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Management considerations for treating vesicoureteral reflux in children with solitary kidneys
L S Palmer1, G J Andros, M Maizels
1Division of Urology, Children's Memorial Medical Center/Northwestern University Medical School, Chicago, Illinois 60614, USA.
Insights
Vesicoureteral reflux (VUR) in a solitary kidney can be managed with observation for low-grade cases and surgery for high-grade reflux, ensuring renal function preservation. Most cases resolve, with diligent monitoring crucial for outcomes.
Area of Science:
- Pediatric Urology
- Nephrology
- Surgical Management
Background:
- Vesicoureteral reflux (VUR) in a solitary kidney presents unique management challenges.
- Understanding optimal strategies is crucial for preserving renal function in affected children.
Purpose of the Study:
- To evaluate the effectiveness of different management approaches for VUR in children with solitary kidneys.
- To compare outcomes of observation versus surgical interventions.
Main Methods:
- Retrospective review of children with solitary kidneys and VUR (1981-1996).
- Diagnosis via nuclear renography, ultrasonography, and cystography for reflux grading.
- Management included observation with antimicrobial prophylaxis or surgical repair (ureteroneocystostomy, STING).
Main Results:
- Twenty-one patients were analyzed with a median follow-up of 26 months.
- Reflux resolved in 20 patients; 5 with low-grade VUR resolved with observation alone.
- Surgical management for high-grade VUR (grades III-V) resulted in stable renal function and no infections.
Conclusions:
- Management strategies for VUR in solitary kidneys mirror those for bilateral kidneys: observation for low grades and surgery for high grades.
- Close monitoring of renal function is essential throughout management.
- Surgical intervention effectively protects renal function in high-grade VUR cases.
Objectives:
To evaluate the management approach for vesicoureteral reflux (reflux) into a solitary kidney.
Methods:
Outcomes of all children with solitary kidneys and reflux managed between 1981 and 1996 were reviewed. Solitary kidneys were documented by nuclear renography and ultrasonography; reflux was graded after cystography. Management consisted of observation and antimicrobial prophylaxis or surgery by ureteroneocystostomy or subureteric injection of polytetrafluoroethylene (STING). Follow-up ranged from 3 months to 14 years and included serial cystography, sonography, and serum creatinine measurement.
Results:
Twenty-one patients with a median follow-up of 26 months were identified. Etiologies included contralateral renal agenesis (14 children), multicystic dysplastic kidney (5 children), or nonfunctioning ureteropelvic junction obstruction (2 children). Low-grade (I to II) reflux was identified in 6 children, and high grade (III to V) was identified in 15. Reflux resolved in 20 patients. Five children with low-grade reflux were managed without surgery and demonstrated reflux resolution after a mean of 20.5 months. Renal function deteriorated in only 1 child. Ureteroneocystostomy was performed in 13 children with grades III to V reflux, and STING was performed in 1 child with grade II reflux. Every surgical patient maintained stable renal function and was infection-free during a mean follow-up of 56 months. Management by observation in 2 children with grades IV to V reflux resulted in spontaneous resolution in one and stable grade IV in the other.
Conclusions:
Reflux into the solitary functioning kidney may be managed by the same strategies used to manage unilateral reflux in children with two normally functioning kidneys: low-grade reflux by observation/ chemoprophylaxis until spontaneous resolution occurs, and higher grades by surgery to protect renal function; however, chemoprophylaxis and serial imaging may be used until well-defined indications for surgery are satisfied. Renal function should be monitored diligently.