services.   Within the ASEAN region, there is also great discrepancy in the distribution of urologists, with good numbers only in  Singapore. The FAUA had initiated discussions on the possible implementation of its MRA, with the first meeting sponsored by the Thai Urological Association at Khao Yai, Thailand in 2012, followed by meeting in Minado, Indonesia on 19.10.2013 and eventually in Penang on 21.11.2014.  Malaysia is one of the countries that recognises hundreds of medical schools throughout the world. Malaysian Medical Council  also has the mechanism (including structured interview, examination, working in an approved setting for up to 1 year) for urologists without “recognised” qualifications.  English is the recognised universal language used. However, mutual legal recognition of exam in  most countries is not possible, possibly because of socioeconomic factors as well.

As in many developing countries, there is a gross maldistribution of quality medical facilities and urologists; 70% of the Malaysian urologists are in private practice, mostly in the bigger towns.  Nevertheless, there is an initiative by the government (Ministry of Health and universities) and the Malaysian Urological Association to enhance PPP (public private partnership). The urology graduates  have a bond of working for 2 years with the government, to be increased to 5 years.  Urology trainees can make use of this opportunity to go for 1 to 2 years’ fellowship programme, e.g. in laparoscopy, robotics, paediatric urology, kidney transplantation, access for kidney failure etc.   Government urologists are allowed to work in the private sector with specified arrangements (usually after office hours, with proposals to extend this to office hours).  Private urologists are encouraged to take up sessions in public hospitals, especially in teaching, on an honorary basis.

Conclusion:

Urology training in Malaysia has progressed stepwise not only to improve the number of urologists but also to collaborate with its ASEAN neighbours as well as the global urological community.  With increased PPP and international sharing of programmes, it is anticipated that urology will continue to be a friendly and thriving speciality. Kuala Lumpur can be a centre of urology, including training and certification. 

Keywords:

Urological training, National Specialist Registry, Malaysian Board of Urology.

Presented 25 th Malaysian Urological Conference KL, 27 Nov 2016

urinary tract infection in children, stress to mothers, an update

VESICO URETERIC REFLUX, VUR: What The Trials Are Telling Us

Clarence Lei Chang Moh

Normah Medical Specialist Centre, Kuching

Introduction and Objectives:

About 40% of children with febrile UTI have been found to have vesico ureteric reflux. The international reflux study in children, first established in 1981, reported on 250 children for 10 years.  The conclusion is that antibiotic prophylaxis is as good as ureteric re-implantation.  Prophylactic antibiotics are associated with problems of compliance, side effects and the induction of antibiotic resistance.  The objective is to review the current evidence.

Materials and Methods:

The recent relevant publications in the English literature are reviewed, especially with regards to the use of antibiotic prophylaxis for vesico ureteric reflux.

Results:

Many RCTs, randomized controlled trials, do not show efficacy in preventing UTI and renal scarring.  Among the trials are:  The Swedish Reflux Trial In Children, published in J Urol 2010 and the RIVUR (Randomized Intervention For Children With Vesico Ureteral Reflux) published in the New England Journal of Medicine in 2014. The RIVUR study represents a collaboration of 15 clinical trial centres throughout North America, recruiting 607 children, followed up for 2 years, with the end points being febrile UTI, VCUG and DMSA scans. There has also been an increased use of injection of the ureteric orifice, namely, STING (sub-trigonal injection) or HIT (hydrodistension technique) as these are simple endoscopic therapy. Results published (e.g. by Puri in Urol 2007 and by Elder JS et al in J Urol 2006) indicated good success rate, 53% resolution after first injection, even for Grade 5 vesico ureteric reflux. However, Deflux is rather costly. There may therefore be a return to ureteric re-implantation for patients with recurrent febrile UTI  not responsive to antibiotic prophylaxis.  There has also been a change in the imaging techniques with more reliance on high quality and focussed ultrasound of the urinary tract.  Ultrasound should include:  bipolar length, anterior  posterior diameter of the pelvis, parenchymal thickness,  scars, ureteric dilation, bladder volume pre and post micturition and bladder wall thickness.  MCUG can be avoided in most patients especially those with mild hydronephrosis.  However, it should be done in males with bilateral hydronephrosis and a abnormal bladder and in patients with severe bilateral hydroureter.  Neonates and young children should not be exposed to radiation, especially that of CT. MRU is occasionally indicated if more detailed anatomy study is required.   Circumcision reduces the risk of recurrent UTI for patients with high grade VUR.  Antibiotic prophylaxis in neuropathic bladders, in patients on clean intermittent catheterisation  confer little benefit. 

Conclusion:

A detailed ultrasound of the urinary tract is usually sufficient as the investigation of the child with UTI.  Radio isotope scan, if available, can be useful looking for scars and excretion.  Most cases do not require antibiotic prophylaxis but rather a vigorous and immediate 5 days’ course of antibiotics, if they develop a febrile UTI.  Antibiotic prophylaxis would be indicated for patients with a history of recurrent febrile UTI, usually in patients with higher grade reflux. When prophylactic antibiotic fails, ureteric   re-implantation may be considered. 

Keywords:

Vesico ureteric reflux, MCUG, antibiotic prophylaxis, Deflux, ureteric re-implantation.

Presented at 25th Malaysian Urological Conference KL 25 Nov 2016

USM Medical Students, drs & staff keen to learn urology!