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.