Summary
Background
Renal changes may have long-term sequalae and prevention is a main goal of management
of primary vesicoureteral reflux (VUR).
Aim
This study aims to reveal how much 99mTc-DMSA scintigraphy findings are reflected in the adopted surgical or non-surgical
treatment in children with diagnosed primary VUR and to give the clinicians information
regarding their final therapeutic decision.
Patients and methods
A total 207 children with primary VUR who underwent non-acute 99mTc-DMSA scan were retrospectively evaluated. The presence of renal changes, their
grading, differential function asymmetry (<45%) and grade of VUR were compared with
subsequent choice of therapy.
Results
Altogether 92 (44%) children had asymmetric differential function, 122 (59%) showed
presence of renal changes, 79 (38%) had high-grade VUR (IV-V). Patients with renal
changes had lower differential function (41%vs.48%) and higher grade of VUR. The incidence
of high-grade changes (G3+G4B) afflicting more than one third of the kidney was significantly
different between grade I-II, III and IV-V VUR (9%, 27%, 48%, respectively). Renal
changes were detected in 76% of surgically and 48% of non-surgically treated patients,
high-grade 99mTc-DMSA changes in 69% and 31%, respectively. In children with no scars/dysplasia
(G0+G4A), non-surgical treatment prevailed in 77%. The independent predictors for
surgical intervention were presence of renal changes and higher grade of VUR, but
not functional asymmetry.
Discussion
Over the last 20 years, there has been a shift toward more non-surgical management
of VUR. The long-term outcome of this approach should be thoroughly studied. This
is the first study analysing renal status in VUR patients using 99mTc-DMSA scan and its grading regarding the adopted treatment. Renal changes in almost
half of non-surgically treated children with VUR should be an indicator for earlier
diagnosis and effective treatment of acute pyelonephritis and VUR. We recommend distinguishing
grade III VUR, as a moderate-grade VUR, because it is linked to higher incidence of
high-grade 99mTc-DMSA changes (G3+G4B); our findings of 65% of grade III VURs treated non-surgically
should be cautionary. Grade III VUR does not mean a low-risk condition and should
alert the clinician to evaluate the extent of renal changes and unmask high-risk cases.
Conclusions
Summary TableRelationship between 99mTc-DMSA scan grading and choice of treatment.
| 99mTc-DMSA scan grading | Conservative n = 124 | Surgery n = 83 | All n = 207 |
|---|---|---|---|
| G0 | 64 (75%) | 21 (25%) | 85 (41%) |
| G1 | 18 (67%) | 9 (33%) | 27 (13%) |
| G2 | 7 (50%) | 7 (50%) | 14 (7%) |
| G3 | 5 (20%) | 20 (80%) | 25 (12%) |
| G4A | 15 (88%) | 2 (12%) | 17 (8%) |
| G4B | 15 (38%) | 24 (62%) | 39 (19%) |
| G1+G2+G3+G4B1) | 45 (43%) | 60 (57%) | 105 (51%) |
| G0+G4A1) | 79 (77%) | 23 (23%) | 102 (49%) |
| G3+G4B1) | 20 (31%) | 44 (69%) | 64 (31%) |
1)p < 0.0001 (Fisher's test).
Keywords
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Article info
Publication history
Published online: February 12, 2023
Accepted:
January 28,
2023
Received in revised form:
January 26,
2023
Received:
May 25,
2022
Publication stage
In Press Journal Pre-ProofIdentification
Copyright
© 2023 Published by Elsevier Ltd on behalf of Journal of Pediatric Urology Company.
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- Commentary to “How the 99mTc-DMSA scintigraphy findings are reflected in the adopted treatment of primary vesicoureteral reflux: One centre experience”Journal of Pediatric Urology
- PreviewChroustova et al ascertain to what degree 99m-Tc-DMSA scintigram findings influence management of primary VUR. [1} While preservation of renal function through avoidance of recurrent pyelonephritis is the priority in VUR management, data suggest that most renal injury precedes the diagnosis of VUR – whether as dysplasia or scarring - rather than during follow-up. [2,3] That is not to say that children are not at risk for recurrent urinary tract infection which represents morbidity in and of itself.
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