Scandinavian Journal of Urology and Nephrology
ISSN: 0036-5599 (Print) 1651-2065 (Online) Journal homepage: http://www.tandfonline.com/loi/isju19
Active Surgical Management of Primary Vesicoureteral Reflux in Adults Matti J. Kontturi & Erkki A. Koskela To cite this article: Matti J. Kontturi & Erkki A. Koskela (1977) Active Surgical Management of Primary Vesicoureteral Reflux in Adults, Scandinavian Journal of Urology and Nephrology, 11:3, 239-244, DOI: 10.3109/00365597709179958 To link to this article: http://dx.doi.org/10.3109/00365597709179958
Published online: 15 Feb 2010.
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Citing articles: 1 View citing articles
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Date: 29 March 2016, At: 18:09
Scand J Urol Nephrol 11: 239-244, 1977
ACTIVE SURGICAL MANAGEMENT OF PRIMARY VESICOURETERAL REFLUX IN ADULTS Matti J . Kontturi and Erkki A. Koskela From the Section of Urology. Department of Surgery, University Central Hospital, Oulu, Finland
Downloaded by [Flinders University of South Australia] at 18:10 29 March 2016
(Submitted for publication September 1, 1976)
Ahstruct. Of 27 adults with primary vesicoureteral reflux.
23 were treated surgically. These patients had suffered from chronic urinary-tract infections with poor response to conservative therapy. Urography revealed inflammatory changes in one or both kidneys in 18 patients, as well as other renal or ureteral deformities. Micturition cystography showed reflux reaching the renal pelvis and dilatation of the pelvis and ureter in 18 patients (28 ureters). An antireflux operation was performed on 32 ureters and in all cases was followed by disappearance of the reflux. N o ureteral stricture developed postoperatively. During an observation period averaging more than three years only three patients had postoperative urinary-tract infections. These occurred when a short period of medication was terminated. On the basis of present experience we consider that antireflux surgery is indicated for all adults with vesicoureteral reflux and urinary-tract infections or progressive dilatation of the upper urinary tract. Vesicoureteral reflux is always considered a pathological phenomenon (Pozzi, 1893; Bumpus, 1924; Hutch, 1952; Kjellberg, Ericsson & Rudhe, 1957; Hodson & Edwards, 1960; Leadbetter, Duxbury & Dreyfuss, 1960; Estes & Brooks, 1970). A relationship between chronic pyelonephritis and reflux has been well documented (Ericsson, 1960; Hutch, Hinman & Miller, 1962; Scott & Stansfeld, 1968; Ambrose, 1969). Histological studies suggest that primary reflux represents a congenital deficiency of the trigonal and distal ureteral musculature, which may prevent effective maturation of the ureterovesical junction (Tanagho, Guthrie & Lyon, 1969). Vesicoureteral reflux is usually considered a problem of childhood. Most surgeons feel that the majority of children with reflux can be treated conservatively. An antireflux operation is usually considered necessary in 2 0 4 0 % of cases (Parkkulainen, 1966; Nanninga, King, Downing & Burden,
1969; Elo, 1971). The opinions on the justification of surgical treatment, a s well a s the operative results, vary in the relatively few reports on vesicoureteral reflux in adults (Zingg, 1967; McGovern & Marshall, 1969; Lipsky & Chisholm, 1971). The objective in the management of vesicoureteral reflux is to prevent recurrent destructive episodes of pyelonephritis. Reflux in children often disappears during long-term conservative antibacterial therapy (Heikel & Parkkulainen, 1966; Elo). Adults, however, d o not display similar maturation. Drug therapy can suppress bacterial growth but does not change anatomic location of misplaced ureteral orifices (Hendren, 1968). This is why we have adopted a n active surgical approach t o vesicoureteral reflux in adults.
MATERIAL A N D METHODS Patients. The material consists of the 27 patients aged over 16 who have been treated in our hospital for primary reflux since October 1967 to December 1974. Twenty-one (78%) were women. The mean age of the patients at the time of operation was 24.7 years, with a range from 16 to
54 years (Table I). Symptoms. Twenty-three patients (85 %) had been referred to urological examination because of chronic urinary infection. These infections had occurred during an average period of 10 years, with a range of 1-30 years. Ten patients (37 %) had suffered from infections in childhood, and seven had had them during pregnancy, which accounts for all those who had been pregnant. The most usual symptoms were pain in the back and lower abdomen, slightly elevated temperature and pollakisuria (Table 11). Four patients, three of them men, had been sent to hospital examination because of accidentally detected albuminuria. One of these had mild hypertonia and renal insufficiency. Roentgenological examinations. All the patients un-
240
M .J . Kontturi und E. A . Koskela Table 11. Symptoms in icoureteral rejlux
uditlts k4ith
Downloaded by [Flinders University of South Australia] at 18:10 29 March 2016
Symptom Low back and abdominal pains Fever Pollakiuria Smarting pain, burning General malaise Urgency Urge incontinence Loss of weight Headache Oedema Ureterolithiasis Anaemia Albuminuria Asymptomatic
primury t ~ s -
No. of patients 18 13 12 10 3 2 1 1 1
I 1
2 5 4
Fig. I . Low grade reflux. Micturition cystography shows
reflux into both ureters without ureteral dilatation.
derwent urography and micturition cystography. Urogrdphy revealed unilateral or bilateral inflammatory changes in 18 patients. In addition to these, there were hypoplastic kidneys, duplications and hydronephroses (Table I l l ) . The classification of the reflux into five degrees proposed by Heikel and Parkkulainen was used in micturition cystography. In grade I the reflux is confined to the lower part of the ureter, in grade 11 it extends up into the renal pelvis, grade I11 shows reflux into a slightly dilated ureter and pelvis, grade IV into a moderately dilated and grade V into a grossly dilated ureter and pelvis. Reflux reaching the renal pelvis and dilatation of the cavity system noted in 28 (70%) ureters in our material (Table IV). Because of its unambiguity, the dichotomous division into low-grade and high-grade reflux according to Scott (1972) was adopted for clinical purposes (Table V). In Scott's grade 2 reflux there is a severely dilated and tortuous ureter. All cases with lesser degrees of ureteral dilatation are classified as grade I reflux (Figs. I , 2). Cysroscopy. In most cases the bladder was relatively large. The orifices of 22 ureters (in 14 patients) were
Table I . Aditlt pcitients with primury \vsicouretrrul rrflux in the University Central Hospital. Oiilu, I96 7-1 974 No. of patients
Age in years
Females
16-20 2 1-30 3140 5 1-60
10
Mean age
25.2 yrs
7 2 2
Males 4
I I -
22.7 yrs
located higher and more laterally than usual. According to the classification of Lyon, Marshall & Tariagho (1%9), 20 of the ureteral orifices wer.: of "golf-hole" type, two of horseshoe type, six slightly dilated and 12 of normal slitshaped type. Trabeculation of the bladder wall was noted in two patients, one of whom also had a paraureteral diverticulum. Urethral calibration with Hegar's dilatators was performed on all the female patients: two were found to have a narrow urethra (Hegar 4). Laboratory findings. The urinary sediment was pathological in 16 patients at the time of hospital admission. Significant bacterial growth was found in the urine of 13 patients (> lo5 micro-organisms/ml). The most common pathogen was E . coli (9 cases). The serum creatinine was normal in 23 patients. It ranged from I .3 to 1.9 mgl100 ml in two patients and from 2.0 to 3.0 mgl100 ml in another two. Anaemia was present in 1 1 patients, with haemoglobin < 12.5 g/l. In two patients the blood pressure exceeded 160/100 mmHg. Operations. Table V I shows that 22 ureters (14 patients) were treated with Glenn & Anderson's (1967) distal tunnel ureteral advancement antirefluxplasty, transposing the orifice of the ureter 2-3 cm distally and slightly medially. This operation is a modification of the methods described by Williams, Scott & Turner-Warwick (1961) and Hutch (1963). The approach was always transvesical. The suture material was 5-0 chromic catgut. Ten ureters (7 patients) were operated on according to Politano & Leadbetter (1958). often with extravesical dissection of the ureter as proposed by Paquin (1959). In two cases with bilateral reflux the Glenn-Anderson method was used on one side and the Politano-Leadbetter method on the other side, at the same operation. Postoperative drainage was accomplished by ureteral catheters through the bladder and abdominal wall for three days and urethral catheter for a week. All the patients received postoperative chemotherapy, usually a combination of long- and short-acting sulphonamides (sulphamethoxydiatsin and sulphafurazol). The Glenn-Anderson operation was used when ureteral
Primary vesicoureteral reflux
24 1
Table IV. Micturition cystographic findings Classification according to Heikel & Parkkulainen (1966) No. of
Grade of reflux
ureters
I I1 IV V
3 1 8 25 3
Total
40
Downloaded by [Flinders University of South Australia] at 18:10 29 March 2016
111
biotic therapy. All three had reflux into the lower section of one ureter. One had previously been nephroureterectomized because of a non-functioning hypoplastic kidney and had reflux to the other ureter. The fourth, male, patient was asymptomatic. Reflux to the left ureter had been detected at an examination for albuminuria. He had dilated ureters and renal cavities as well as a slight unilateral constriction of the pyeloureteral junction.
RESULTS Fig. 2. High grade reflux. Micturition cystography shows
marked dilatation of the ureter with a paraureteral diverticulum. dilatation was slight or moderate or the ureteral orifices were located high and laterally. The Politano-Leadbetter technique was used when the ureter was markedly dilated or the ureteral orifice was normally located. In two patients with l .5 cm-wide ureters the Politano-Leadbetter technique was combined with tailoring of the lower third of the ureters. Nephroureterectomy was performed on three patients with a non-functioning hypoplastic kidney and reflux. In a patient who had previously undergone nephrectomy the refluxing ureteral stump was removed. The only surgical complication was bleeding after nephroureterectomy. Four patients (four ureters) with reflux were conservatively treated. Three were women with long-term anti-
Table 111. Urographicfindings No. of
Finding
patients
Inflammatory changes in both kidneys Inflammatory changes in one kidney H ydronephrosis Bilateral Unilateral Renal hypoplasia Ureteral and pelvic duplication
IS
I6 -712928
3 8 5 3 6 5
Twenty-five of the patients (93%) were followed up. Of the two who could not be traced, one had undergone nephroureterectomy and the other excision of a refluxing ureteral stump. The follow-up period ranged from 6 months to 7 years and averaged 3 1/6 years. Urography was performed 1-3 months after the antireflux operations in order to detect any ureteral obstruction. Urography and micturition cystography were performed 6 months postoperatively and subsequently at intervals of 6-12 months. The usual laboratory tests were done at the same time. The reflux was abolished by the operation in all cases (Table VII). Reflux to the contralateral ureter was diagnosed on follow-up in two patients. This reflux had not previously been detected, though urographically demonstrated deformities in the renal cavities had suggested its presence. A second unilateral operation was therefore performed in these cases, In no case did postoperative ureteral stricture occur. The patients were ordered prophylactic medication against urinary-trxt infection for 6 months postoperatively. If urinary cultures were then negative, the medication would be stopped. Five patients, however, discontinued treatment as early as one month after the operation. In three of them, who had undergone the Glenn-Anderson operation, urinary-tract infection then appeared within a few
242
M . J . Kontturi und E. A . Koskelu
Table V . Clinical classification of vesicoureterul rejlux in adults according to Scott (1972) Grade of reflux I II
No. of patients
No. of ureters
23
32 8
4 27
Total
40
Downloaded by [Flinders University of South Australia] at 18:10 29 March 2016
Table VI. Therapeutic procedure Methods of treatment Glenn-Anderson Politano-Leadbetter Nephroureterectomy Ureterectomy Conservative treatment Total
No. of patients
ureters
14
22
7 3 I 4
10
27
40
No. of
3 I 4
"
In 2 cases the Glenn-Anderson method was performed on one side and the Politano-Leadbetter procedure on the other side.
days. The cultures showed E . coli in two patients and Pseudomonas and Klebsiella in one (>I00000 bacterialml). After resumption of medication these patients have been free from urinary-tract infections. Two patients have remained infection-free after only one month of postoperative antibiotic therapy. Bilateral Politano-Leadbetter operation had been performed in one case and nephroureterectomy in the other. Six patients have continued the prophylactic medication for some years on the advice of their own doctors o r by personal wish, though they have been infection-free. The longest continuous period of medication is more than 6 years in a patient treated conservatively for reflux. This patient
Table VII. Current
.stutus
Result Reflux cured Still reflux No infections after treatment Recurrent infections On long-term chemotherapy Uraemia
tried to discontinue treatment 2 years after the initial hospital examination, but was forced by reinfections to resume it. The average duration of postoperative antibiotic therapy was 10 months. In one of the patients with renal insufficiency before the reflux operation (serum creatinine 1.9 mg/100 ml) uraemia developed and necessitated repeated dialysis 2 3/4 years postoperatively. Even then there was no evidence of ureteral stricture or reflux. The preoperative reflux was of high grade (Scott's classification) and the kidney hypoplastic. The daily albuminuria exceeded 3 g/l and the creatinine clearance was 1.2 ml/s/1.73 mz. In two of the four conservatively treated patients the reflux disappeared during the observation period. One of these two had previously had a Marshall-Marchetti-Krantz operation for urinary incontinence and had been treated for endometriosis. The other had undergone nephroureterectomy of the destroyed refluxing contralateral side. She is receiving continuous chemotherapy for recurrent urinary infections. The first patient ceased medication after 2 years and has since been infection-free. The third patient is a man who has remained asymptomatic without medication. His reflux is unaffected. The fourth patient is on continuous medication. She has one hypoplastic and one normal kidney and the ureteral reflux is unchanged or is less.
DISCUSSION The success rate in the surgical treatment of vesicoureteral reflux exceeds 90 per cent in many series (Politano, 1963; Hendren: Scott. 1969: Herberman, Markman & Payne, 1969; Gonzales. Glenn & Anderson. 1972). The poor results in some adult series (Lipsky & Chisholm) may have been attributable to the selection of patients o r to the
4 2 5 putients trcutrd f o r r~e.sicwrireteru1rc
ISSN: 0036-5599 (Print) 1651-2065 (Online) Journal homepage: http://www.tandfonline.com/loi/isju19
Active Surgical Management of Primary Vesicoureteral Reflux in Adults Matti J. Kontturi & Erkki A. Koskela To cite this article: Matti J. Kontturi & Erkki A. Koskela (1977) Active Surgical Management of Primary Vesicoureteral Reflux in Adults, Scandinavian Journal of Urology and Nephrology, 11:3, 239-244, DOI: 10.3109/00365597709179958 To link to this article: http://dx.doi.org/10.3109/00365597709179958
Published online: 15 Feb 2010.
Submit your article to this journal
Article views: 1
View related articles
Citing articles: 1 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=isju19 Download by: [Flinders University of South Australia]
Date: 29 March 2016, At: 18:09
Scand J Urol Nephrol 11: 239-244, 1977
ACTIVE SURGICAL MANAGEMENT OF PRIMARY VESICOURETERAL REFLUX IN ADULTS Matti J . Kontturi and Erkki A. Koskela From the Section of Urology. Department of Surgery, University Central Hospital, Oulu, Finland
Downloaded by [Flinders University of South Australia] at 18:10 29 March 2016
(Submitted for publication September 1, 1976)
Ahstruct. Of 27 adults with primary vesicoureteral reflux.
23 were treated surgically. These patients had suffered from chronic urinary-tract infections with poor response to conservative therapy. Urography revealed inflammatory changes in one or both kidneys in 18 patients, as well as other renal or ureteral deformities. Micturition cystography showed reflux reaching the renal pelvis and dilatation of the pelvis and ureter in 18 patients (28 ureters). An antireflux operation was performed on 32 ureters and in all cases was followed by disappearance of the reflux. N o ureteral stricture developed postoperatively. During an observation period averaging more than three years only three patients had postoperative urinary-tract infections. These occurred when a short period of medication was terminated. On the basis of present experience we consider that antireflux surgery is indicated for all adults with vesicoureteral reflux and urinary-tract infections or progressive dilatation of the upper urinary tract. Vesicoureteral reflux is always considered a pathological phenomenon (Pozzi, 1893; Bumpus, 1924; Hutch, 1952; Kjellberg, Ericsson & Rudhe, 1957; Hodson & Edwards, 1960; Leadbetter, Duxbury & Dreyfuss, 1960; Estes & Brooks, 1970). A relationship between chronic pyelonephritis and reflux has been well documented (Ericsson, 1960; Hutch, Hinman & Miller, 1962; Scott & Stansfeld, 1968; Ambrose, 1969). Histological studies suggest that primary reflux represents a congenital deficiency of the trigonal and distal ureteral musculature, which may prevent effective maturation of the ureterovesical junction (Tanagho, Guthrie & Lyon, 1969). Vesicoureteral reflux is usually considered a problem of childhood. Most surgeons feel that the majority of children with reflux can be treated conservatively. An antireflux operation is usually considered necessary in 2 0 4 0 % of cases (Parkkulainen, 1966; Nanninga, King, Downing & Burden,
1969; Elo, 1971). The opinions on the justification of surgical treatment, a s well a s the operative results, vary in the relatively few reports on vesicoureteral reflux in adults (Zingg, 1967; McGovern & Marshall, 1969; Lipsky & Chisholm, 1971). The objective in the management of vesicoureteral reflux is to prevent recurrent destructive episodes of pyelonephritis. Reflux in children often disappears during long-term conservative antibacterial therapy (Heikel & Parkkulainen, 1966; Elo). Adults, however, d o not display similar maturation. Drug therapy can suppress bacterial growth but does not change anatomic location of misplaced ureteral orifices (Hendren, 1968). This is why we have adopted a n active surgical approach t o vesicoureteral reflux in adults.
MATERIAL A N D METHODS Patients. The material consists of the 27 patients aged over 16 who have been treated in our hospital for primary reflux since October 1967 to December 1974. Twenty-one (78%) were women. The mean age of the patients at the time of operation was 24.7 years, with a range from 16 to
54 years (Table I). Symptoms. Twenty-three patients (85 %) had been referred to urological examination because of chronic urinary infection. These infections had occurred during an average period of 10 years, with a range of 1-30 years. Ten patients (37 %) had suffered from infections in childhood, and seven had had them during pregnancy, which accounts for all those who had been pregnant. The most usual symptoms were pain in the back and lower abdomen, slightly elevated temperature and pollakisuria (Table 11). Four patients, three of them men, had been sent to hospital examination because of accidentally detected albuminuria. One of these had mild hypertonia and renal insufficiency. Roentgenological examinations. All the patients un-
240
M .J . Kontturi und E. A . Koskela Table 11. Symptoms in icoureteral rejlux
uditlts k4ith
Downloaded by [Flinders University of South Australia] at 18:10 29 March 2016
Symptom Low back and abdominal pains Fever Pollakiuria Smarting pain, burning General malaise Urgency Urge incontinence Loss of weight Headache Oedema Ureterolithiasis Anaemia Albuminuria Asymptomatic
primury t ~ s -
No. of patients 18 13 12 10 3 2 1 1 1
I 1
2 5 4
Fig. I . Low grade reflux. Micturition cystography shows
reflux into both ureters without ureteral dilatation.
derwent urography and micturition cystography. Urogrdphy revealed unilateral or bilateral inflammatory changes in 18 patients. In addition to these, there were hypoplastic kidneys, duplications and hydronephroses (Table I l l ) . The classification of the reflux into five degrees proposed by Heikel and Parkkulainen was used in micturition cystography. In grade I the reflux is confined to the lower part of the ureter, in grade 11 it extends up into the renal pelvis, grade I11 shows reflux into a slightly dilated ureter and pelvis, grade IV into a moderately dilated and grade V into a grossly dilated ureter and pelvis. Reflux reaching the renal pelvis and dilatation of the cavity system noted in 28 (70%) ureters in our material (Table IV). Because of its unambiguity, the dichotomous division into low-grade and high-grade reflux according to Scott (1972) was adopted for clinical purposes (Table V). In Scott's grade 2 reflux there is a severely dilated and tortuous ureter. All cases with lesser degrees of ureteral dilatation are classified as grade I reflux (Figs. I , 2). Cysroscopy. In most cases the bladder was relatively large. The orifices of 22 ureters (in 14 patients) were
Table I . Aditlt pcitients with primury \vsicouretrrul rrflux in the University Central Hospital. Oiilu, I96 7-1 974 No. of patients
Age in years
Females
16-20 2 1-30 3140 5 1-60
10
Mean age
25.2 yrs
7 2 2
Males 4
I I -
22.7 yrs
located higher and more laterally than usual. According to the classification of Lyon, Marshall & Tariagho (1%9), 20 of the ureteral orifices wer.: of "golf-hole" type, two of horseshoe type, six slightly dilated and 12 of normal slitshaped type. Trabeculation of the bladder wall was noted in two patients, one of whom also had a paraureteral diverticulum. Urethral calibration with Hegar's dilatators was performed on all the female patients: two were found to have a narrow urethra (Hegar 4). Laboratory findings. The urinary sediment was pathological in 16 patients at the time of hospital admission. Significant bacterial growth was found in the urine of 13 patients (> lo5 micro-organisms/ml). The most common pathogen was E . coli (9 cases). The serum creatinine was normal in 23 patients. It ranged from I .3 to 1.9 mgl100 ml in two patients and from 2.0 to 3.0 mgl100 ml in another two. Anaemia was present in 1 1 patients, with haemoglobin < 12.5 g/l. In two patients the blood pressure exceeded 160/100 mmHg. Operations. Table V I shows that 22 ureters (14 patients) were treated with Glenn & Anderson's (1967) distal tunnel ureteral advancement antirefluxplasty, transposing the orifice of the ureter 2-3 cm distally and slightly medially. This operation is a modification of the methods described by Williams, Scott & Turner-Warwick (1961) and Hutch (1963). The approach was always transvesical. The suture material was 5-0 chromic catgut. Ten ureters (7 patients) were operated on according to Politano & Leadbetter (1958). often with extravesical dissection of the ureter as proposed by Paquin (1959). In two cases with bilateral reflux the Glenn-Anderson method was used on one side and the Politano-Leadbetter method on the other side, at the same operation. Postoperative drainage was accomplished by ureteral catheters through the bladder and abdominal wall for three days and urethral catheter for a week. All the patients received postoperative chemotherapy, usually a combination of long- and short-acting sulphonamides (sulphamethoxydiatsin and sulphafurazol). The Glenn-Anderson operation was used when ureteral
Primary vesicoureteral reflux
24 1
Table IV. Micturition cystographic findings Classification according to Heikel & Parkkulainen (1966) No. of
Grade of reflux
ureters
I I1 IV V
3 1 8 25 3
Total
40
Downloaded by [Flinders University of South Australia] at 18:10 29 March 2016
111
biotic therapy. All three had reflux into the lower section of one ureter. One had previously been nephroureterectomized because of a non-functioning hypoplastic kidney and had reflux to the other ureter. The fourth, male, patient was asymptomatic. Reflux to the left ureter had been detected at an examination for albuminuria. He had dilated ureters and renal cavities as well as a slight unilateral constriction of the pyeloureteral junction.
RESULTS Fig. 2. High grade reflux. Micturition cystography shows
marked dilatation of the ureter with a paraureteral diverticulum. dilatation was slight or moderate or the ureteral orifices were located high and laterally. The Politano-Leadbetter technique was used when the ureter was markedly dilated or the ureteral orifice was normally located. In two patients with l .5 cm-wide ureters the Politano-Leadbetter technique was combined with tailoring of the lower third of the ureters. Nephroureterectomy was performed on three patients with a non-functioning hypoplastic kidney and reflux. In a patient who had previously undergone nephrectomy the refluxing ureteral stump was removed. The only surgical complication was bleeding after nephroureterectomy. Four patients (four ureters) with reflux were conservatively treated. Three were women with long-term anti-
Table 111. Urographicfindings No. of
Finding
patients
Inflammatory changes in both kidneys Inflammatory changes in one kidney H ydronephrosis Bilateral Unilateral Renal hypoplasia Ureteral and pelvic duplication
IS
I6 -712928
3 8 5 3 6 5
Twenty-five of the patients (93%) were followed up. Of the two who could not be traced, one had undergone nephroureterectomy and the other excision of a refluxing ureteral stump. The follow-up period ranged from 6 months to 7 years and averaged 3 1/6 years. Urography was performed 1-3 months after the antireflux operations in order to detect any ureteral obstruction. Urography and micturition cystography were performed 6 months postoperatively and subsequently at intervals of 6-12 months. The usual laboratory tests were done at the same time. The reflux was abolished by the operation in all cases (Table VII). Reflux to the contralateral ureter was diagnosed on follow-up in two patients. This reflux had not previously been detected, though urographically demonstrated deformities in the renal cavities had suggested its presence. A second unilateral operation was therefore performed in these cases, In no case did postoperative ureteral stricture occur. The patients were ordered prophylactic medication against urinary-trxt infection for 6 months postoperatively. If urinary cultures were then negative, the medication would be stopped. Five patients, however, discontinued treatment as early as one month after the operation. In three of them, who had undergone the Glenn-Anderson operation, urinary-tract infection then appeared within a few
242
M . J . Kontturi und E. A . Koskelu
Table V . Clinical classification of vesicoureterul rejlux in adults according to Scott (1972) Grade of reflux I II
No. of patients
No. of ureters
23
32 8
4 27
Total
40
Downloaded by [Flinders University of South Australia] at 18:10 29 March 2016
Table VI. Therapeutic procedure Methods of treatment Glenn-Anderson Politano-Leadbetter Nephroureterectomy Ureterectomy Conservative treatment Total
No. of patients
ureters
14
22
7 3 I 4
10
27
40
No. of
3 I 4
"
In 2 cases the Glenn-Anderson method was performed on one side and the Politano-Leadbetter procedure on the other side.
days. The cultures showed E . coli in two patients and Pseudomonas and Klebsiella in one (>I00000 bacterialml). After resumption of medication these patients have been free from urinary-tract infections. Two patients have remained infection-free after only one month of postoperative antibiotic therapy. Bilateral Politano-Leadbetter operation had been performed in one case and nephroureterectomy in the other. Six patients have continued the prophylactic medication for some years on the advice of their own doctors o r by personal wish, though they have been infection-free. The longest continuous period of medication is more than 6 years in a patient treated conservatively for reflux. This patient
Table VII. Current
.stutus
Result Reflux cured Still reflux No infections after treatment Recurrent infections On long-term chemotherapy Uraemia
tried to discontinue treatment 2 years after the initial hospital examination, but was forced by reinfections to resume it. The average duration of postoperative antibiotic therapy was 10 months. In one of the patients with renal insufficiency before the reflux operation (serum creatinine 1.9 mg/100 ml) uraemia developed and necessitated repeated dialysis 2 3/4 years postoperatively. Even then there was no evidence of ureteral stricture or reflux. The preoperative reflux was of high grade (Scott's classification) and the kidney hypoplastic. The daily albuminuria exceeded 3 g/l and the creatinine clearance was 1.2 ml/s/1.73 mz. In two of the four conservatively treated patients the reflux disappeared during the observation period. One of these two had previously had a Marshall-Marchetti-Krantz operation for urinary incontinence and had been treated for endometriosis. The other had undergone nephroureterectomy of the destroyed refluxing contralateral side. She is receiving continuous chemotherapy for recurrent urinary infections. The first patient ceased medication after 2 years and has since been infection-free. The third patient is a man who has remained asymptomatic without medication. His reflux is unaffected. The fourth patient is on continuous medication. She has one hypoplastic and one normal kidney and the ureteral reflux is unchanged or is less.
DISCUSSION The success rate in the surgical treatment of vesicoureteral reflux exceeds 90 per cent in many series (Politano, 1963; Hendren: Scott. 1969: Herberman, Markman & Payne, 1969; Gonzales. Glenn & Anderson. 1972). The poor results in some adult series (Lipsky & Chisholm) may have been attributable to the selection of patients o r to the
4 2 5 putients trcutrd f o r r~e.sicwrireteru1rc
