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Surgical results in the International Reflux Study in Children (Europe)
K Hjälmås1, G Löhr, T Tamminen-Möbius
1Department of Pediatric Surgery, East Hospital, Gothenberg, Sweden.
Insights
Surgical reimplantation effectively treats severe vesicoureteral reflux in children, with a 97.5% success rate and fewer pyelonephritic episodes compared to medical management. Long-term follow-up shows good outcomes.
Area of Science:
- Pediatric Urology
- Surgical Outcomes
- Renal Health
Background:
- Vesicoureteral reflux (VUR) is a common condition in children, potentially leading to kidney damage.
- Primary grades III and IV VUR often require intervention to prevent complications.
- Surgical management aims to restore normal urinary tract function and prevent renal scarring.
Purpose of the Study:
- To evaluate the long-term efficacy and safety of surgical reimplantation for primary grades III and IV VUR in children.
- To compare surgical outcomes with medical management regarding reflux resolution, obstruction, and renal scarring.
- To determine the rate of uncomplicated postoperative courses following ureteral reimplantation.
Main Methods:
- A randomized study involving 151 infants and children with primary grades III and IV VUR.
- Surgical ureteral reimplantation performed unilaterally or bilaterally on 237 ureters.
- Patients followed for 5 years, with regular assessments including voiding cystourethrography and excretory urography.
Main Results:
- Reflux resolved in 97.5% of reimplanted ureters after 5 years.
- Postoperative obstruction occurred in 4.2% of ureters, requiring reoperation in 7 cases.
- The surgical group experienced significantly fewer pyelonephritic episodes than the medically treated group.
- New renal scars were equally distributed between surgical and medical groups over 5 years.
- 74% of patients had an uncomplicated postoperative course.
Conclusions:
- Ureteral reimplantation is a highly effective treatment for severe VUR in children, offering a high success rate and reduced risk of pyelonephritis.
- While postoperative obstruction is a potential complication, it is manageable and does not negate the overall benefits of surgery.
- Early normalization of imaging post-surgery reliably indicates successful reflux eradication and absence of significant obstruction.
Abstract:
In the European part of the International Reflux Study in Children (7 participating centers) 151 infants and children were randomly allocated to surgical treatment of primary grades III and IV vesicoureteral reflux. Reimplantation was performed unilaterally in 65 patients and bilaterally in 86, for a total of 237 ureters reimplanted. The patients were followed at regular intervals for 5 years. Reflux was absent in 231 of the reimplanted ureters (97.5%) at the end of 5 years. No patient underwent reoperation for reflux. In 10 ureters (4.2%, 10 patients) obstruction developed postoperatively and 7 needed reoperation. All reoperations were performed on the left side. Of the obstructed kidneys new scars developed in 6 during the 5-year followup. Including these cases, the number of new renal scars was equal in the surgical and medical groups (20 each). The number of pyelonephritic episodes during followup was significantly less in the surgical group (without chemoprophylaxis) than in the medical group (on chemoprophylaxis). No kidneys were lost and no child became hypertensive. If voiding cystourethrography and excretory urography were normal 6 months postoperatively, the reflux had been permanently eradicated and postoperative obstruction could be ruled out. In this study the patients who underwent reimplantation had a 74% (112 of 151) chance of an uncomplicated postoperative course (no persisting reflux, obstruction, pyelonephritis or severe renal damage).