SURGICAL-MANAGEMENT OF GRADE-III AND GRADE-IV PRIMARY VESICOURETERAL REFLUX IN CHILDREN WITH AND WITHOUT ACUTE PYELONEPHRITIS AS BREAKTHROUGH INFECTIONS - A COMPARATIVE-ANALYSIS

Purpose: Although high grade vesicoureteral reflux associated with bre akthrough infection may be an indication for surgical intervention, it remains uncertain whether acute pyelonephritis as breakthrough infect ion is a risk for renal scar formation and whether surgery performed w ithout it has any advantage. We assessed the results of antireflux sur gery for high grade vesicoureteral reflux in children with and without acute pyelonephritis as breakthrough infections. Materials and Method s: A total of 33 boys and 27 girls (102 refluxing units) less than 3 y ears old with grades III and IV vesicoureteral reflux who underwent su rgical management because of breakthrough infections were retrospectiv ely studied in a 3-year period. Of the 60 patients 30 (group 1) presen ted with breakthrough infections of acute pyelonephritis, although the y were maintained on prophylactic antibacterials. The remaining 30 pat ients (group 2) underwent surgery without acute pyelonephritis as the breakthrough infections. There was no renal scar formation at the diag nosis of vesicoureteral reflux in either group. Patients with renal sc ars were excluded from study. There was no significant difference in p atient gender (p = 0.795) or distribution of bilateral vesicoureteral reflux (p = 0.781) in the groups. Group 1 patients were significantly younger at the diagnosis of vesicoureteral reflux (p = 0.006). Results : Although 55 patients presented with a febrile urinary tract infectio n at the diagnosis of vesicoureteral reflux, the infection was not sig nificantly related to the development of renal scars (p = 0.066). Of t he 55 patients 12 presented with acute pyelonephritis as the initial e pisode of urinary tract infection. The presence of acute pyelonephriti s at the diagnosis of vesicoureteral reflux was also not significantly related to renal scar formation (p = 0.207). Postoperative urinary tr act infections developed in 34 patients but there was no significant c orrelation between postoperative urinary tract infections and renal sc ar formation (p = 0.235). At followup 17 group 1 and 7 group 2 patient s (29 renal units) were found to have renal scars. Conclusions: Renal scars were significantly more common in younger children with than wit hout acute pyelonephritis as breakthrough infections (p = 0.010). Alth ough breakthrough infections in high grade reflux may be an indication for antireflux surgery, the most appropriate results were achieved wh en acute pyelonephritis was not a breakthrough infection.