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[Results of antireflux surgery in infants with vesicoureteral reflux]
K Shimada1, S Hosokawa, F Matsumoto
1Osaka Medical Center and Research Institute for Maternal and Child Health.
Insights
Early antireflux surgery in infants with high-grade vesicoureteral reflux shows a 100% success rate. This study supports prompt surgical intervention for better outcomes in young children with this condition.
Area of Science:
- Pediatric Urology
- Surgical Innovation
- Infant Health
Background:
- Increased detection of vesicoureteral reflux (VUR) in infants due to advanced screening.
- Ongoing debate regarding optimal management: conservative versus surgical treatment for VUR.
Purpose of the Study:
- To evaluate the efficacy of early antireflux surgery in infants under one year of age.
- To assess outcomes and identify factors contributing to successful surgical management of VUR.
Main Methods:
- Analysis of clinical data from 51 infants with primary VUR undergoing antireflux surgery before age one.
- Surgical techniques included Cohen transverse advancement, modified Politano-Leadbetter, and Glenn-Anderson advancement.
Main Results:
- 80% of infants presented with febrile urinary tract infections; high-grade reflux (IV-V) was common (79%).
- Renal parenchymal abnormalities were noted in 74% of kidneys.
- A 100% success rate was achieved with no persistent reflux in 49 children at 6-month follow-up.
Conclusions:
- Early antireflux surgery in infants with high-grade VUR demonstrates a 100% success rate.
- Key factors for success include thorough pre-operative evaluation, specialized instruments, ureteral tapering when needed, and use of operative loupes.
Background:
Due to the advancement of prenatal and postnatal ultrasound screening in addition to better understanding by pediatricians, more infants have been detected to have vesicoureteal reflux. There are still debates, however, about their management whether to take conservative or surgical treatment.
Methods:
We analysed clinical courses of 51 children with primary reflux undergoing antireflux surgery when they were under 1 year.
Results:
A total of 41 infants (80%) presented with febrile urinary tract infections. The first UTI was seen as early as 7th day after birth, with the average age of 2 months. Seven infants had hydronephrosis detected by prenatal ultrasound, and 2 were identified by neonatal screening ultrasonography. Sixty-eight of 86 reflux ureters (79%) showed high grade reflux (grade IV approximately V). All the other 18 ureters with mild to moderate grade of reflux except one accompanied with contralateral high grade reflux. One ureter with grade II reflux was associated with contralateral obstructed meganreter. Renal parenchymal abnormalities, either with scarring and/or small kidney, were identified in 64 kidneys (74%) at or before the reimplantation. The operation was done as early as 1 month-old with the average age of 5.6 months. Among the children, 24 (47%) underwent anti-reflux surgery before 6 month-old. Smallest infant weighted 2500 gr at the time of operation. Reimplantation was done by the Cohen transverse advancement technique in 75 ureters (87%). The modified Politano-Leadbetter method in 6 with Hutche's diverticulum, and the Glenn-anderson advancement method in 5 with moderate to mild reflux. Two dilated ureters were treated with folding of the intravesical segment. Follow-up voiding cystourethrogram of 49 children at 6 months revealed no evidences of persistent reflux. There were no patients with obstruction of reimplantation except one with slight upper-tract dilatation. One infant revealed new low grade contralateral reflux, and he is being observed. Two children presented pyelonephritis after the operation.
Conclusion:
Our success rate of 100% in antireflux surgery enables us to continue our policy to perform early operative interventions in infants with high grade reflux. In addition to the meticulous and careful technique, the conditions for successful results include; 1) A through checkup of the lower tracts by VCG and endoscopy. 2) Find the better operative instruments for the small bladder. 3) Do not hesitate to perform the ureteral tapering. 4) Make good use of operative loupe.