Belloli G, Bolla G, Cappellari F, Musi L
Department of Pediatric Surgery, Section of Urology, Regional Hospital, Vicenza, Italy.
Pediatr Surg Int. 1996 Jun;11(5-6):334-8. doi: 10.1007/BF00497806. Epub 2013 Sep 21.
We report the results of a medium-term follow-up study of 52 patients with bilateral, massive primary vesicorenal reflux (PVRR) with renal damage at presentation. Ten infants between 2 and 5 months of age, with a total of 19 renal units, had a temporary vesicostomy followed by ureteral reimplantation after 12-15 months; 42 patients with 81 renal units had primary ureteral reimplantation. The postoperative observation period covered 9.5 years on average (20 months - 21.5 years). The study showed that: (1) urinary specific gravity remained reduced in about 61% of patients; (2) proteinuria improved significantly, in a direct proportion to the favorable evolution of renal function; (3) the frequency of acute pyelonephritis decreased significantly from 98% to 23%. Postoperatively, 27 patients (51%) had one or more episodes of urinary tract infection (UTI) and 12 (23.0%) still had episodes of acute pyelonephritis. (4) At follow-up 7 patients (13.5%) had stable hypertension, while 3 others had unstable hypertension (19.2%); 8 had chronic renal insufficiency or end-stage renal disease. When only adolescents more than 12 years old were considered, the incidence of hypertension increased to 34.4% (10.29). (5) Some renal scarring developed despite successful antireflux surgery, and parenchymal growth, which was severely impaired prior to surgery, restarted although it remained below - 2 standard deviations from the mean. (6) In the overall series glomerular filtration rates (GFR) significantly improved after successful surgery. However, this improvement was much more evident in patients operated upon within the 1st year of life and in those who had had a temporary vesicostomy. In the subgroup of patients operated upon after 6 years of age, successful surgery had no effect on the further decline of renal function when this was already severely compromised. We conclude that early antireflux surgery or, in selected cases, temporary vesicostomy followed by ureteral reimplantation was effective in significantly improving GFR and sharply decreasing febrile UTIs in patients with massive bilateral PVRR and renal damage at presentation.
我们报告了一项对52例双侧重度原发性膀胱输尿管反流（PVRR）且就诊时伴有肾损害患者的中期随访研究结果。10例年龄在2至5个月的婴儿，共19个肾单位，先行临时膀胱造瘘术，12至15个月后再行输尿管再植术；42例患者共81个肾单位，直接进行了原发性输尿管再植术。术后观察期平均为9.5年（20个月至21.5年）。研究表明：（1）约61%的患者尿比重持续降低；（2）蛋白尿显著改善，与肾功能的良好进展成正比；（3）急性肾盂肾炎的发生率从98%显著降至23%。术后，27例患者（51%）发生过一次或多次尿路感染（UTI），12例（23.0%）仍有急性肾盂肾炎发作。（4）随访时，7例患者（13.5%）患有稳定型高血压，另有3例患有不稳定型高血压（19.2%）；8例患有慢性肾功能不全或终末期肾病。仅考虑12岁以上的青少年时，高血压发生率增至34.4%（10/29）。（5）尽管抗反流手术成功，但仍出现了一些肾瘢痕形成，术前严重受损的实质生长重新开始，尽管仍低于均值2个标准差。（6）在整个系列中，成功手术后肾小球滤过率（GFR）显著改善。然而，这种改善在1岁以内接受手术的患者以及接受过临时膀胱造瘘术的患者中更为明显。在6岁以后接受手术的患者亚组中，当肾功能已经严重受损时，成功的手术对肾功能的进一步下降没有影响。我们得出结论，早期抗反流手术，或在特定情况下，先行临时膀胱造瘘术再行输尿管再植术，对于显著改善重度双侧PVRR且就诊时伴有肾损害患者的GFR以及大幅降低发热性UTI是有效的。
