0022-5347/78/1192-0199$02. 00/0
Vol. 119, February
THE JOURNAL OF UROWGY
Copyright © 1978 by The Williams & Wilkins Co.
Printed in U.SA.
FOLLOWUP STUDY AFTER CONSERVATIVE AND SURGICAL TREATMENT OF VESICOURETERAL REFLUX KOHEi SENOH, EIJI IWATSUBO
AND
SHUNRO MOMOSE
From the Department of Urology, Faculty of Medicine, Kyushu University, Fukuoka, Japan
ABSTRACT
Our series of 94 cases (145 ureters) of vesicoureteral reflux is reviewed. The occasional disappearance of reflux during conservative treatment should not be mistaken for cure because of its variable nature. To avoid such a mistake voiding cystography under fluoroscopic monitoring is repeated indefinitely. Those patients who were treated surgically were followed for at least 2 to 3 years before cure was established. Transient ureteral dilatation after reimplantation was eradicated within 3 months. Postoperative urinary infection was observed at various intervals, ranging from 1 week to 5 months, and the erythrocyte sedimentation rate was likely to be influenced by infection. Postoperative chemotherapy was continued until the erythrocyte sedimentation rate was normal and there was no infection and/or dilatation of the upper tract. It is now well known that vesicoureteral reflux can persist or recur. In some cases, such as reflux in infants and children, medical treatment alone is successful. However, because of the variable nature of reflux, an apparent cure is seen occasionally and persistence or recurrence of reflux is detected at followup. The success rate of ureteral reimplantation reported previously varies among many authors, even when the same technique is used. However, it is probable that persistence or recurrence of reflux escapes our notice because of improper followup examination. Herein we discuss some problems regarding the treatment of vesicoureteral reflux, including the requirement of prophylactic chemotherapy.
vesicoureteral reflux was noted in 24 (22 cases). However, as a result of repeated examination 14 ureters (13 cases) proved to be only an apparent cure (fig. 1). The remaining 10 ureters were in children and infants, and proved to be cured. In most cases misjudgment was ascertained within 3 years from the time of first observation of apparent elimination. These inconGrade Cysto1r•m
MATERIALS
From 1965 through 1975, 36 adults (53 ureters) and 58 children (92 ureters), ranging in age from 5 months to 60 years, with vesicoureteral reflux, excluding those with neurogenic bladder, were treated at this hospital. Conservative treatment was maintained for more than 6 months in 23 adults (34 ureters) and 33 children (51 ureters). Maintenance therapy consisted primarily of sulfonamides combined with nitrofurantoin and/or methenamine mandelate. Routine urinalysis was done monthly during medical treatment and once 3 to 6 months during followup observation without medication. Voiding cystography was performed repeatedly every several months in each patient to confirm the therapeutic effect. Antireflux operations were performed on 18 adults (29 ureters) and 29 children (47 ureters). The methods used included the Politano-Leadbetter in 46 ureters, Lich-Gregoir in 12, Paquin in 12, Hutch I in 3 and an advancement technique in 3. Each patient was followed for at least 12 months and received cystographic examination more than 3 times postoperatively. Postoperative chemotherapy was given in the same manner as the conservative maintenance therapy for variable terms. In some cases medication was stopped when the operative wound and postoperative cystitis healed and in others it was continued for 3 months to 3 years or more. The erythrocyte sedimentation rate, urinalysis, excretory urography (IVP) and voiding cystography were examined repeatedly.
",-•:f.)lys lmos
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1------8~-8-ffi lys 9mos
4
Ila (V)
-e, - - - - - - f f i
5
Ila (II)
-~.:.®,-· -8-ffi 2mos I mos 8-ffi3mos
lys.lmos
2mS
6
Ila (lI)
7
IA ( l)
8
IA ( l)
9
IIA ( I)
10
Ila ( l)
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IIA ( l)
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,~
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14
Ill
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ys.
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118 { lllb}
,-,
e-----e--------------------------® lys
6yslmos
1------------0-------------------------ffi 2ys.4mos 4ys 9mos
e
2ys
e-ffi
lys8mos
1------------e-,,,-®,,... >-------------8-ffi 2ys.6mS.
(ll)
-
- - - - - - f f ilys 83mos
~e--® 3mos.
4mos
!Smos
Fm. 1. Cases of apparent elimination of vesicoureteral reflux during conservative treatment.
RESULTS
Apparent cure during conservative treatment. Of the 85 ureters (56 cases) treated conservatively disappearance of Accepted for publication April 1, 1977. 199
sistencies of reflux were observed in rather low grade cases, according to our classification described previously.' Length of observation after ureteral reimplantation. Among the 47 patients (76 ureters) who received various types of antireflux operations reflux was eliminated successfully in 35 (60 ureters), excluding the unilateral cure in bilateral cases. One patient who became slightly stenotic was excluded from the study. Of the 11 unsuccessful cases 2 involved contralateral occurrence after the antireflux procedure. Postoperative occurrence ofureteral regurgitation was detected at the second to fourth examinations and in 3 months to less than 2 years in almost all instances (table 1). Although those patients with a successful repair were on prophylactic chemotherapy at various intervals reinfection was noted in 7 cases (table 2). All of these patients had simple cystitis, 3 of whom had it even during the course of chemotherapy, although evidence of infection of the kidney was not noted. The postoperative results of urinalysis are shown in figure 2. The infection was cured within 21 weeks (about 5 months).
200
SENOR, IWATSUBO AND MOMOSE
1. Cases of1Jnsuccessful operation and contralateral occurrence of vesicoureteral refiux postoperatively
TABLE
Side
Pt.
TA
KG TH HY AO
Rt. Lt. Rt. Rt. Rt. Lt. Lt. Rt. Lt. Lt. Rt. Lt. Contralat.
SN
Contralat.
KO YT TS YT SW
Frequency of Time of Re- No. Recurrences Reflux/Total Detected No. currence Cystography
Technique Paquin Paquin Gregoir Gregoir Gregoir Gregoir HutchI HutchI Hutch II Gregoir Gregoir Gregoir Modified Paquin* Gregoir
6mos.
4
4/7
7mos. 3mos. 5mos.
2 2 2
4/8 1/4 5/6
1 yr. 8 mos. 6mos. 1 yr. 10 mos. 5mos. 3 yrs. 2 mos. 1 yr. 9 mos. Immediately postop. Immediately postop.
2 1 3 2 4 1
2/3 2/3 1/3 3/4 1/8 1/9 2/4
1
3/5
8
* Politano = Leadbetter, with cuff. TABLE
The erythrocyte sedimentation rate generally increased soon after surgical intervention and decreased rapidly within 2 months or more in most cases (fig. 3). However, the rate of decrease was slow and fluctuated above the normal limit (10 mm. per hour in male and 15 mm. per hour in female subjects) in patients who had prolonged urinary infection (fig. 3, 1 to 3). Three other patients showing abnormal values had been affected by chronic hepatitis and disease of the interbrain (fig. 3, 4 to 6). COMMENT
Various techniques have been described to improve the diagnostic value of cystography when vesicoureteral regurgitation in examined. It generally is accepted that voiding cystography under fluoroscopic monitoring is the most effective method for detecting reflux. 2 However, it is impossible to draw a conclusion from only chance cystography, whether there is reflux or not, since ureteral reflux has a variable nature. 3' 4 Therefore, to avoid a mistaken diagnosis cystographic examination should be repeated several times after
2. Length of prophylactic chemotherapy postoperatively Intervals
TABLE
No. Cases
None lmo. 1 to 3 mos. 3 to 6 mos. 6 mos. to 1 yr. 1 yr.
1 1 5 (1)*
3. Time required for recovery of postoperative ureteral dilatation Intervals 2wks. 2 wks. to 1 mo. 1 to 2 mos. 2 to 3 mos. 3 to 6 mos. 6mos.
9 (1)*
9 (3)* 10 (2)*
* Number of cases in which urinary infection developed during followup.
No. Cases 9 8
8 6
3 1
I 1rvt.lhr,w,rt." sedimentation rate :returned to normal within 2 to in almost all ,Jm"~'""U Those who had J.J"""'"'""u m.1ec1t10n showed a slow decrease and ~-"+,,~,,mrl-~ sedin'lentation rate.
l. Sen oh, K., Iwatsubo, E., Momose, S., Goto, !VI. and n.c,uau""· H.: Non-obstructive vesicoureteral reflux in adults: value conservative treatment. J. Urol., 117: 566, 1977. 2. Hutch, J. A.: Vesicoureteral reflux. In: The Ureter. Edited H. Bergman. New York Harper & Row, Inc., 3. Hutch, J. A., E. R. and Hinman, F., Jr.: reflux: role in e10,nepnrurn Amer. J. Med., 34: 338, 1963. 4. McGovern, J. ,,,cuo ... ~,,, V. F. and A. J., Jr . : Vesicoureteral. regurgitation in children. Urol., 83: 1960. 5. Leadbetter, G. and Leadbetter, W. F.: Ureteral reimplantation and neck reconstruction. Four and half years' i,x1,i,r1ti,n,ce J.A.M.A., 175: 349, 1961. 6. Politano, V. A.: hundred reimplantations and five years. J. Urol., 90: 1963. 7. Williams, D. and Eckstein, H. B.: 0u.rg1cm treatment reflux in children" Brit. J. Urol., 37: 13, 8. Hendren, W. H.: Ureteral reimplantation in children. J. PediaL Surg., 3: 649, 1968. 9. Price, S. E., Johnson, S. Experience ureteral n:,m 1,,,o,ucac,,v" in the treatment of recurring urinary infections in childhood. J. Urol., Hl3: 485, 1970.
Vol. 119, February
THE JOURNAL OF UROWGY
Copyright © 1978 by The Williams & Wilkins Co.
Printed in U.SA.
FOLLOWUP STUDY AFTER CONSERVATIVE AND SURGICAL TREATMENT OF VESICOURETERAL REFLUX KOHEi SENOH, EIJI IWATSUBO
AND
SHUNRO MOMOSE
From the Department of Urology, Faculty of Medicine, Kyushu University, Fukuoka, Japan
ABSTRACT
Our series of 94 cases (145 ureters) of vesicoureteral reflux is reviewed. The occasional disappearance of reflux during conservative treatment should not be mistaken for cure because of its variable nature. To avoid such a mistake voiding cystography under fluoroscopic monitoring is repeated indefinitely. Those patients who were treated surgically were followed for at least 2 to 3 years before cure was established. Transient ureteral dilatation after reimplantation was eradicated within 3 months. Postoperative urinary infection was observed at various intervals, ranging from 1 week to 5 months, and the erythrocyte sedimentation rate was likely to be influenced by infection. Postoperative chemotherapy was continued until the erythrocyte sedimentation rate was normal and there was no infection and/or dilatation of the upper tract. It is now well known that vesicoureteral reflux can persist or recur. In some cases, such as reflux in infants and children, medical treatment alone is successful. However, because of the variable nature of reflux, an apparent cure is seen occasionally and persistence or recurrence of reflux is detected at followup. The success rate of ureteral reimplantation reported previously varies among many authors, even when the same technique is used. However, it is probable that persistence or recurrence of reflux escapes our notice because of improper followup examination. Herein we discuss some problems regarding the treatment of vesicoureteral reflux, including the requirement of prophylactic chemotherapy.
vesicoureteral reflux was noted in 24 (22 cases). However, as a result of repeated examination 14 ureters (13 cases) proved to be only an apparent cure (fig. 1). The remaining 10 ureters were in children and infants, and proved to be cured. In most cases misjudgment was ascertained within 3 years from the time of first observation of apparent elimination. These inconGrade Cysto1r•m
MATERIALS
From 1965 through 1975, 36 adults (53 ureters) and 58 children (92 ureters), ranging in age from 5 months to 60 years, with vesicoureteral reflux, excluding those with neurogenic bladder, were treated at this hospital. Conservative treatment was maintained for more than 6 months in 23 adults (34 ureters) and 33 children (51 ureters). Maintenance therapy consisted primarily of sulfonamides combined with nitrofurantoin and/or methenamine mandelate. Routine urinalysis was done monthly during medical treatment and once 3 to 6 months during followup observation without medication. Voiding cystography was performed repeatedly every several months in each patient to confirm the therapeutic effect. Antireflux operations were performed on 18 adults (29 ureters) and 29 children (47 ureters). The methods used included the Politano-Leadbetter in 46 ureters, Lich-Gregoir in 12, Paquin in 12, Hutch I in 3 and an advancement technique in 3. Each patient was followed for at least 12 months and received cystographic examination more than 3 times postoperatively. Postoperative chemotherapy was given in the same manner as the conservative maintenance therapy for variable terms. In some cases medication was stopped when the operative wound and postoperative cystitis healed and in others it was continued for 3 months to 3 years or more. The erythrocyte sedimentation rate, urinalysis, excretory urography (IVP) and voiding cystography were examined repeatedly.
",-•:f.)lys lmos
elOmos
8, •.,
2
IA (V)
3
IIA ( l)
1------8~-8-ffi lys 9mos
4
Ila (V)
-e, - - - - - - f f i
5
Ila (II)
-~.:.®,-· -8-ffi 2mos I mos 8-ffi3mos
lys.lmos
2mS
6
Ila (lI)
7
IA ( l)
8
IA ( l)
9
IIA ( I)
10
Ila ( l)
II
IIA ( l)
12
,~
13
Ila (II)
14
Ill
(lib)
ys.
3
2
(IVP)
118 { lllb}
,-,
e-----e--------------------------® lys
6yslmos
1------------0-------------------------ffi 2ys.4mos 4ys 9mos
e
2ys
e-ffi
lys8mos
1------------e-,,,-®,,... >-------------8-ffi 2ys.6mS.
(ll)
-
- - - - - - f f ilys 83mos
~e--® 3mos.
4mos
!Smos
Fm. 1. Cases of apparent elimination of vesicoureteral reflux during conservative treatment.
RESULTS
Apparent cure during conservative treatment. Of the 85 ureters (56 cases) treated conservatively disappearance of Accepted for publication April 1, 1977. 199
sistencies of reflux were observed in rather low grade cases, according to our classification described previously.' Length of observation after ureteral reimplantation. Among the 47 patients (76 ureters) who received various types of antireflux operations reflux was eliminated successfully in 35 (60 ureters), excluding the unilateral cure in bilateral cases. One patient who became slightly stenotic was excluded from the study. Of the 11 unsuccessful cases 2 involved contralateral occurrence after the antireflux procedure. Postoperative occurrence ofureteral regurgitation was detected at the second to fourth examinations and in 3 months to less than 2 years in almost all instances (table 1). Although those patients with a successful repair were on prophylactic chemotherapy at various intervals reinfection was noted in 7 cases (table 2). All of these patients had simple cystitis, 3 of whom had it even during the course of chemotherapy, although evidence of infection of the kidney was not noted. The postoperative results of urinalysis are shown in figure 2. The infection was cured within 21 weeks (about 5 months).
200
SENOR, IWATSUBO AND MOMOSE
1. Cases of1Jnsuccessful operation and contralateral occurrence of vesicoureteral refiux postoperatively
TABLE
Side
Pt.
TA
KG TH HY AO
Rt. Lt. Rt. Rt. Rt. Lt. Lt. Rt. Lt. Lt. Rt. Lt. Contralat.
SN
Contralat.
KO YT TS YT SW
Frequency of Time of Re- No. Recurrences Reflux/Total Detected No. currence Cystography
Technique Paquin Paquin Gregoir Gregoir Gregoir Gregoir HutchI HutchI Hutch II Gregoir Gregoir Gregoir Modified Paquin* Gregoir
6mos.
4
4/7
7mos. 3mos. 5mos.
2 2 2
4/8 1/4 5/6
1 yr. 8 mos. 6mos. 1 yr. 10 mos. 5mos. 3 yrs. 2 mos. 1 yr. 9 mos. Immediately postop. Immediately postop.
2 1 3 2 4 1
2/3 2/3 1/3 3/4 1/8 1/9 2/4
1
3/5
8
* Politano = Leadbetter, with cuff. TABLE
The erythrocyte sedimentation rate generally increased soon after surgical intervention and decreased rapidly within 2 months or more in most cases (fig. 3). However, the rate of decrease was slow and fluctuated above the normal limit (10 mm. per hour in male and 15 mm. per hour in female subjects) in patients who had prolonged urinary infection (fig. 3, 1 to 3). Three other patients showing abnormal values had been affected by chronic hepatitis and disease of the interbrain (fig. 3, 4 to 6). COMMENT
Various techniques have been described to improve the diagnostic value of cystography when vesicoureteral regurgitation in examined. It generally is accepted that voiding cystography under fluoroscopic monitoring is the most effective method for detecting reflux. 2 However, it is impossible to draw a conclusion from only chance cystography, whether there is reflux or not, since ureteral reflux has a variable nature. 3' 4 Therefore, to avoid a mistaken diagnosis cystographic examination should be repeated several times after
2. Length of prophylactic chemotherapy postoperatively Intervals
TABLE
No. Cases
None lmo. 1 to 3 mos. 3 to 6 mos. 6 mos. to 1 yr. 1 yr.
1 1 5 (1)*
3. Time required for recovery of postoperative ureteral dilatation Intervals 2wks. 2 wks. to 1 mo. 1 to 2 mos. 2 to 3 mos. 3 to 6 mos. 6mos.
9 (1)*
9 (3)* 10 (2)*
* Number of cases in which urinary infection developed during followup.
No. Cases 9 8
8 6
3 1
I 1rvt.lhr,w,rt." sedimentation rate :returned to normal within 2 to in almost all ,Jm"~'""U Those who had J.J"""'"'""u m.1ec1t10n showed a slow decrease and ~-"+,,~,,mrl-~ sedin'lentation rate.
l. Sen oh, K., Iwatsubo, E., Momose, S., Goto, !VI. and n.c,uau""· H.: Non-obstructive vesicoureteral reflux in adults: value conservative treatment. J. Urol., 117: 566, 1977. 2. Hutch, J. A.: Vesicoureteral reflux. In: The Ureter. Edited H. Bergman. New York Harper & Row, Inc., 3. Hutch, J. A., E. R. and Hinman, F., Jr.: reflux: role in e10,nepnrurn Amer. J. Med., 34: 338, 1963. 4. McGovern, J. ,,,cuo ... ~,,, V. F. and A. J., Jr . : Vesicoureteral. regurgitation in children. Urol., 83: 1960. 5. Leadbetter, G. and Leadbetter, W. F.: Ureteral reimplantation and neck reconstruction. Four and half years' i,x1,i,r1ti,n,ce J.A.M.A., 175: 349, 1961. 6. Politano, V. A.: hundred reimplantations and five years. J. Urol., 90: 1963. 7. Williams, D. and Eckstein, H. B.: 0u.rg1cm treatment reflux in children" Brit. J. Urol., 37: 13, 8. Hendren, W. H.: Ureteral reimplantation in children. J. PediaL Surg., 3: 649, 1968. 9. Price, S. E., Johnson, S. Experience ureteral n:,m 1,,,o,ucac,,v" in the treatment of recurring urinary infections in childhood. J. Urol., Hl3: 485, 1970.
