Surgical intervention in children with vesicoureteric reflux: are we intervening too late?

Abstract

Background: Vesicoureteric reflux is usually managed medically. When medical management fails, the patient is referred for surgical intervention. The aim is to protect the kidneys from progressive damage. This study investigates if significant kidney damage has occurred during medical treatment prior to surgical intervention.

Materials and methods: Case notes of all children treated with ureteric re-implantation for vesicoureteric reflux in a 5-year period were reviewed. Demographic details, radiological investigations, surgery and follow-up were recorded. Indication for surgery was failure of medical treatment. Kidney damage was defined as the presence of a scar on the DMSA scans and/or kidney function below 45% in one kidney.

Results: Forty-two patients underwent ureteric re-implantation with 24 having a bilateral procedure resulting in a total of 66 renal units. Mean age at surgery was 7.4 years. Thirty-eight kidneys (58%) showed reduced function prior to medical treatment. Twenty-four kidneys (36%) had deterioration of renal function associated with recurrent urinary tract infections during the course of medical treatment with the overall mean function of the worst affected kidney being 28%. Thirty-five patients (83%) demonstrated scarring on their kidneys on DMSA scan prior to surgery.

Conclusions: More than half of patients who eventually need ureteric re-implantation for vesicoureteric reflux have already suffered kidney damage prior to start of medical treatment. A third will have progressive deterioration of their renal functions. Early referral for medical management coupled with early surgical intervention in selected cases should hopefully reduce the number of children with renal damage due to VUR.