小儿原发性膀胱输尿管反流的临床研究

目的　探讨小儿原发性膀胱输尿管反流的发病机制、临床特点、肾损害评价、治疗及预后。方法　回顾性研究 1990～ 2 0 0 2年复旦大学附属儿科医院 5 0例小儿原发性膀胱输尿管反流 ,对反流程度、尿路感染、肾疤痕形成、尿液分析及血管紧张素转化酶 (ACE)基因型进行了分析 ,并将药物和手术治疗组的随访结果进行比较。结果　 5 0例中双侧反流者 2 2例 (44 % ) ,单侧反流者 2 8例 (5 6 % ) ;39例行膀胱尿道造影检查发现反流Ⅰ度2 9 5 % (2 3/ 78) ,Ⅱ度 7 7% (6 / 78) ,Ⅲ度 14 1% (11/ 78) ,Ⅳ度 4 1 0 % (32 / 78) ,Ⅴ度 7 7% (6 / 78)。尿液 β2 微球蛋白、尿视黄醇结合蛋白、N乙酰半胱氨酸异常升高与肾疤痕形成相关 (P <0 0 5 ) ,血ACE基因型ID或DD型与肾疤痕形成相关 (P <0 0 5 )。药物与手术治疗组尿路感染复发率、肾疤痕形成率及反流有效控制率无显著差别。结论　小儿原发性膀胱输尿管反流需要及早诊断 ,同时通过对尿液微量蛋白及血ACE基因型检测 ,对肾损害作出预测 ,建立个体化的有效的治疗方案     

膀胱输尿管反流的诊疗争议和研究进展

小儿原发性膀胱输尿管反流(vesicoureteric reflux,VUR)与尿路感染、排尿功能障碍相伴发生,常常导致肾疤痕、肾萎缩、高血压、肾功能减退等一系列反流性肾病的表现,重者甚至进展为终末期肾病.目前,随着对VUR治疗经验的累积,在诊断策略及治疗上都出现了一定的争议.无论手术治疗或非手术治疗结果仍不令人满意,VUR的发病机制目前还不清楚,需要进行进一步的研究和探索.     

Treatment of vesicoureteral reflux in children by endoscopic injection of Teflon

From November 1986 to April 1990, 326 refluxing ureters in 197 children were treated by endoscopic injection of Teflon paste. Complications were observed in only 3 cases: 1 child had immediate bilateral ureteral stenosis requiring surgery at 48 h. In 1 case it was impossible to probe 1 ureteral orifice after injection, and Cohen reimplantation was immediately performed; in a 3rd case ureteral dilatation occurred 1 year later without anatomic stenosis at surgery. Three hundred twenty-two ureters were examined after 1 month: reflux had disappeared in 286 (88.82%). The stability of these results after one injection was verified 1 year later for 179 ureters: recurrence of reflux was observed in 19 cases (10.60%); 21 non refluxing ureters were again examined 2 years later: reflux reappeared in 2 cases. Analysis of the midterm results showed that failure was observed in 17.31% of cases of primary reflux and 19.04% of malformative or secondary refluxes. It was more significant in grade IV or V (21.11%) than in grade I–III (16.85%) reflux. Of the 57 immediate or secondary residual refluxes, 10 were followed and 2 spontaneously disappeared, 24 underwent successful surgical reimplantation, and 23 had a repeat injection with 22 successes and only 1 failure that was secondarily cured by surgery. Overall, reflux disappeared after one or two injections in 165 children (83.25%). Offprint requests to: H. Dodat     

腹腔镜Lich-Gregoir手术治疗儿童双侧原发性膀胱输尿管反流

目的 评价腹腔镜Lich-Gregoir手术治疗儿童双侧原发性膀胱输尿管反流治疗效果.方法 对2007年9月至2009年9月4例腹腔镜Lich-Gregoir手术治疗双侧原发性膀胱输尿管反流患儿的临床资料进行回顾性分析.结果 4例患儿,均因反复尿路感染收治.平均年龄6.5岁(5～8岁).男1例,女3例,排尿行膀胱尿道造影(VCUG)均提示双侧VUR,其中Ⅴ级2侧,Ⅳ级3侧,Ⅲ级3侧.二巯丁二酸(DMSA)肾图均证实存在一侧或双侧肾瘢痕.所有病例均经腹腔路径成功于膀胱外完成腹腔镜Lich-Gregoir手术.平均手术时间为200min(140～300min),术中无明显出血,术后平均住院时间6 d(5～7 d).平均随访18.5个月(6～30个月),所有患儿术后6个月VCUG复查证实膀胱输尿管反流均完全消失,无发热性尿路感染及新的肾瘢痕形成.1例患儿术后出现短期尿潴留,留置导尿1周后症状消失.结论 我们的初步经验显示腹腔镜Lich-Gregoir手术安全、有效、创伤小、术后恢复快,有望成为治疗儿童原发性膀胱输尿管反流,尤其是双侧病变较理想的治疗方法.     

神经性膀胱输尿管反流治疗对策的探讨

目的探讨神经性膀胱患儿输尿管反流的治疗措施。方法脊膜修补术后神经性膀胱并输尿管反流患儿45例,男29例,女16例,年龄4～14岁。排泄性膀胱尿道造影(VCUG)示膀胱输尿管反流左侧19例,右侧11例．双侧15例,其中Ⅰ°-Ⅲ°12例(15条),Ⅲ°-Ⅴ°33例(45条)。Ⅰ°-Ⅱ°中,5例(7条)仅行清洁间歇导尿,7例(8条)行保留膀胱黏膜肠浆肌层膀胱扩大术；Ⅲ°-Ⅴ°中,9例(12条)仅行间歇导尿。24例(33条)行保留膀胱黏膜肠浆肌层膀胱扩大术,其中19例(28条)同时行Lich-Gregoir手术,术后配合间歇导尿。结果6个月后随访,Ⅰ°-Ⅱ°15条中,7条行清洁间歇导尿,3条反流消失(42．9%),8条行保留膀胱黏膜肠浆肌层膀胱扩大术者,6条反流减轻或消失(75．0%)；Ⅲ°-Ⅴ°45条中,12条行间歇导尿者,10条反流程度进一步加重,5条单纯行膀胱扩大术者,2条反流减轻或消失(40．0%),28条同时行Lich-Gregoir手术者,23条反流减轻或消失(82．1%)。结论神经性膀胱输尿管反流的治疗方法取决于输尿管反流的程度。Ⅰ°-Ⅱ°单纯行膀胱扩大术,也可考虑只行清洁间歇导尿；Ⅲ°-Ⅴ°反流须在行膀胱扩大术的同时行输尿管抗反流术,术后配合间歇导尿。     

Occurrence of vesicoureteral reflux in children

Aim: The reported low occurrence of vesicoureteral reflux in the general population seems implausible. We wanted to test the hypothesis that reflux is more common and more independent of urinary‐tract infection than has previously been thought. Methods: We tested our hypothesis by analysing the characteristics of 406 consecutive children aged <5 years who had been referred for consultation because of urinary‐tract infection. Using data on their urine samples, we evaluated the reliability of the urinary‐tract infection diagnosis and analysed the frequencies of vesicoureteral reflux and abnormal ultrasound findings in three reliability groups (A: certain urinary‐tract infection, B: possible and C: improbable). Results: The occurrence of reflux was the same irrespective of the diagnostic reliability of urinary‐tract infection (A: 98/276 [36%] versus B: 13/46 [28%] versus C: 9/25 [36%]). Most of the abnormal ultrasound findings (58/71, 80%) were found among patients with a certain diagnosis (Group A). Conclusion: We suggest that vesicoureteral reflux is more common in children even without urinary‐tract infection than has been thought previously. The guidelines recommending a search for reflux by means of voiding cystourethrography should be reconsidered.     

Endoscopic treatment of vesicoureteral reflux using cross-linked bovine dermal collagen

To assess the efficacy of endoscopic treatment of vesicoureteral reflux (VUR) with cross-linked bovine collagen, 59 patients with grade I through V VUR were evaluated and treated. Follow-up consisted of a voiding cystourethrogram and renal ultrasound at 1 month and 1 year with urinalysis and urine culture. Repeat treatment was carried out in cases in which no resolution of the reflux was noted up to three times. The procedure was performed on an outpatient basis in 56 patients and was not associated with any major morbidity or mortality. Cure at 1 month was observed in 75% of ureters treated; cure persisted in 79% of these ureters at 1 year. The overall cure rate was 65% at 1 year. Given the simplicity of the procedure, its low complication rate, and overall success in the majority of patients, we feel that endoscopic treatment of VUR with cross-linked bovine dermal collagen is a safe and effective method and worthy of further study to enhance its efficacy. Offprint requests to: M. Cendron     

Detection of low-grade vesicoureteral reflux in children by color Doppler imaging mode

Vesicoureteral reflux (VUR) is common in children with urinary tract infections (UTI) and may result in renal scarring or reflux nephropathy. To date, the primary diagnostic tool has been voiding cystourethrography (VCUG). A new technique for evaluation of grade 1 and 2 VUR is described using color Doppler imaging-mode cystography (CDIMC): 77 children, aged 7 months to 14 years, were examined for VUR by CDIMC and standard VCUG. According to the established reflux sonography (US) using a real-time mode, all patients selected for this study had a normal urinary tract on conventional gray-scale US. We studied 154 ureters, and a total of 31 were found to be refluxing on CDIMC and 30 on VCUG. A positive sonogram was defined as visualization of Doppler signals from the bladder to the ureter during the course of bladder filling. Taking VCUG as the gold standard, we had ten false-positive findings. The false-positive rate of 18.5% may have been due to the shorter observation time of fluoroscopy. Comparison of the two methods shows CDIMC to be 70% sensitive with a specificity of 92% in the detection of VUR grade 1 and 2. To evaluate the incidence of asymptomatic low-grade VUR in a non-infected population, a second series of 38 children (19 males, 19 females) aged 3 to 15 years (mean 8.8 years) with normal urologic status and urine cultures were studied by color Doppler imaging mode (CDIM) for detection of asymptomatic low-grade VUR. Four children were found to have a unilateral refluxing ureter. The incidence of VUR in children with a normal urinary tract and no prior UTI was 10.5%. In conclusion, CDIMC can be used as a possible alternative to standard VCUG for the screening and follow-up of low-grade VUR. In addition, our study indicates that asymptomatic grade 1 and 2 reflux might be a physiological condition.     

Primary vesicoureteral reflux in infants with a dilated fetal urinary tract

Vesicoureteral reflux (VUR) was recognized neonatally by voiding cystography in 25 of 117 infants with a dilated fetal urinary tract. There was a male preponderance (76%) and a high percentage (40%) of associated urinary malformations. Thirtynine refluxing units were studied. All grades of VUR were detected but gross dilating VUR dominated (59%). Spontaneous resolution was excellent in lower grades of VUR but was poor in gross VUR. Surgery was successfully performed in 13 renal units of nine patients with gross reflux [8], additional ipsilateral malformations [4], or pyelonephritis during antibiotic prophylaxis [1]. Segmental renal scars developed in four kidneys after urinary infections, and a diffuse parenchymal lesion was noted in nine kidneys even at birth. One boy with duplication had a non-functioning refluxing system. Our results in a small number of infants show differences to children with VUR detected after urinary infections and seem to support the existence of a congenital reflux nephropathy.     

Results of surgery for vesicoureteral reflux in children: 6 years' experience in an Asian country

From January 1990 to December 1995, a total of 181 patients underwent reimplantation of 318 ureters for primary vesicoureteral reflux (VUR); 87.8% received bilateral reimplantation. Surgical indications included breakthrough infection (35%), high-grade (≥IV) reflux (33%), or both (29%). The operative success rate was 99.4% at 3 months postoperatively and 100% ultimately. The complications included: contralateral sequential reflux in 3.9%, postoperative bladder diverticula in 1.1%, postoperative urinary infection in 1.1%, residual reflux in 0.3%, postoperative vesicoureteral stenosis in 0.3%, and slippage of the drainage tube in 0.3% of cases. Two patients had renal failure due to VUR that was proven by renal biopsy (one 4-year-old and one 8-year-old). The incidence of associated anomalies was higher than in the normal population. The average number of hospital admission days was 7.9 (3–63). After 1992, no ureteral stent was left in postoperatively. All patients received prophylactic antibiotics for 3 months postoperatively until the VUR disappeared. The surgical results were satisfactory in this series. Accepted: 4 February 1997     

小儿神经源性膀胱伴膀胱输尿管反流临床特点分析

目的 探讨神经源性膀胱(NB)患儿伴膀胱输尿管反流(VUR)的临床特征,为其临床早期诊断及治疗提供参考依据.方法 收集2014年1月至2019年12月于儿童肾内科收治并诊断为NB伴尿路感染的26例患儿的临床资料,根据有无VUR分为反流组(11例)与无反流组(15例),分析比较两组的临床特点.结果 相比无反流组,反流组患...     

Management of vesicoureteral reflux secondary to neurogenic bladder

The authors encountered 108 cases of vesicoureteral reflex (VUR) in 231 cases of neurogenic bladder complicating spina bifida. Bladder compliance and percent volume (% vol.) were measured pre- and postoperatively and the patients were divided into four groups retrospectively according to the treatment. Ninety-five percent of low-grade VUR (grades I and II) disappeared spontaneously with conservative therapy or after augmentation cystoplasty without antireflux surgery; 92% of high-grade VUR (grade III or more) required ureteral reimplantation with or without bladder augmentation. Reflux did not recur in any case of ureteral reimplantation with bladder augmentation, however, it did recur in 20.4% of the cases of simple ureteral reimplantation without bladder augmentation. Percent volume and bladder compliance in cases of recurrence following simple ureteral reimplantation were significantly lower than in the successful cases. This study suggests that low-grade VUR can resolve spontaneously with conservative therapy or with a suitable maneuver to improve bladder compliance. High-grade reflux in cases of preserved bladder volume (% vol.>75%) and compliance (>7 ml/cmH₂O) can be treated successfully with simple ureteral reimplantation, however, in cases of low volume (% vol.<60%) and low compliance (<4 ml/cmH₂O), reimplantation with bladder augmentation is recommended. Accepted: 6 January 1998     

小儿遗尿与膀胱输尿管反流的相关性研究

目的 探讨小儿遗尿与膀胱输尿管反流(vesicoureteral reflux,VUR)的关系,筛选小儿VUR的高危因素为临床诊治提供依据.方法 选取郑州大学第一附属医院小儿尿动力学中心以遗尿为主诉就诊并且神经功能正常的儿童和青少年83例(男36例,女47例),年龄5～16岁,平均(9.42±3.21)岁.所有患儿进行排尿性膀胱尿道造影(VCUG)检查以评估VUR情况,并进行尿常规、尿培养、肾脏和膀胱超声检查.尿动力学检查包括尿流率、盆地肌电图和膀胱压力容积测定.泌尿系检查的准入标准包括泌尿系超声异常、白天尿失禁、尿动力学检查异常、尿路感染或者同胞兄妹中有VUR病史等.结果 48例(57.8％)出现单症状性夜遗尿(MNE),35例(42.2％)非单症状性夜遗尿(NMNE).13例(15.7％)出现VUR.t检验结果显示,白天尿失禁患儿、女性患儿和当前伴有尿路感染的患儿VUR发病率明显升高(P＜0.05);多自变量logistic回归分析结果显示,只有性别、白天尿失禁和当前尿尿路感染的回归系数检验有统计学意义(P＜0.05),VUR与患儿年龄、遗尿类型(原发性、继发性)、遗尿频率、有无遗尿家族史、尿路感染病史、有无排便异常和除白天尿失禁外的白天尿路症状无统计学意义(P＞0.05).结论 VUR明显常见于白天尿失禁的遗尿患儿,建议存在白天尿失禁的遗尿患儿进一步进行相关检查.当前尿路感染是遗尿患儿发生VUR的高危因素.     

膀胱输尿管反流相关基因的研究进展

膀胱输尿管反流是先天性肾脏和尿路畸形中最常见的一种类型,主要与输尿管膀胱连接部发育异常有关。除非伴有尿路感染症状,或是综合征的一部分,多数患儿临床表现不明显。膀胱输尿管反流的确切病因还不清楚,可能是由基因异常引起,也可能受环境因素影响。膀胱输尿管反流患者后代和同胞间的患病率明显高于正常儿童,提示了基因筛查的必要性。该文将对膀胱输尿管反流相关基因的研究进展及相互作用作一综述。     

Reliability of voiding cystourethrogram for the grading of vesicoureteral reflux

ObjectiveThe voiding cystourethrogram (VCUG) is a commonly employed radiographic test used in the management of vesicoureteral reflux (VUR). Recently, the reliability of VCUG to accurately grade VUR has been questioned. The purpose of this study is to examine reliability of the VCUG for the grading of VUR in a setting mimicking daily practice in a busy pediatric hospital.Materials and methodsTwo-hundred consecutive VCUGs were independently graded by two pediatric urologists and two pediatric radiologists according to the International Classification of Vesicoureteral Reflux. A weighted kappa coefficient was calculated to determine inter-rater agreement and a modified McNemar test was performed to assess rater bias. Further assessment for impact on clinical and research decision-making was made for disagreement between grades II and III.ResultsWeighted kappa values reflect strong reliability of VCUG for grading VUR between and among urologists and radiologists ranging from 0.95 to 0.97. There was statistically significant bias with radiologists reporting higher grades. Despite high kappa values, disagreement between raters was not infrequent and most common for grades II–IV.ConclusionsVCUG is reliable for grading VUR, but small differences in grading between raters were detected and may play an important role in clinical decision-making and research outcomes.     

Urinary bladder volume and pressure at reflux as prognostic factors of vesicoureteral reflux outcome

Background: Controversy exists as to whether the outcome of vesicoureteral reflux (VUR) can be prognosticated by direct radionuclide cystography (DRC).Objective:To correlate the quantitative data obtained by DRC with disease outcome in infants with VUR and positive DRC 1 year after diagnosis. Materials and methods: The medical records of 109 children with known primary VUR diagnosed during the first year of life were studied retrospectively. One year after diagnosis all patients underwent DRC. Children with a positive first DRC were followed up for the next 36 months. Fishers exact test was used to calculate the statistical significance of differences in the number of ureters with resolved reflux, as related to quantitative data obtained during the first DRC. Results:The first DRC, performed 1 year after the initial diagnosis, was positive in 49 children (26 with bilateral reflux). Quantitative data derived from this first examination could not establish any prognostic value for a refluxing volume of <2% of the total vesical volume or a reflux at a bladder volume of more than 60% of total bladder capacity. When this limit was lowered to 45%, a statistically significant difference was found (P=0.046). Moreover, when a bladder pressure at the time of reflux of more than 20 cm H₂O was set as a criterion, an extremely significant probability value was calculated (P=0.0009). Conclusions: VUR occurring at a bladder pressure of less than 20 cm H₂O and a filling volume of less than 45% of the total bladder volume indicate a low probability for VUR resolution within the subsequent 36 months, in infants with known reflux.     

儿童膀胱输尿管反流行超声尿路造影病例系列报告

目的 探讨超声尿路造影(CeVUS)对诊断和随访膀胱输尿管反流(VUR)的价值。方法 选择复旦大学附属儿科医院2018年9月27日至2019年5月10日收治的VUR高危患儿,利用六氟化硫微泡造影剂经膀胱内给药,进行CeVUS检查。总结CeVUS的检查结果,并结合临床特点进行分析。结果 50例患儿行CeVUS检查,男21例(42%,孤立肾2例),女29例(孤立肾1例),中位年龄25.0(2.3~99)月。①首次接受CeVUS检查者26例(50个PUUs),阳性15例(57.7%),其中低级别反流6例(40.0%),中、高级别反流9例(60.0%)。21/50个PUUs存在VUR,中、高级别反流14个(66.7%)。②24例(47个PUUs)既往行MCU,随访行CeVUS检查仍有24/47个(51.1%)PUUs 存在反流。反流好转患儿CeVUS与MCU检查间隔时间明显长于随访恶化或相仿患儿的随访时间(19.1月 vs 12.2月,P=0.02)。③在接受CeVUS的患儿中,14例已通过前期B超等检查发现存在除VUR以外的泌尿系发育畸形或有肾外表现。9例在完善CeVUS检查前已行MCU检查提示存在VUR。未发现造影剂相关的不良事件。结论 CeVUS可用于VUR的诊断和随访。