Untersuchung zur Notwendigkeit der Miktionszysturethrographie in der Nachsorge nach Antirefluxplastik

Urinary tract infections represent a frequent disease in children. Up to 15-50% of all urinary tract infections in these patients are caused by vesico-ureteral reflux (VUR). Parenchymal renal scars can be found in 30-60% of all patients at the time of diagnosis. The kidney damage progresses according the severity level of the VUR. The VUR is divided into a primary and secondary VUR. The primary VUR is caused by an insufficient locking mechanism of the vesicoureteral junction. Secondary reflux can have multifactorial causes. The outflow of urin out of the bladder in secondary VUR is often impaired by subvesical obstructions. Heikel and Parkkulainen have established levels of severity for VUR from I to V. Generally accepted indications for surgical treatment of reflux are breakthrough infections despite antibiotic prophylaxis in conservative therapy, lack of therapy adherence, high grade reflux, new renal scars or insufficient growth, deterioration of the renal function, persistent reflux in girls, or associated malformations. Different surgical approaches (extra- and intravescial) have been developed. The underlying common principle is the creation of a sufficiently long submucous tunnel around the ureter. Success rates of surgery in primary VUR range between 60% and 99%. The department of urology at the university of Marburg performs two voiding cystourethro-gram studies (VCUG) in follow up investigations as a matter of routine 3 and 12 months after the intervention. A VCUG is an invasive investigation with non-negligible radiation exposure. Given the high primary success rate of therapy, the question arose whether such an elaborate follow up is necessary, or whether simple indicators can be identified which point to treatment failure (persisting reflux or reflux re-appearance). The data of 184 children which received surgical treatment of VUR between 1989 and 1999 were retrospectively analysed in the present study. Among them were 123 girls and 61 boys, and 243 renal units were treated in these patients. Questionnaires were dispatched to the treating doctors of these patients. Items included among the rest were the re-appearance of a VUR, and the occurrence of febrile and non-febrile urinary tract infections. Changes in serum creatinine and urea levels as well as changes in blood pressure and the appearance of enuresis were recorded. The average follow-up period was 36.5 months (range 4 to 108 months). A statistically significant relationship for treatment failure (persisting reflux or reflux re-appearance) could be proved only for the occurrence of febrile urinary tract infections after surgical therapy. In 9 patients febrile urinary tract infections occurred in the follow-up period. In 4 patients caused by persistent or re-appeared reflux. In another 5 children due to hitherto unknown reflux of the opposite side. All these children received surgery for their newly diagnosed reflux. We conclude that, in contrast to the past practice in follow up in patients with VUR, the VCUG may be waived since all treatment failures (persisting reflux or reflux re-appearance) were consistently indicated by the occurrence of febrile urinary tract infections.