MANAGEMENT CONSIDERATIONS FOR TREATING VESICOURETERAL REFLUX IN CHILDREN WITH SOLITARY KIDNEYS

Objectives. To evaluate the management approach for vesicoureteral ref lux (reflux) into a solitary kidney. Methods. Outcomes of all children with solitary kidneys and reflux managed between 1981 and 1996 were r eviewed. Solitary kidneys were documented by nuclear renography and ul trasonography; reflux was graded after cystography. Management consist ed of observation and antimicrobial prophylaxis or surgery by ureteron eocystostomy or subureteric injection of polytetrafluoroethylene (STIN G). Follow-up ranged from 3 months to 14 years and included serial cys tography, sonography, and serum creatinine measurement. Results. Twent y-one patients with a median follow-up of 26 months were identified. E tiologies included contralateral renal agenesis (14 children), multicy stic dysplastic kidney (5 children), or nonfunctioning ureteropelvic j unction obstruction (2 children). Low-grade (I to II) reflux was ident ified in 6 children, and high grade (III to V) was identified in 15. R eflux resolved in 20 patients. Five children with low-grade reflux wer e managed without surgery and demonstrated reflux resolution after a m ean of 20.5 months. Renal function deteriorated in only 1 child. Urete roneocystostomy was performed in 13 children with grades III to V refl ux, and STING was performed in 1 child with grade II reflux. Every sur gical patient maintained stable renal function and was infection-free during a mean follow-up of 56 months. Management by observation in 2 c hildren with grades IV to V reflux resulted in spontaneous resolution in one and stable grade IV in the other. Conclusions. Reflux into the solitary functioning kidney may be managed by the same strategies used to manage unilateral reflux in children with two normally functioning kidneys: low-grade reflux by observation/chemoprophylaxis until spont aneous resolution occurs, and higher grades by surgery to protect rena l function; however, chemoprophylaxis and serial imaging may be used u ntil well-defined indications for surgery are satisfied. Renal functio n should be monitored diligently. (C) 1997, Elsevier Science Inc.