Belman A B
Department of Pediatric Urology, Children's National Medical Center, Washington, DC.
Urol Clin North Am. 1995 Feb;22(1):139-50.
Prevention of UTI appears to be the most important way to avoid the serious complications of vesicoureteral reflux, which then requires early recognition, ideally prior to bacterial invasion. With early evaluation of children noted to have dilated collecting systems in utero and the screening of siblings and offspring of those with reflux, this prevention becomes possible. This screening should be performed in the first weeks to months after birth, before the first UTI. The choice of management appears to be less important than control of infection, because the results of both medical and surgical management are equal; however, because mild-to-moderate (grades I-III) reflux is likely to resolve, it seems appropriate to pursue an aggressive nonsurgical course in these patients, at least until some minimally invasive, safe interventional treatment becomes available. If reflux remains severe (grades IV and V) beyond 24 to 48 months of age, surgical intervention appears appropriate because resolution is unlikely, assuming, of course, that an experienced surgeon performs the procedure. As was evident from the European branch of the IRS, renal scarring occurred most frequently in the few patients who had ureteral obstruction after failed surgical correction. In those who continued to have mild reflux beyond 5 to 7 years of age, a trial of medication is justifiable. If infection occurs during that time and reflux persists, correction should be considered for those with clinical or scan-documented pyelonephritis. Patients who have reflux plus bacteriuria present a special problem because it is unclear whether their risks are increased. Finally, we must forewarn all our female patients with UTI in childhood that they are at risk for bacilluria during pregnancy and may require prophylaxis regardless of the state of their reflux at that time.
预防泌尿道感染似乎是避免膀胱输尿管反流严重并发症的最重要方法，而这需要早期识别，理想情况下是在细菌入侵之前。通过对子宫内发现有集合系统扩张的儿童进行早期评估，以及对反流患者的兄弟姐妹和后代进行筛查，这种预防成为可能。这种筛查应在出生后的头几周至几个月内进行，在首次发生泌尿道感染之前。治疗方法的选择似乎不如控制感染重要，因为药物治疗和手术治疗的结果是相同的；然而，由于轻度至中度（I-III级）反流可能会自行缓解，在这些患者中采取积极的非手术治疗方案似乎是合适的，至少要等到有一些微创、安全的介入治疗方法出现。如果反流在24至48个月龄后仍很严重（IV级和V级），手术干预似乎是合适的，因为自行缓解的可能性不大，当然，前提是由经验丰富的外科医生进行手术。正如国际反流研究学会欧洲分会所表明的，肾瘢痕形成最常发生在手术矫正失败后出现输尿管梗阻的少数患者中。对于那些在5至7岁后仍有轻度反流的患者，进行药物试验是合理的。如果在此期间发生感染且反流持续存在，对于有临床或扫描记录的肾盂肾炎患者应考虑进行矫正。有反流加菌尿的患者存在一个特殊问题，因为不清楚他们的风险是否增加。最后，我们必须预先警告所有童年时有泌尿道感染的女性患者，她们在怀孕期间有患杆菌尿的风险，无论当时她们的反流情况如何，都可能需要进行预防。
