Non-operative Treatment of Vesicoureteral Reflux

--0022-534 7/78/1203-0336$02. 00/0 Vol. 120, September

THE JOURNAL OF UROLOGY

Printed in U.SA.

Copyright © 1978 by The Williams & Wilkins Co.

NON-OPERATIVE TREATMENT OF VESICOURETERAL REFLUX JOHN J. MULCAHY*

AND

PANAYOTIS P. KELALIS

From the Division of Urology, University of Kentucky Medical Center, Lexington, Kentucky, and the Department of Urology, Mayo Clinic, Rochester, Minnesota ABSTRACT

Varying degrees of vesicoureteral reflux in 193 ureters were followed conservatively. Prediction of in which ureters reflux would stop could not be made from an evaluation of the configuration and position of the orifice, the presence or absence of infection, the grade of the reflux or the age of the patient. The management of such patients is discussed. The management of vesicoureteral reflux has evolved from a lack of understanding of its significance to overzealous operative correction and, more recently, to a rational combination of conservatism and judicious surgical intervention. In the early 1950s Hutch popularized the concept of reflux being detrimental to renal development and function. 1 His ureteral advancement operation to correct reflux together with the intravesical ureteroneocystostomy of Politano and Leadbetter was followed by a rash of new surgical approaches to ureteral reimplantation. 2 By the mid 1960s all ureters with reflux and even some that looked like they might become incompetent were provided with a longer submucosal tunnel. A few years later King and associates reported success with conservative management of ureters with reflux. 3 Renal growth progressed, urinary tract infection could be controlled with chemotherapeutic agents and, frequently, the reflux ceased as the length of the intramural segment of ureter increased with age. With this realization the pendulum has now swung from early surgical intervention to expectant management of reflux whenever possible. The determination of in which ureters reflux will stop or in which reflux will or will not result in renal deterioration has been a problem. METHODS

To determine if it would be possible to predict which instances of vesicoureteral reflux would stop spontaneously various parameters were evaluated in 128 children in whom reflux was followed without surgical intervention. These children ranged in age from 1 to 16 years when first seen. There were 122 girls and 6 boys. A total of 193 ureters were evaluated, 98 on the left side and 95 on the right side. Urine culture, serum creatinine or urea, excretory urogram (IVP), cystoscopy and cystogram or voiding cystourethrogram were done in each case. Reflux was graded on the basis of I to IV: grade I-partial reflux, grade II-total reflux with normal caliber collecting system, grade III-total reflux with slight dilation of the collecting system and/or minimal caliceal clubbing and grade IV - gross dilation of the collecting system with cortical atrophy. When a decision to manage the child conservatively was made semiannual followup visits were recommended. At each visit IVP, voiding cystourethrogram, urine culture and serum creatinine or urea were repeated and a decision on whether to continue with conservative management was made. Urinary tract infections were treated with the appropriate antibiotics and, if there was a recurrence of infection, continuous suppressive chemotherapy was instituted. In 29 patients internal urethrotomy was done and an additional 29 patients sustained urethral dilation. For the purposes of this study Accepted for publication December 22, 1977. address: Department of Surgery, Wishard Memorial Hospital, Indianapolis, Indiana 46202.

* Current

336

urine culture was considered positive if there were greater than 104 colonies per ml. on 2 or more evaluations, that is if it was a recurrent problem. The grade of reflux was assigned for each patient as the most consistent or predominant grade manifest throughout the period of study as determined from interpretation of the IVP and voiding cystourethrogram. RESULTS

Of the 193 ureters evaluated reflux stopped in 77 (40 per cent) and persisted in 116 (60 per cent). There was relapse of reflux in 35 instances (18 per cent), that is reflux decreased in grade or ceased entirely only to return to the previous grade on subsequent evaluation. In all patients values of serum creatinine and/or urea were within normal limits. Table 1 shows the distribution by age of those patients in whom reflux stopped together with the number of ureters exhibiting each grade of reflux at a particular age. There is a slight peak in the late oedipal and early latency years (ages 5 to 8) but in a number of patients reflux did not stop until adolescence and beyond. The number of ureters showing cessation of reflux is inversely proportional to the grade of reflux. Table 2 presents the age at which those patients in whom reflux persisted were last seen and included 39 instances in which conservative management was abandoned in favor of ureteroneocystostomy. As one might suspect there is no particular pattern of age in the distribution and an approximately equal occurrence of grades I, II and III reflux. An attempt was made to correlate the configuration and location of the ureteral orifice as noted at cystoscopy and the presence or absence of repeated infection with cessation or persistence of reflux (table 3). Abnormal-appearing ureteral orifices showed a persistence of reflux twice as often as a cessation of the process. There appeared to be no difference in this regard between moderately abnormal orifices, that is TABLE

1. Distribution by age at which vesicoureteral reflux ceased

(77 ureters) Pt. Age When Reflux Stopped (yrs.) 3 4 5 6 7 8 9 10 11

12 13 Older Totals

Totals 2 5 12 10 10 13 4 7 3 6 1 4

Grade of Reflux

Cumulative Totals 2 7 19

29 39 52 56 63 66 72 73 77

II 1 3 3 6 5 9 2 4 1 5

1 2 9 2 4 3 1

III

IV

2 1 1 1 3

2 1

1

1 2

3

40

27

12

0

r ABLE 2. Distribution b) Pt.

ihe patient tcith persistent 1..H?sicourt!terul re.flux u__,1as last seen (11 fl ureters) -- - - - - - - - - - - - - - - ~ - - - - - - - - - - - - - - - ---of Reflux Cun1ulative - - - -Grade - - - - - - - ------Totals Totals II III IV

-----------·-

----

--------

----------

2 3 4

5 6 7 8 9

10 11 12 13

Older Totals

----------

l 6 3 l 3 5 5

11 24

3

38

4

43 57 72

2 4 7

20

92

10

6

8 7 4

100 107 111

3 1 3

3

2

2

4

4

116

10 13 14 5

14 15

112

-------

4

6

1

7

2

5 3 4

1 3 40

1 37

36

3

-----

TABLE 3_ Correlation of persistence or cessation of reflux with configuration and location of the ureteral orifice and the presence or absence of urinary tract infection Urine Culture

Normal ureteral orifice (58 ureters): Cessation of reflux, 30 Persistence of reflux, 28 Moderately abnormal ureteral orifice (69 ureters): Cessation of reflux, 25 Persistence of reflux, L14

Pos.

Neg.

16

14 15

13

25

9 19

8 15

9 23

16

Severely abnormal ureteral orifice (55 ureters): Cessation of reflux, 17 Persistence of reflux, 38

Six patients (11 ureters) did not undergo cystoscopy.

those with slight lateral displacement and/or stadium or horseshoe configuration, and severely abnormal ureteral orifices, that is those that were gaping and exhibiting marked lateral displacement on the trigone. In normal-appearing ureteral orifices reflux stopped or continued equally. The presence or absence of recurrent infection did not seem to be an influencing factor in maintenance of reflux involving either normal or abnormal orifices. DISCUSSION

It is obvious from parameter or combination of diction of in which ureters

that there is no J that will allow prestop. Grade I reflux In 10 ureters grade III and/or time. -~·'-'-"""" orifice, or the presence or absence of infection cannot be cited with ,vhether reflux ·,vill abate. in the reflux "'"'Ji--'11--'"''u before the patient was 10 years a significant number in which reflux stopped after that It is also nn.rc.uu,rr that in several instances in which ureteral orifice was abnormal reflux stopped. The 40 per cent spontaneous regression rate noted for ureters with reflux in this series is comparable with the results of other authors. In a series of 50 cases Fisher and Darling noted a 34 per cent recovery rate for conservatively treated reflux and none of the uncured cases showed any increase in hydronephrosis. 4 Lenaghan' reports 48 per cent cessation of reflux, Heike! and Parkkulainen'; 27 per cent, Blight and O'Shaughnessy' 43 per cent, and Brannan and associates" 39 per cent. King and associates treated 323 renal units with reflux primarily by surveillance and found a direct linear correlation between the estimated length of the intravesical ureter at the time of diagnosis with the eventual

cessation of reflux \~1ithout cent of these chiidrer,_ then should be our with reflux when an is indicated? Cerit is highly doubtful that grade IV reflux will stop spontaneously and surgical intervention is indicated on initial With the other 3 grades of reflux the chance of spontaneous cessation is greater and a conservative approach may be adopted. on initial evaluation, a patient with grade I, II or III reflux shows radiographic evidence of renal damage a watchful course may be taken. The scars may be owing to previous reflux and the present situation may be a stable state urologically_ However, if there is evidence that the reflux is a permanent phenomenon, such as the presence of a golf hole orifice, or if subsequent examination shows progression of renal damage, ureteroneocystostomy should be done. Serial serum creatinine or urea determinations are not useful in deciding on operative intervention since they remain fairly normal until an extensive degree of renal damage has occurred. The chances of reflux stopping spontaneously become less after the patient is 9 or 10 years old. If the child is stable otherwise one must decide at this juncture whether to follow the patient with x-ray studies for an indefinite period or subject him to ureteral reimplantation. The presence of recurrent infection would steer one toward the latter course. REFERENCES

L Hutch, J_ A.: Vesico-ureteral reflux in the paraplegic: cause and correction. J_ UroL, 68: 457, 1952. 2. Politano, V_ A. and Leadbetter, W. F.: m'"""'-'" technique for the correction of vesicoureteral reflux. UroL, 79: 932, 1958. 3. King, L_ R., Surian, M.A., Wendel, R. M_ and Burden, J_ J.: Vesicoureteral reflux. A classification based on cause and the results of treatment. J_A.M.A., 203: 169, 1968. 4_ Fisher, J. H_ and Darling, D. B.: The course of vesicoureteric reflux associated with urinary tract infections in children_ J _ Pediat. Surg., 2: 221, 1967 _ 5_ Lenaghan, D.: Results of conservative treatment of vesicoureteric reflux in children. Brit. J_ UroL, 42: 736, 1970. 6. Heike!, P_ Kand Parkkulainen, KV.: Vesico-ureteric reflux in children. A classification and results of conservative treatment_ Ann. RadioL, 9: 37, 1966_ 7_ Blight, E_ M., Jr_ and O'Shaughnessy, E_ J_: Vesicoureteral reflux in children: a prospective study. J_ UroL, 102: 44, 1969. 8_ Brannan, W., Ochsner, M. G., Rosencrantz, D. R, Whitehead, C_ JI.IL, Jr. and Goodier, E. H.: Experiences with vesicoureteral reflux. J_ UroL, Hl9: 46, 1973_ g_ King, L_ R, Kazrni, S_ Q_ and vesicoureteral reflux. Outcome a trail therapy UroL Clin_ N_ Amer., 1: 441, 1974_

EDITORIAL COMMENT Reflux holds the upper urinary tract at r-isk to renal damage from infection. This paper is further evidence that reflux spontaneously corrects itself, indicating that an initial conservative to reflux with careful control of infection and regular indicated in almost all patients. Reflux also may occur, so management does not cease with a normal cystographic examination. The parameters of evaluation used in this study indicate our ability to predict when reflux will correct itself. The surgical result of antireflux procedures benefits by a preoperative period of strict infection control and improved vesical function. The aim should be to start all patients on a conservative course. Operative treatment will be recommended early in the conservative period when reflux is of high grade, when there is obvious persistent abnormality of the orifice, when infection control fails and when upper tract changes are progressive_ In other patients with persistent reflux age and compliance with conservative treatment will dictate eventual management of the reflux. R .D _J_