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.