Early versus late surgical management of fetal reflux nephropathy

Correlation of Renal Scarring to Urinary Tract Infections and Vesicoureteral Reflux in Children

Objective

To study the association of the grade of vesicoureteral reflux (VUR) and urinary tract infections (UTI) with renal scarring at the first clinical presentation of patients who underwent antireflux surgery. Materials and methods. Between 2015 and 2020, 150 patients (194 units) who underwent antireflux surgery had dimercaptosuccinic acid (DMSA) renal scans preoperatively. Patients were classified into the nonscar and scar groups according to DMSA scan results. Moreover, cases were classified into afebrile UTI, febrile UTI, and antenatal hydronephrosis (ANH) according to the mode of presentation. We correlated the mode of presentation and the grade of VUR to the presence/absence of renal scars in both groups.

Results

The mean follow-up was 45 months preoperatively. The mode of presentation was afebrile, febrile UTIs, and antenatal hydronephrosis in (50, 14), (20, 46), and (10, 10) patients in the nonscar and scar groups, respectively. Of the 20 patients who presented ANH, 10 (50%) had scars. Clinical presentation was correlated to the presence of renal scarring and its degree. The scar group had significantly higher grades of VUR than the nonscar group (grades I–II (50 units versus 10 units), grade III (28 units versus 40 units), and grade IV–V (22 units versus 44 units) for the nonscar versus scar groups, respectively (pvalue <0.001).

Conclusion

Renal scarring is associated with higher grades of reflux and urinary tract infections. We advocate further research investigating infants who had UTIs with or without fever for early detection of reflux.

Endoscopic bulking materials for the treatment of vesicoureteral reflux: a review of our 20 years of experience and review of the literature

Purpose. We reviewed our 20 years of experience and the current literature regarding the long-term outcome of endoscopic treatment of vesicoureteric reflux (VUR) using the different tissue bulking substances with a special emphasis on the long-term efficacy. Material and Methods. Our own experience and the current literature on the long-term results after endoscopic treatment using various bulking agents were reviewed. Results. Short-term data following endoscopic treatment of VUR is similar to the various substances and comparable in the majority of the series to the success rate following open surgery. Recently, a relatively high recurrence rate was noticed especially with the use of dextranomer hyaluronic acid (Dx/HA) as a tissue augmenting material which raises the need for further search for alternative substances. Conclusions. Unfortunately, there is a significant shortage of evidence-based literature on the long-term followup after endoscopic correction of reflux with various substances. No doubt, there is a high recurrence rate during long-term followup after Dx/HA injection, and there is probably lack of proper evaluation regarding the long-term efficacy of other bulking materials. These facts demand long-term close observation and long-term studies beyond the routine protocols following endoscopic treatment of VUR and the correct parental counseling upon the endoscopic correction.

Long-term results of endoscopic treatment of vesicoureteric reflux with different tissue-augmenting substances

OBJECTIVE

To review the current literature regarding the outcome of endoscopic treatment of vesicoureteric reflux (VUR) using different tissue-augmenting substances, with special emphasis on long-term efficacy.

MATERIAL AND METHODS

The current literature, including our own experience, on long-term results after endoscopic treatment was reviewed by MEDLINE/PubMed search.

RESULTS

The short-term results are similar in the majority of series to those of open surgery, but there is a high recurrence rate with use of dextranomer/hyaluronic acid (Deflux) as a tissue-augmenting material.

CONCLUSIONS

There is a significant shortage of evidence-based literature on long-term follow-up after endoscopic correction of VUR utilizing dextranomer/hyaluronic acid. The high recurrence rate that has been reported after Deflux injection highlights a need for close observation beyond routine protocols and appropriate parental counseling upon endoscopic correction, and also the need to search further for alternative tissue-augmenting substances. The algorithm for treating VUR is yet to be finally determined.

Renal scarring and urinary tract infection after successful endoscopic correction of vesicoureteral reflux

PURPOSE

We evaluated renal function and the incidence of urinary tract infection after successful endoscopic correction of vesicoureteral reflux.

MATERIALS AND METHODS

From 1988 to 2007, 169 male and 338 female patients (696 refluxing renal units) with a median age of 3.7 years underwent successful endoscopic correction of primary vesicoureteral reflux using polytetrafluoroethylene and dextranomer/hyaluronic acid copolymer. Reflux was grades I to V in 36 (5.2%), 178 (25.6%), 298 (42.7%), 163 (23.4%) and 21 refluxing renal units (3.1%), respectively. Renal ultrasound and (99m)technetium-dimercaptosuccinic acid scan were performed in all patients preoperatively, and in all patients and in 509 of 696 refluxing renal units (73%) postoperatively, respectively. All patients were followed 1 to 20 years (median 13).

RESULTS

Preoperatively (99m)technetium-dimercaptosuccinic acid scan revealed scarring in 543 of 696 refluxing renal units (78%). Reflux resolved after 1 injection in 473 refluxing renal units (68%), in 161 (23%) after 2 and in 25 ureters (3.6%) after 3. In 37 refluxing renal units (5.4%) reflux improved to grade I, which required no further treatment. Renal deterioration was noted in 11 of 26 refluxing renal units with initially severe renal scarring (less than 20% uptake on (99m)technetium-dimercaptosuccinic acid scan). The remaining refluxing renal units in this group showed an insignificant 2.3% change in relative function after successful reflux correction (p >0.005). Patients with vesicoureteral reflux downgrading did not show new renal scars. Of the remaining 446 refluxing renal units 27 (6.1%) showed a greater than 5% decrease in relative function without new scarring. Eight children in the polytetrafluoroethylene group and 3 in the dextranomer/hyaluronic acid copolymer group (overall 2.2%) had febrile urinary tract infection after successful endoscopic correction, leading to reevaluation that resulted in the diagnosis of recurrent reflux in 8 (72.7%). A total of 28 children (5.6%) had afebrile urinary tract infection without recurrent vesicoureteral reflux.

CONCLUSIONS

Our data show that successful endoscopic correction of vesicoureteral reflux is accompanied by a low incidence of new renal scarring and febrile urinary tract infection. Patients who initially have corrected reflux but who have a febrile urinary tract infection at long-term followup require prompt revaluation to rule out recurrent reflux.

Risk of renal scarring in vesicoureteral reflux detected either antenatally or during the neonatal period

OBJECTIVES

To evaluate both the demographic features and the renal outcome of fetal vesicoureteral reflux (VUR), two well-defined populations were analyzed: those with hydronephrosis detected by obstetric ultrasonography, and neonates diagnosed after developing their first urinary tract infection within the first 4 postnatal weeks.

METHODS

Twenty-one neonates with antenatally detected VUR were compared with 30 patients with neonatally detected symptomatic disease. The mode of presentation, fate of reflux, and renal outcome were analyzed.

RESULTS

Significantly more bilateral dilating VUR was found in postnatally versus antenatally diagnosed patients (53% versus 29%; P = 0.05). Fourteen percent presented with congenital renal dysplasia. No difference was found in the incidence of congenital dysplasia between the two groups. Focal renal scars developed during follow-up in 19% of renal units. New scars were observed in dilating VUR only, especially in grades 4 and 5 (P <0.05), and these were exclusively in the postnatal patient group (P <0.005).

CONCLUSIONS

Several demographic features of fetal VUR differ, depending on whether detected antenatally or postnatally. The incidence of bilateral dilating VUR was greater in postnatally detected cases, suggesting a more severe manifestation of the disease. Renal injury occurred in an appreciable number of renal units. The damage may be of congenital origin or may be acquired secondary to urinary tract infection. The risk of acquired renal scarring is particularly significant if dilating VUR is not detected until neonatally after the first urinary tract infection.

Infant vesicoureteral reflux: a comparison between patients presenting with a prenatal diagnosis and those presenting with a urinary tract infection

OBJECTIVES

To evaluate the severity, laterality, and gender distribution of infant vesicoureteral reflux (VUR) and its potential impact on renal outcome, we compared patients presenting fetally (FDR group) and those presenting with a urinary tract infection (INF group).

METHODS

A retrospective review of 202 patients with the diagnosis of VUR before 6 months of age was performed. The grade of VUR, gender, laterality, initial renal scarring, breakthrough urinary tract infections, new renal scarring, and surgical intervention were compared between the INF group (n = 146) and FDR group (n = 56).

RESULTS

The male/female ratio in the FDR group was 1.67:1 compared with 0.60:1 in the INF group. The FDR group had more unilateral VUR than the INF group (P <0.001), and no significant difference was found between the two groups in terms of VUR grade distribution (P = 0.13), percentage of initial damage (28% of FDR patients versus 23% of INF patients), or clinical course. In either group, boys and girls exhibited a very similar distribution of grade and renal damage.

CONCLUSIONS

Our findings do not support the commonly held belief that fetally diagnosed reflux is an overwhelmingly male, bilateral, and high-grade phenomenon. Few differences were observed between infants diagnosed fetally and those diagnosed subsequent to urinary tract infection. Once diagnosed, from either group, infant reflux has neither great morbidity nor a frequent need for surgery.

Reflux nephropathy in infancy: a comparison of infants presenting with and without urinary tract infection

PURPOSE

We compared the incidence of renal scarring in infants with high grade vesicoureteral reflux in those presenting with and without urinary tract infection.

METHODS AND METHODS

We reviewed the medical records of 81 male and 46 female infants (194 renal refluxing units) with a mean age of 4 months who had grade IV or V primary vesicoureteral reflux and underwent an anti-reflux procedure between 1984 and 1997. Dimercapto-succinic acid (DMSA) scans and voiding cystourethrography were performed in all cases. Patients were followed for 2 to 16 years, including 90% for greater than 3 years. Renal ultrasound and DMSA scan were done at followup.

RESULTS

A total of 97 patients (76%) (148 refluxing renal units) presented clinically with urinary tract infection. The initial DMSA scan demonstrated renal scarring in 40 of the 106 grade IV (38%) and 28 of the 42 grade V (67%) refluxing renal units. There was no scarring on followup in previously normal refluxing renal units. Of the patients 30 (24%) (46 refluxing renal units) were diagnosed before a urinary tract infection developed, 16 underwent screening due to vesicoureteral reflux in a sibling and in 10 reflux was initially suspected due to hydronephrosis on prenatal ultrasound. In the remaining 4 patients vesicoureteral reflux was suspected during abdominal ultrasound to investigate abdominal pain, jaundice, associated hypospadias and fetal alcohol syndrome, respectively. DMSA scan showed evidence of scarring in 6 of 21 grade IV (29%) and 9 of 25 grade V (36%) refluxing renal units in this group. Followup revealed scarring in only 1 previously normal refluxing renal unit.

CONCLUSIONS

The incidence of reflux nephropathy in primary grade V vesicoureteral reflux is lower in cases detected by screening and with treatment it remained lower than in cases of urinary tract infection that presented clinically. Early treatment of grade V vesicoureteral reflux made possible by screening may prevent renal damage.

The natural history of neonatal vesicoureteral reflux associated with antenatal hydronephrosis

PURPOSE

In an attempt to evaluate the natural history of neonatal vesicoureteral reflux, patients with antenatal history of hydronephrosis and documented reflux in the first 30 days of life were analyzed.

MATERIALS AND METHODS

Between 1993 and 1998, 260 patients with a history of antenatal hydronephrosis were referred for evaluation. Of these patients 31 were diagnosed with unilateral or bilateral refluxing renal units (54 renal units). Patients were treated with a prospective plan of observational therapy and prophylactic antibiotics, and resolution rate was calculated in patients with adequate followup. Reflux grade was correlated with postnatal ultrasonographic findings, urinary tract infections and differential renal function. Outcome analysis of 34 high grade (III to V) refluxing renal units using the Kaplan-Meier survival curves was undertaken with the end point being complete resolution or improvement. Three patients with vesicostomy and 2 who underwent ureteral reimplantation were excluded from analysis.

RESULTS

Reflux was grade I in 5% (33% males), II in 15% (62% males), III in 32% (71% males), IV in 18% (90% males) and V in 30% (100% males) of the patients. Postnatal ultrasound findings correlated poorly with the presence and degree of vesicoureteral reflux. Of 17 patients followed for at least 14 months (average followup 20) there was complete resolution in 60% with grade III, 50% with grade IV and 28% with grade V reflux. Using the Kaplan-Meier estimate there was a 50% chance of improvement (decrease in reflux grade by at least 2 grades) in high grade reflux by age 16 months. Urinary tract infections developed in 8 patients (26%) while on antibiotics. Of 46 renal units in 23 patients evaluated with a renal scan before urinary tract infection, 12 had less than 35% function.

CONCLUSIONS

A normal postnatal ultrasound should not be a basis for excluding the use of cystography. Our Kaplan-Meier estimate shows that high grade reflux does improve and may resolve spontaneously. In addition, renal scarring may be seen with high and low grade reflux in the absence of urinary tract infection but high grade reflux is associated with a higher incidence of infection.

Surgical treatment of vesicoureteral reflux in infants under 3 months of age

PURPOSE

Surgical treatment for vesicoureteral reflux (VUR) is controversial in infants, especially small infants because of technical difficulty and higher rate of spontaneous resolution. However, in some conditions, such as high-grade reflux, breakthrough infection, or severe renal scarring, early operation may be justified. This study is to evaluate the results of ureteral reimplantation in infants with VUR under 3 months of age.

METHODS

From January 1993 to July 1997, 13 boys and five girls (24 ureters) under 3 months of age (range, 18 days to 3 months; mean age, 2 months) received ureteral reimplantation for VUR. The initial symptoms were urinary tract infection (UTI) in 16 infants, hydronephrosis found by prenatal ultrasound scan in one, and early postnatal screening ultrasound scan in one. The indications for 24 ureter reimplantations were high-grade reflux (grade V, n = 7), breakthrough infection under medical treatment (n = 5), and severe renal scarring (n = 8) and contralateral low-grade refluxing ureters (n = 4). All patients had Glenn-Anderson's or Cohen's ureteral reimplantation. Ureteral stents were required in six ureters. All patients had renal sonogram 1 month after operation to rule out ureteral obstruction. Fifteen patients had voiding cystourethrogram (VCUG) after operation. Renal growth was evaluated in 15 patients (20 reflux renal units) using serial ultrasound or differential perfusion renal scan. The operative time, use of ureteral stent, complication rate, hospital stay, and time needed for clearing urine, were compared with those of 115 counterpart patients at age over 3 months. Data were analyzed using X(2) test or t test.

RESULTS

All patients, except one, were free of UTI during the follow-up of 6 months to 5 years. In fifteen infants who had postoperative VCUG, 14 were free of reflux, and one had persistent lower-grade VUR. One patient had transient ureteral obstruction that resolved spontaneously. One patient had postoperative ileus for 2 weeks. Renal growth of 20 reflux renal units was similar to that of the contralateral nonreflux kidneys. The only significant difference when compared with the patients over 3 months of age, was the higher incidence of ureteral stenting (25% v 4.2%, P<.01).

CONCLUSIONS

Ureteral reimplantation should be performed in infants under 3 months of age when it is indicated.