Puri Prem, Mohanan Nochiparambil, Menezes Maria, Colhoun Eric
National Children's Hospital, Dublin, Ireland.
J Urol. 2007 Oct;178(4 Pt 2):1714-6; discussion 1717. doi: 10.1016/j.juro.2007.03.172. Epub 2007 Aug 17.
Renal parenchymal injury in vesicoureteral reflux occurs early, in most patients before age 3 years. It is generally believed that early prevention of urinary tract infections may decrease the amount of renal parenchymal damage. Endoscopic treatment for vesicoureteral reflux has become an established alternative to long-term antibiotic prophylaxis and ureteral reimplantation. We prospectively evaluated the effectiveness and safety of dextranomer/hyaluronic acid copolymer for high grade vesicoureteral reflux in infants.
A total of 276 infants, including 124 boys and 152 girls, with a median age of 7 months (range 2 to 12) underwent endoscopic treatment for vesicoureteral reflux with dextranomer/hyaluronic acid. Reflux was detected in 225 infants following investigation for urinary tract infection, in 46 following screening for sibling vesicoureteral reflux and in 5 for prenatally diagnosed hydronephrosis. Vesicoureteral reflux was unilateral in 85 infants and bilateral in 191 (467 refluxing ureters). Reflux was grade II in 14 ureters, grade III in 188, grade IV in 248 and grade V in 17. Dimercapto-succinic acid scan was performed in 250 infants and it demonstrated renal scarring in 43 (17.2%).
Vesicoureteral reflux completely resolved in 373 ureters (79.9%) after a single injection of dextranomer/hyaluronic acid and it was downgraded to grade I in 21 (4.4%). Of the ureters 65 (14%) required a second injection and 8 (1.7%) required a third injection to resolve reflux. All patients underwent endoscopic treatment on an outpatient basis. There were no complications except in 1 patient, who was readmitted to the hospital the next day with acute pyelonephritis. Three children had urinary tract infections during followup, of whom 1 was found to have recurrent reflux on investigation.
Endoscopic treatment with dextranomer/hyaluronic acid is safe and highly effective for eradicating high grade vesicoureteral reflux in infants. Early intervention in infants with high grade reflux may change its natural history and protect against renal scarring.
膀胱输尿管反流导致的肾实质损伤出现较早，多数患者在3岁前发病。一般认为，早期预防尿路感染可能会减少肾实质损伤的程度。膀胱输尿管反流的内镜治疗已成为长期抗生素预防和输尿管再植术之外的一种既定选择。我们前瞻性评估了葡聚糖/透明质酸共聚物治疗婴儿重度膀胱输尿管反流的有效性和安全性。
共有276例婴儿接受了葡聚糖/透明质酸内镜下膀胱输尿管反流治疗，其中男124例，女152例，中位年龄7个月（2至12个月）。225例婴儿因尿路感染检查发现反流，46例因筛查同胞膀胱输尿管反流发现反流，5例因产前诊断肾积水发现反流。85例婴儿为单侧膀胱输尿管反流，191例为双侧（467条反流输尿管）。14条输尿管为Ⅱ级反流，188条为Ⅲ级，248条为Ⅳ级，17条为Ⅴ级。250例婴儿进行了二巯基丁二酸扫描，其中43例（17.2%）显示有肾瘢痕形成。
单次注射葡聚糖/透明质酸后，373条输尿管（79.9%）的膀胱输尿管反流完全消失，21条输尿管（4.4%）反流降级为Ⅰ级。65条输尿管（14%）需要第二次注射，8条输尿管（1.7%）需要第三次注射才能消除反流。所有患者均在门诊接受内镜治疗。除1例患者外无并发症发生，该患者次日因急性肾盂肾炎再次入院。3例患儿在随访期间发生尿路感染，其中1例检查发现有复发性反流。
葡聚糖/透明质酸内镜治疗对根除婴儿重度膀胱输尿管反流安全且高效。对重度反流婴儿进行早期干预可能会改变其自然病程并防止肾瘢痕形成。
