<prompt> Tt of choice for grade IV vesicoureteric reflux with recurrent UTICotrimox azoleBilateral reimplantation of ureterInjection of Collegen in the ureterEndoscopic resection of ureter  <response>: Ans. is a ie. Cotrimoxazole Ref. Nelson, 18e p2233 16e, p 1628Dont get misled by this statement given in O.P. Ghai - Operative correction of VUR is indicated inpts. with - persistent severe grade IV or V refluxThis statement does not mean that any pt. with grade IV V reflux will be given surgical management and rest medical management. Treatment is not so clear-cut.The choice bw medical or surgical modality is based on certain principles go through the following text to understand it.The below given explanation is a bit lengthy. Bear with me for giving such a long text, as it is one of the most important but less read topic UG books do not give sufficient information on its treatment.This explanation will help you to tackle any future question on tt of VUR with different patient profile as tt changes with grades as well as age of the patientVesicoureteral reflux VURis the retrograde flow of urine from the bladder to the ureter and the renal pelvisGrading of VUR : is based on the appearance of the urinary tract on Micturating Cystourethrogram MCU.Grade 1reflux into a non-dilated ureterGrade IIreflux into the upper collecting system without dilatation.Grade IIIreflux into dilated ureter and or blunting of calyceal fornicesGrade IVreflux into a grossly dilated ureterGrade VGross dilatation of the ureter, renal pelvis calyces : calyces show loss of papillary impression. Complications of VURReflux predisposes to renal infection pyelonephritis by facilitating the transport of bacteria from the bladder to the upper urinary tract.The inflammatory reaction caused by a pyelonephritic infection may result in renal injury or scarring.Extensive renal scarring impair renal function and may result in renin mediated hypertension, reflux nephropathy, renal insufficiency, end stage renal disease, reduced somatic growth and morbidity during pregnancy. TreatmentThe goals of tt are to prevent pyelonephritis, renal injury, and other complication of reflux.Treatment modality is either medical or surgical.Medical therapyis based on the principle that reflux often resolves over time and the antibiotics maintain urine sterility and prevent infection and complication while awaiting spontaneous resolution.Surgical therapy :the basis for surgical therapy is that in selected children, ongoing reflux has caused or has significant potential for causing renal injury.The decision to do medical or surgical tt is based on certain principles and parental, patient preferences.Below is given a chart listing the treatment recommendation for VUR.Before going through the chart lets see the basic principles on which this chart is based -With bladder growth and maturation, there is tendency for reflux to resolve or improve over time.Lower grades of reflux are much more likely to resolve than are higher grades.For grades I II reflux, the likelihood of resolution is similar irrespective of age at diagnosis and whether if it unilateral or bilateral.For grade III IV a younger age at diagnosis and unilateral reflux generally are associated with a higher rate of spontaneous resolution.Grade V reflux rarely resolves.The mean age for reflux resolution is 6 - 7 yrs.Reflux is unlikely to cause any renal injury in the absence of infection.Treatment Recommendation for VUR diagnosed following a UTI.GradeAge yrsScarringInitial ttFollow-upI-iiAny-Antibiotic prophylaxis-III - IV0-5-Antibiotic prophylaxisSurgeryIII - IV6- 10-UL: Antibiotic prophylaxisSurgeryIII - IV6 - 10-BL: Surgery V1-Antibiotic prophylaxisSurgeryV1 - 5NoUL: Antibiotic prophylaxisSurgeryV1 - 5NoBL: Surgery V1 - 5YesSurgery V6- 10-Surgery ThusMedical Management is the initial tt in almost all children except for -Grade III IV BilateralGrade V MostlyMedical management antibiotic prophylaxis is continued till the reflux resolves.Pt. is shifted from medical to surgical management, in children withbreakthrough UTI Recurrent UTI despite prophylaxisDevelopment of new renal scarsFailure of reflux to resolve.Thus in this question we will begin with medical management ie cotrimoxazole. This pt is having recurrent UTI. This will not alter our tt. If the pt. had recurrent UTI despite prophylaxis, we would have done a surgical management.If you have a close look at the statement of O.P. Ghai, you will note that he is not stating that grades IV V will be tt surgically. It is persistent grades IV V that are tt surgically persistent means VUR that are not resolving over time. 