Division of Pediatric Urology, Brady Urological Institute, The Johns Hopkins Medical Institutions, Baltimore, MD.
Pediatric Urology Research Center, Section of Tissue Engineering and Stem Cell Therapy, Department of Pediatric Urology, Children's Pediatric Center of Excellence, Children's Hospital Medical Center, Tehran University of Medical Sciences, Tehran, Iran.
Urology. 2014 Jan;83(1):199-205. doi: 10.1016/j.urology.2013.07.033. Epub 2013 Oct 19.
To represent our experience in the management of posterior urethral valves and concomitant vesicoureteral reflux (VUR).
A total of 326 children with posterior urethral valve who had underwent valve ablation/bladder neck incision were studied, and those who had persistent VUR and were categorized under 3 main groups were followed up. Group 1 (n = 71) received prophylactic antibiotic, group 2 (n = 50) underwent Deflux injection (2a) (n = 28): Deflux injection alone, group 2b (n = 22) Deflux with concomitant autologous blood injection (HABIT), and group 3 (n = 19) underwent ureteroneocystostomy before referral and was followed up conservatively. VUR resolution, incidence of urinary tract infections (UTI), and bladder function were assessed.
Mean duration of follow-up was 3.8 years; VUR resolution occurred in 66.1%, 86.0%, and 94.0% of groups 1-3, respectively (P = .013). Resolution rate in group 2b was significantly higher than group 2a (90.9% vs 78.5%). Patients in group 2 experienced a longer UTI-free period compared with others (P <.05). Urodynamic studies demonstrated significant decrease in maximum voiding detrusor pressure and detrusor overactivity in all groups (P <.001). Children in group 3 ended up with lower compliance compared with others (P <.001). After toilet training, only 2.8%, 21.4%, 13.6%, and 27% children were diagnosed with lower urinary tract dysfunction in groups 1-3, respectively (P = .027). Myogenic failure developed only in 3 boys in group 3.
Ablation/bladder neck incision leads to significant improvement in VUR status in part because of improvement in bladder function. After successful valve removal, conservative therapy can be regarded as the mainstay of reflux treatment, whereas HABIT is recommended for high grade VUR associated with febrile UTI or deterioration in renal function.
介绍我们在治疗后尿道瓣膜合并膀胱输尿管反流（VUR）方面的经验。
共研究了 326 例接受后尿道瓣膜消融/膀胱颈部切开术的患儿，对其中持续存在 VUR 的患儿分为 3 个主要亚组进行随访。第 1 组（n=71）接受预防性抗生素治疗，第 2 组（n=50）接受 Deflux 注射（2a）（n=28）：单独使用 Deflux 注射，第 2b 组（n=22）接受 Deflux 联合自体血注射（HABIT）治疗，第 3 组（n=19）在转诊前接受输尿管肠吻合术，并保守随访。评估 VUR 缓解率、尿路感染（UTI）发生率和膀胱功能。
平均随访时间为 3.8 年；第 1-3 组的 VUR 缓解率分别为 66.1%、86.0%和 94.0%（P=.013）。第 2b 组的缓解率明显高于第 2a 组（90.9%比 78.5%）。与其他组相比，第 2 组的 UTI 无复发期更长（P<.05）。尿动力学研究显示，所有组的最大排尿逼尿肌压和逼尿肌过度活动均显著降低（P<.001）。第 3 组的顺应性明显低于其他组（P<.001）。在完成如厕训练后，第 1-3 组分别有 2.8%、21.4%、13.6%和 27%的患儿被诊断为下尿路功能障碍（P=.027）。第 3 组仅 3 名男孩出现肌源性失能。
消融/膀胱颈部切开术可显著改善 VUR 状态，部分原因是膀胱功能改善。在成功切除瓣膜后，保守治疗可作为反流治疗的主要方法，而对于伴有发热性 UTI 或肾功能恶化的高等级 VUR，建议使用 HABIT。
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