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Early versus late surgical management of fetal reflux nephropathy
1Department of Pediatric Urology, Chang Gung Medical College, Kaohsiung, Taiwan.
Insights
Early antireflux surgery for infants with congenital reflux nephropathy prevents urinary tract infections and new kidney scarring. This approach offers a better prognosis compared to delayed surgery, especially in high-grade vesicoureteral reflux cases.
Area of Science:
- Pediatric Urology
- Nephrology
- Surgical Innovation
Background:
- Infants with reflux nephropathy are prone to urinary tract infections (UTIs) and prolonged postnatal vesicoureteral reflux (VUR).
- High-grade VUR necessitates careful management to prevent renal damage.
Purpose of the Study:
- To evaluate the efficacy of early antireflux surgery versus chemoprophylaxis in infants with congenital reflux nephropathy.
- To compare outcomes of early versus late surgical intervention for high-grade VUR.
Main Methods:
- Retrospective analysis of 22 neonates with primary high-grade VUR (grade III-IV).
- 11 neonates diagnosed with congenital reflux nephropathy underwent either early surgery (before UTI) or late surgery (after UTI).
- All patients were monitored for up to 2 years post-intervention.
Main Results:
- Early surgery (mean 8 weeks) in 5 neonates without UTI showed no postoperative UTIs or new scarring.
- Late surgery (mean 24 weeks later) in 6 neonates with prior UTI resulted in postoperative infections and significantly more new scarring (90% vs 22%).
- Renal growth retardation occurred in units with general nephropathy in both groups.
Conclusions:
- Congenital reflux nephropathy increases susceptibility to UTIs and renal scarring.
- Early antireflux surgery before UTI offers a superior prognosis, reducing complications in high-grade VUR.
Purpose:
Considering that infants with reflux nephropathy may be susceptible to urinary tract infection or longer postnatal vesicoureteral reflux, an early antireflux procedure rather than chemoprophylaxis may be indicated after birth.
Materials And Methods:
In 15 male and 7 female neonates bilateral and unilateral primary high grade vesicoureteral reflux was detected prenatally in 15 and 7, respectively, on the basis of dilatation of the urinary tract. There was grade III or IV reflux in the 37 refluxing renal units and all patients received chemoprophylaxis after birth. In 11 neonates congenital reflux nephropathy was diagnosed during month 1 of life, including 5 (9 refluxing renal units) who underwent early antireflux surgery without evidence of urinary tract infection and 6 (11 refluxing renal units) who underwent late surgery with a history of urinary tract infection. All patients treated nonsurgically and surgically were monitored up to 2 years and for 2 years postoperatively, respectively.
Results:
Of the 11 patients (17 renal units) without congenital reflux nephropathy reflux improved in 53%, a documented urinary tract infection occurred in 2 and there was no development of new scars in a previously normal kidney. In the 11 patients (20 renal units) with congenital reflux nephropathy the parenchymal defect detected during month 1 of life was general or focal, that is at the mid zone as well as the poles. Surgery was performed at a mean of 8 weeks of life in 5 patients without a documented urinary tract infection, 24 weeks earlier than in the 6 with a history of urinary tract infections. Postoperative breakthrough infections occurred in all 6 infants who underwent late surgery and in none who underwent early surgery (p < 0.05). New scarring developed in previously scarred renal units but there was more new scarring in the renal units treated with late surgery (10 of 11, 90%) than in those treated with early surgery (2 of 9, 22%, p < 0.001). In both groups retardation of growth was identified in the renal units with general nephropathy.
Conclusions:
Renal units with fetal reflux nephropathy were susceptible to urinary tract infections and new scar formation. Early antireflux surgery performed before a urinary tract infection develops offers a better prognosis than late surgery.