Results
The mean follow-up duration of the 1345 patients (1988 RUs) with the
mean age of 5.18 ±3.6 (0-18) years, was 32 (1-184) months. 70% (941)
percentage of patients was female and 30% (404) were male. 118 (8.8%)
patients were known to have anatomic abnormalities like ureterocele,
solitary kidney, ectopic ureter, Hutch or paraureteral diverticulum and
most commonly duplications (3.7%). 35.8% (482) of patients were
treated due to LUTD prior to the treatment of reflux. Renal scar was
detected on preoperative DMSA scintigraphy in 64.2% (864) percentage of
patients (defining at least a moderate risk according to guidelines.)
The percentages of patients with right, left sided and bilateral reflux
were 18.7%, 33.4% and 47.8% respectively. 54.1 % of the renal units
were presented with low grade reflux (grade 1-3), while 45.9% were high
(grade 4-5). 811 (60.3%) patients initially referred with breakthrough
urinary tract infection (Table 1).
Among the preoperative parameters, only the presence of renal scar on
DMSA and treating lower urinary tract symptoms were found to determine
the postoperative success rates significantly (p:0.002, p:0.000); while
age, sex, grade of reflux, risk groups had no effect. (regression
analysis results)
65 (3.3%) RUs were excluded in analysis of surgical treatment success
due to lost to follow-up or insufficient data. Accordingly, 1238
(%62.3) RUs were treated with subureteric injection (STING) (533
unilateral; 705 bilateral) and 685(34.4%) RUs with Cohen type
ureteroneocystostomy (UNC) (199 unilateral; 486 bilateral). The
percentages of both endoscopic and open reimplantations were 63.1%,
36.1% before 2013 and 61.2%, 32.3% after 2013, respectively. 353
(17.7%) children had urinary tract infection and 275 (13.8%) children
had new renal scar formation on DMSA postoperatively. Also 83 children
with new renal scar had postoperative urinary tract infection
additionally. 67 (3.4%) patients had increasing hydronephrosis while
persistent reflux was detected in 541 (27.2%) patients among ones who
had postoperative VCUG. Success rates of endoscopic and UNC operations
were 65% and 92.9% before 2013, 60% and 78.5% after 2013,
respectively. Thus the overall success rate for surgery was
72.6%. There was significant difference between success rates of UNC
operations before and after 2013(p=0.000), while the difference was not
significant in the STING group (p=0.076).
Then, the patients were grouped into three risk groups according to EAU
VUR risk classification and percentages of the low, moderate and high
risk groups were 18.9%, 52.6% and 28.5% respectively. The data were
analyzed due to risk groups, time of diagnosis and initial treatment
modalities. As stated before among all the referred 1345 consecutive
patients 1426(71.7%) RUs were treated initially conservatively prior to
surgery and 562(28.2%) RUs were initially treated with surgery on
referral. Mean time elapsed between initial treatment and operation was
16.67 months (1-192). In initially surgically treated group, success
rates of surgery decreased significantly in low and moderate risk groups
after 2013 (p=0.046, p=0.0001, respectively), while success rates were
not significantly different in high risk group (p=0.46) (Table 2). The
overall success rate in initially surgically treated group before 2013
was 80.9%. That was decreased to 70.5% after 2013 (p=0.004).
While 26.6% of patients in low risk group were surgically treated
before 2013, this rate has increased to 34.6% after 2013, but the
difference was not statistically significant (p=0.096). However,
performing surgery as the initial treatment approach increased
significantly in both moderate and high risk groups (p=0.000 and
p=0.0001, respectively) after 2013. Thus, we can say that there was
increased preference for surgical treatment initially in moderate and
high risk groups after 2013 (Table 3).
Among the patients with low grade 1-2 reflux (Grade 1-2), only one
patient had UNC and 71 patients had subureteric injection initially.
During follow up, the total number of patients who had subureteric
injection had risen to 206 while 20 patients had UNC. The mean time
between the initial treatment and surgical intervention was 14.2 months
and the mean follow-up duration of this group was 24.8 months. 69.5 %
percentage of these low grade VURs had successful clinical outcomes
after surgery.