Urology Department, Children's Hospital at Westmead and Discipline of Imaging and Paediatrics, Sydney, New South Wales, Australia.
J Urol. 2010 Oct;184(4 Suppl):1598-603. doi: 10.1016/j.juro.2010.04.021. Epub 2010 Aug 21.
We evaluated the incidence of new permanent defects in boys with grade 4 or 5 vesicoureteral reflux, identified the risk factors for new permanent defects and reviewed the outcome of different management approaches by assessing the rates of urinary tract infection and new permanent defects.
This prospective cohort study recruited patients from July 1995 to December 2006. Study inclusion criteria were male gender and grade 4 or 5 primary vesicoureteral reflux. Patients were divided into 2 groups by presentation mode, including group 1-prenatal reflux diagnosis and group 2-reflux diagnosed after investigation for urinary tract infection. All patients underwent initial renal (99m)Tc-dimercapto-succinic acid scan evaluation. Continuous antibiotic prophylaxis was given in all patients until at least age 2 years. Surgical correction for reflux was done in 28 patients and 76 were circumcised. Followup included renal (99m)Tc-dimercapto-succinic acid scan with renal ultrasound at age 12 months with repeat (99m)Tc-dimercapto-succinic acid scan at ages 2 and 4 years.
Included in our study were 151 patients (206 high grade refluxing renal units) with a median age at diagnosis of 1.9 months (range 1 day to 8.8 years). Median age at first followup was 14 months (range 3 months to 3 years) and at next followup it was 39 months (range 10 months to 11.3 years). There were 52 boys (34%) in group 1 and 99 (66%) in group 2. Baseline perfusion defects on initial renal (99m)Tc-dimercapto-succinic acid scan were identified in 41 of 52 boys (78.8%) in group 1 and in 74 of 99 (74.7%) in group 2. During followup new permanent defects developed in 8 of 52 boys (15%) in group 1 and in 10 of 99 (10%) in group 2. In 18 patients a total of 20 renal units showed new permanent defects, including 13 in kidneys with baseline perfusion defects and 7 in previously normal kidneys (p >0.9). In groups 1 and 2 combined infection developed before and after circumcision in 62 of 137 (45.2%) and 5 of 74 cases (6.7%), respectively (p <0.001). New permanent defects were seen in 4 of 76 circumcised (5.2%) and in 14 of 137 uncircumcised boys (10.2%) (p >0.3).
Baseline perfusion defects were seen on (99m)Tc-dimercapto-succinic acid scan at presentation in 115 of our 151 patients (76%) independent of presentation mode. New permanent defects developed in abnormal and previously normal kidneys, and were associated with urinary tract infection. Being circumcised was associated with fewer urinary tract infections and a lower incidence of observed new permanent defects (5.2% vs 10.2%).
我们评估了患有 4 或 5 级膀胱输尿管反流的男孩中新永久性缺陷的发生率，确定了新永久性缺陷的危险因素，并通过评估尿路感染和新永久性缺陷的发生率来评估不同治疗方法的结果。
本前瞻性队列研究招募了 1995 年 7 月至 2006 年 12 月的患者。研究纳入标准为男性和 4 或 5 级原发性膀胱输尿管反流。患者根据表现模式分为两组，包括组 1-产前反流诊断和组 2-尿路感染后诊断。所有患者均接受初始肾脏（99m）Tc-二巯丁二酸扫描评估。所有患者均接受持续抗生素预防治疗，直至至少 2 岁。28 例患者接受手术矫正反流，76 例患者接受割礼。随访包括在 12 个月龄时进行肾脏（99m）Tc-二巯丁二酸扫描和肾脏超声检查，并在 2 岁和 4 岁时重复进行（99m）Tc-二巯丁二酸扫描。
我们的研究纳入了 151 名患者（206 个高级反流性肾单位），中位诊断年龄为 1.9 个月（范围 1 天至 8.8 岁）。首次随访的中位年龄为 14 个月（范围 3 个月至 3 年），下一次随访为 39 个月（范围 10 个月至 11.3 年）。组 1 中有 52 名男孩（34%），组 2 中有 99 名男孩（66%）。组 1 中 52 名男孩中有 41 名（78.8%）和组 2 中有 74 名（74.7%）在初始肾脏（99m）Tc-二巯丁二酸扫描时存在灌注缺损。在随访期间，组 1 中有 8 名（15%）男孩和组 2 中有 10 名（10%）男孩出现新的永久性缺陷。在 18 名患者中，总共 20 个肾脏单位出现新的永久性缺陷，其中 13 个在基线灌注缺陷的肾脏中，7 个在以前正常的肾脏中（p>0.9）。组 1 和组 2 中，分别有 62 例（45.2%）和 5 例（6.7%）在割礼前和割礼后发生感染（p<0.001）。在 76 名接受割礼的男孩中，有 4 名（5.2%）和在 137 名未接受割礼的男孩中有 14 名（10.2%）出现新的永久性缺陷（p>0.3）。
在我们的 151 名患者中（76%），115 名患者在出现时的（99m）Tc-二巯丁二酸扫描上出现灌注缺损，与表现模式无关。新的永久性缺陷发生在异常和以前正常的肾脏中，并与尿路感染有关。接受割礼与尿路感染较少和观察到的新永久性缺陷发生率较低（5.2%比 10.2%）有关。
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