[Long=term evaluation of renal damage in primary vesico-renal reflux after corrective surgery]

Traditionally 3 mechanisms are responsible for the development of renal damage when primary vesico-renal reflux is present: reflux is a manifestation of abnormal embryological development of the ureteral bud, with subsequent dysplasia; sterile reflux damages the kidney, perhaps trough a mechanical or/and an immunological mechanism; renal damage occurs as a result of the reflux of infected urine into susceptible renal papilla (intrarenal reflux). Whatever the mechanism, it is apparent that reflux and renal damage are intimately related. It does appear that for the most part damage is done at an early age. Operative repair of vesico-renal reflux has been advocated as a reliable method to stop reflux, with attendant cessation of renal damage and improvement in renal function. However some recent prospective study found that the rate of continued renal scarring is independent of medical or surgical therapy. The aim of the present paper is to study the functional and radiological long-term results after successful antireflux surgery (mean follow-up 6 years 4/12). 90 patients for a total of 140 refluxing ureters were studied for assessment of urinary infection, blood pressure and renal function. 40 patients for a total of 62 refluxing ureters were evaluated for determination of renal parameters evolution. At follow-up from 3 to 14 years (mean 6 4/12 years), less than 10% of the patients showed pathological bacteriuria generally without episodes of acute pyelonephritis. Hypertension was present in 4 (4.4%) out of 90 patients, aged from 14 to 18 years. There was a significant improvement in renal function after operation, especially in infants operated on in the first two years of life. The postoperative radiological study showed a growing of affected kidneys in about 89%. In almost 47%, the affected kidneys showed an increased growth. Only about the 5% of the kidneys showed a decreased development with a final evolution toward a small pyelonephritic kidney. The best results were obtained in patients operated on very early in the life. Our greatest challenge is to prevent the early destruction of nephrons. This means an early diagnosis of urinary tract infection and detection of vesico-renal reflux with an early treatment. The administration of prophylactic antibiotics and, when indicated, an early surgical treatment can minimize, in our opinion, the magnitude of renal damage for the most part of patients.