Surgical treatment of vesicoureteral reflux in infants under 3 months of age

Abstract

Purpose: Surgical treatment for vesicoureteral reflux (VUR) is controversial in infants, especially small infants because of technical difficulty and higher rate of spontaneous resolution. However, in some conditions, such as high-grade reflux, breakthrough infection, or severe renal scarring, early operation may be justified. This study is to evaluate the results of ureteral reimplantation in infants with VUR under 3 months of age. Methods: From January 1993 to July 1997, 13 boys and five girls (24 ureters) under 3 months of age (range, 18 days to 3 months; mean age, 2 months) received ureteral reimplantation for VUR. The initial symptoms were urinary tract infection (UTI) in 16 infants, hydronephrosis found by prenatal ultrasound scan in one, and early postnatal screening ultrasound scan in one. The indications for 24 ureter reimplantations were high-grade reflux (grade V, n = 7), breakthrough infection under medical treatment (n = 5), and severe renal scarring (n = 8) and contralateral low-grade refluxing ureters (n = 4). All patients had Glenn-Anderson's or Cohen's ureteral reimplantation. Ureteral stents were required in six ureters. All patients had renal sonogram 1 month after operation to rule out ureteral obstruction. Fifteen patients had voiding cystourethrogram (VCUG) after operation. Renal growth was evaluated in 15 patients (20 reflux renal units) using serial ultrasound or differential perfusion renal scan. The operative time, use of ureteral stent, complication rate, hospital stay, and time needed for clearing urine, were compared with those of 115 counterpart patients at age over 3 months. Data were analyzed using χ 2 test or t test. Results: All patients, except one, were free of UTI during the follow-up of 6 months to 5 years. In fifteen infants who had postoperative VCUG, 14 were free of reflux, and one had persistent lower-grade VUR. One patient had transient ureteral obstruction that resolved spontaneously. One patient had postoperative ileus for 2 weeks. Renal growth of 20 reflux renal units was similar to that of the contralateral nonreflux kidneys. The only significant difference when compared with the patients over 3 months of age, was the higher incidence of ureteral stenting (25% v 4.2%, P<.01). Conclusions: Ureteral reimplantation should be performed in infants under 3 months of age when it is indicated.