Material and Methods
The study group consisted of 1988 renal units (RU) of 1345 consecutive
patients who were referred to 9 different urology clinics in all across
our country and treated surgically due to VUR between years 2003-2017.
The institutions that agreed to send their data for this study are
composed of mostly members of European Society for Pediatric Urology
(ESPU) and also members of Turkish Pediatric Urology Society and are in
collaboration with each other and reference centers for treatment of
pediatric urology patients in our country. Accordingly, the protocols
for initial evaluation, treatment decisions and follow up were basically
the same. The study was based on clinical registry and a data extraction
form (Appendix 1) including parameters agreed by the board of Turkish
Pediatric Urology Society was sent to all centers included in this study
and gathered back for analysis. Thus all of the consecutive cases with
available data and follow up were included. The main intention of the
study was whether we followed the new guidelines for reflux and how did
it affect our success.
Among all the referred 1345 consecutive patients 1426 (71.7%) RUs were
treated initially conservatively and 562 (28.2%) RUs were initially
treated with surgery. Mean time elapsed between initial treatment and
operation was 16.67 months (1-192).
Diagnostic evaluation included medical history (age, sex, history of
urinary tract infection, presence of LUTS), physical examination, urine
culture, renal ultrasonography (USG) and voiding cystourethrography
(VCUG). Demarcaptosuccinic acid scanning (DMSA) was used to affirm the
parenchymal changes detected by USG or in patients with high grade
reflux or history of acute pyelonephritis. Patients were treated
regarding the institutional preference and categorized retrospectively
according to the risk classification of EAU guidelines on VUR. Surgical
indications were presence of additional ureteral anomaly, high grade
reflux, gender, age beyond resolution-persistent reflux, breakthrough
infections, renal scarring and noncompliance with medical management
(especially for rural patients). Conservative treatment consisted of
continuous antibiotic prophylaxis (CAP) and/or anticholinergic drugs.
Dosages of antibiotics were 50-100 mg/kg/day for Ampicillin
(<2 months old patients) and 2 mg/kg/day for
Trimethoprim-Sulfamethoxazole (>2 months). All the patients
beyond toilet training age were evaluated for LUTS and treated if needed
prior to the choice of treatment method. LUTS of patients were treated
with urotherapy (timed voiding, dietary manipulation for fluid intake
and constipation and anticholinergics (mainly oxybutynin hydrochloride).
In all patients endoscopic subureteric transurethral injection and/or
open ureteral reimplantation were carried out to correct the reflux.
Patients were divided into two groups according to time of initial
treatment being before or after 2013 and also grouped according to risk
factors under guidance of “EAU guidelines on Vesicoureteral Reflux in
Children”. Preoperative and postoperative data of patients with VUR
were retrospectively reviewed. Preoperative clinical parameters such as
age and gender of the patient, grade and laterality of reflux, presence
of renal scar and lower urinary tract symptoms, initial and follow-up
treatments and durations, outcomes of medical treatment and surgical
procedures and postoperative data of patients were analyzed
retrospectively. After treatment modalities patients were followed
clinically by presence of symptoms, regular urine culture, USG and DMSA
scan. Breakthrough infections, new renal scars on DMSA, reflux on VCUG
(if performed) or additional complications like increase in
hydronephrosis were accepted as surgical treatment failure.
Postoperative VCUG was not routinely performed in all patients. The main
indications for postoperative VCUG were new renal scar formation on DMSA
scan and having breakthrough urinary tract infection. Statistical
analysis was performed by SPSS ver. 15.0 (SPSS Inc., Chicago, IL, USA).
Categorical variables were compared using the chi-square test and
regression analysis was carried out. Statistical significance was
considered as p≤0.05.