Stein R, Ziesel C, Rubenwolf P, Beetz R
Abteilung Kinderurologie der Urologischen Klinik und Poliklinik, Universitätsmedizin Mainz, Johannes Gutenberg-Universität Mainz.
Urologe A. 2013 Jan;52(1):39-47. doi: 10.1007/s00120-012-3079-z.
The never ending discussion about the diagnostics and treatment of vesicoureteral reflux (VUR) now includes arguments for diagnostic nihilism as well as invasive diagnostics and therapy, which is reminiscent of the debate on prostate cancer in adulthood. The common goal of all currently competing diagnostic strategies and approaches is the prevention of renal scars by the most effective and least burdensome approach. There is a difference between acquired pyelonephritic scars with VUR (acquired reflux nephropathy) and congenital reflux nephropathy (primary dysplasia) which cannot be influenced by any therapy.The VUR can be verified by conventional radiological voiding cystourethrography (VCUG), by urosonography, radionuclide cystography or even by magnetic resonance imaging (MRI). The guidelines of the European Association of Urology/European Society for Paediatric Urology (EAU/ESPU) recommend radiological screening for VUR after the first febrile urinary tract infection. Significant risk factors in patients with VUR are recurrent urinary tract infections (UTI) and parenchymal scarring and the patients should undergo patient and risk-adapted therapy. Infants with dilating reflux have a higher risk of renal scarring than those without dilatation of the renal pelvis. Bladder dysfunction or dysfunctional elimination syndrome represents a well-known but previously neglected risk factor in combination with VUR and should be treated prior to any surgical intervention as far as is possible.Certainly not every patient with VUR needs therapy. The current treatment strategies take into account age and gender, the presence of dysplastic or pyelonephritic renal scars, the clinical symptoms, bladder dysfunction and frequency and severity of recurrent UTI as criteria for the therapy decision. The use of an antibacterial prophylaxis as well as the duration is controversially discussed. Endoscopic therapy can be a good alternative to antibacterial prophylaxis or a surveillance strategy in patients with low grade VUR. In patients with dilating VUR and given indications for surgery, endoscopic treatment can be offered. However, parents should be completely informed about the significantly lower success rate of endoscopic therapy compared to open surgical procedures. The open surgical techniques guarantee the highest success rates and should be used in patients with a dilating VUR and high risk of renal damage.
关于膀胱输尿管反流（VUR）诊断与治疗的无休止讨论，如今涵盖了支持诊断虚无主义以及侵入性诊断和治疗的观点，这让人想起了关于成人前列腺癌的争论。当前所有相互竞争的诊断策略和方法的共同目标，是以最有效且负担最小的方式预防肾瘢痕。伴有VUR的后天性肾盂肾炎瘢痕（后天性反流性肾病）与先天性反流性肾病（原发性发育异常）之间存在差异，任何治疗都无法对后者产生影响。VUR可通过传统放射学排尿性膀胱尿道造影（VCUG）、超声检查、放射性核素膀胱造影甚至磁共振成像（MRI）来证实。欧洲泌尿外科学会/欧洲小儿泌尿外科学会（EAU/ESPU）指南建议在首次发热性尿路感染后对VUR进行放射学筛查。VUR患者的重要危险因素是反复尿路感染（UTI）和实质瘢痕形成，患者应接受个体化且根据风险调整的治疗。伴有扩张性反流的婴儿发生肾瘢痕的风险高于肾盂无扩张的婴儿。膀胱功能障碍或功能性排尿障碍综合征是与VUR相关的一个众所周知但此前被忽视的危险因素，应在尽可能的情况下在任何手术干预之前进行治疗。当然，并非每个VUR患者都需要治疗。当前的治疗策略将年龄和性别、发育异常或肾盂肾炎性肾瘢痕的存在、临床症状、膀胱功能障碍以及反复UTI的频率和严重程度作为治疗决策的标准。抗菌预防的使用及其持续时间存在争议。对于轻度VUR患者，内镜治疗可以是抗菌预防或监测策略的良好替代方案。对于伴有扩张性VUR且有手术指征的患者，可以提供内镜治疗。然而，应让家长充分了解内镜治疗与开放手术相比成功率显著较低的情况。开放手术技术保证了最高成功率，并应用于伴有扩张性VUR且肾损伤风险高的患者。
