Rationale and procedures.

摘要

When the incompetence of the ureterovesical junction was first considered a congenital defect, the response was to devise a successful approach to its repair. Subsequently pyelonephritis coexisting with vesicoureteral reflux (VUR) was associated with renal scarring, hypertension and chronic renal insufficiency which, for some, indicated a causal relationship and the term reflux nephropathy was introduced. It was plausible that correcting the VUR would reduce or eliminate consequential renal injury. After all, virtually all medical progress made in the 100 years between the germ theory of disease and the development of antibiotics was the result of surgical innovations facilitated by general anesthesia. When various techniques were described and used, the treatment of childhood urinary tract infection (UTI) changed forever. Initially a child with UTI was subjected to radiologic studies to detect VUR and, when identified, was referred to a surgeon. Open repair by experienced surgeons was eventually successful in up to 98% of cases which, if the defect were corrected, should have eliminated further renal injury associated with VUR. Short-term observations after surgery proved shortsighted in that febrile and symptomatic UTI still developed in patients who no longer had VUR, and the progression of existing renal scars and the appearance of new ones meant that some part of the problem, probably UTI, had not been controlled. Simultaneously the individual and consistent medical management of VUR in children seemed to ensure better long-term outcomes than those produced by surgical repair. VUR was eliminated with surgery or UTI was controlled with daily antibiotic prophylaxis, hygienic practice, and bladder and bowel habits. The problem was that outcomes of either treatment were uncontrolled, untested and, at best, anecdotal. When appropriately designed prospective trials were conducted and cases randomly allocated to surgical repair or medical management, no advantage of either treatment was found after 5 years of study. Treatment choices were equally good or bad, and none completely eliminated further UTI or additional renal injury. Moreover, the spontaneous disappearance of VUR occurred in 80% of non-dilating VUR and 35% or more of dilating VUR. Therefore, the conclusion to be drawn from these studies was that any treatment, regardless of the claims made for or against it, must be proven to reduce the risk of further renal damage.