Yang Yi,Liu Xin.Several focal issues in the treatment of vesicoureteral reflux in children[J].Journal of Clinical Pediatric Surgery,2023,22(10):901-907.[doi:10.3760/cma.j.cn101785-202302027-001]
关于儿童膀胱输尿管反流治疗中的几个焦点问题
- Title:
- Several focal issues in the treatment of vesicoureteral reflux in children
- Keywords:
- Vesico-Ureteral Reflux; Therapy; Urinary Tract Infection; Antibiotic Prophylaxis; Clinical Decision Rules; Bladder And Bowel Dysfunction; End-Stage Kidney Disease; Child
- 摘要:
- 随着小儿泌尿外科和肾内科医师对儿童膀胱输尿管反流认识的深入,国内儿童膀胱输尿管反流的整体治疗模式也发生了转变。膀胱输尿管反流患儿的临床转归个体差异大,且受多种因素影响,需要根据风险分层采取个体化评估与处理措施。如何监测及预防发热性尿路感染的发生,如何评估肾瘢痕发生的风险、预防终末期肾病,如何在干预治疗与保守治疗之间权衡利弊,是当前临床医师治疗膀胱输尿管反流患儿时面临的难点,也是临床关注的焦点。本文结合国内外相关文献及作者多年临床诊疗体会,对儿童膀胱输尿管反流治疗中的几个焦点问题进行阐述。
- Abstract:
- As pediatric urologists and nephrologists gradually deepen their understandings of pediatric vesicoureteral reflux (VUR),the overall treatment mode has also undergone a great transformation in China.Clinical outcomes of VUR children vary greatly and are influenced by various factors.Based upon risk stratifications,individualized assessment and managements are mandatory.How to monitor and prevent the occurrence of febrile urinary tract infections,evaluate the risk of renal scarring,prevent end-stage renal disease and balance the advantages and disadvantages between interventions and conservative treatments are currently dilemmas.Based upon literature reviews and personal experiences,this review discussed several key issues in the treatment of pediatric VUR.
参考文献/References:
[1] Yeung CK,Godley ML,Dhillon HK,et al.The characteristics of primary vesico-ureteric reflux in male and female infants with pre-natal hydronephrosis[J].Br J Urol,1997,80(2):319-327.DOI:10.1046/j.1464-410x.1997.00309.x.
[2] Coco C,Jacobs M.Surgical indications for operative management of vesicoureteral reflux in children[J].Curr Opin Pediatr,2021,33(2):243-246.DOI:10.1097/MOP.0000000000001000.
[3] Brandstr?m P,Esbj?rner E,Herthelius M,et al.The Swedish reflux trial in children:Ⅲ.Urinary tract infection pattern[J].J Urol,2010,184(1):286-291.DOI:10.1016/j.juro.2010.01.061.
[4] Roussey-Kesler G,Gadjos V,Idres N,et al.Antibiotic prophylaxis for the prevention of recurrent urinary tract infection in children with low grade vesicoureteral reflux:results from a prospective randomized study[J].J Urol,2008,179(2):674-679.DOI:10.1016/j.juro.2007.09.090.
[5] Wang HHS,Gbadegesin RA,Foreman JW,et al.Efficacy of antibiotic prophylaxis in children with vesicoureteral reflux:systematic review and meta-analysis[J].J Urol,2015,193(3):963-969.DOI:10.1016/j.juro.2014.08.112.
[6] Gnech M,Lovatt CA,McGrath M,et al.Quality of reporting and fragility index for randomized controlled trials in the vesicoureteral reflux literature:where do we stand?[J].J Pediatr Urol,2019,15(3):204-212.DOI:10.1016/j.jpurol.2019.02.014.
[7] Hoberman A,Greenfield SP,Mattoo TK,et al.Antimicrobial prophylaxis for children with vesicoureteral reflux[J].N Engl J Med,2014,370(25):2367-2376.DOI:10.1056/NEJMoa1401811.
[8] Garin EH.Primary vesicoureteral reflux; what have we learnt from the recently published randomized,controlled trials?[J].Pediatr Nephrol,2019,34(9):1513-1519.DOI:10.1007/s00467-018-4045-9.
[9] Wang ZT,Wehbi E,Alam Y,et al.A reanalysis of the RIVUR trial using a risk classification system[J].J Urol,2018,199(6):1608-1614.DOI:10.1016/j.juro.2017.11.080.
[10] Bertsimas D,Li M,Estrada C,et al.Selecting children with vesicoureteral reflux who are most likely to benefit from antibiotic prophylaxis:application of machine learning to RIVUR[J].J Urol,2021,205(4):1170-1179.DOI:10.1097/JU.0000000000001445.
[11] Damm T,Mathews R.The RiVUR study outcomes and implications on the management of vesicoureteral reflux[J].Arch Nephrol Ren Stud,2022,2(1):1-5.
[12] Mathews R,Mattoo TK.The role of antimicrobial prophylaxis in the management of children with vesicoureteral reflux-the RIVUR study outcomes[J].Adv Chronic Kidney Dis,2015,22(4):325-330.DOI:10.1053/j.ackd.2015.04.002.
[13] Shaikh N,Haralam MA,Kurs-Lasky M,et al.Association of renal scarring with number of febrile urinary tract infections in children[J].JAMA Pediatr,2019,173(10):949-952.DOI:10.1001/jamapediatrics.2019.2504.
[14] Wang HH,Kurtz M,Logvinenko T,et al.Why does prevention of recurrent urinary tract infection not result in less renal scarring? A deeper dive into the RIVUR trial[J].J Urol,2019,202(2):400-405.DOI:10.1097/JU.0000000000000292.
[15] Shaikh N,Hoberman A,Keren R,et al.Predictors of antimicrobial resistance among pathogens causing urinary tract infection in children[J].J Pediatr,2016,171:116-121.DOI:10.1016/j.jpeds.2015.12.044.
[16] 中华医学会小儿外科学分会泌尿外科学组.儿童原发性膀胱输尿管反流的专家共识[J].临床小儿外科杂志,2019,18(10):811-816.DOI:10.3969/j.issn.1671-6353.2019.10.002.Group of Pediatric Urology,Branch of Pediatric Surgery,Chinese Medical Association:Expert Consensus on Managing Primary Vesicoureteral Reflux in Children[J].J Clin Ped Sur,2019,18(10):811-816.DOI:10.3969/j.issn.1671-6353.2019.10.002.
[17] Holzman SA,Chamberlin JD,Davis-Dao CA,et al.Retractable foreskin reduces urinary tract infections in infant boys with vesicoureteral reflux[J].J Pediatr Urol,2021,17(2):209.e1-209.e6.DOI:10.1016/j.jpurol.2021.01.007.
[18] 李宁,张潍平,田军,等.糖皮质激素外用治疗包茎对原发膀胱输尿管反流婴幼儿发生尿路感染的影响[J].中华医学杂志,2022,102(38):3007-3011.DOI:10.3760/cma.j.cn112137-20220329-00657.Li N,Zhang WP,Tian J,et al.Effect of topical glucocorticoid in treating phimosis on urinary tract infection of vesicoureteral reflux in infants[J].Natl Med J China,2022,102(38):3007-3011.DOI:10.3760/cma.j.cn112137-20220329-00657.
[19] Wahyudi I,Raharja PAR,Situmorang GR,et al.Circumcision reduces urinary tract infection in children with antenatal hydronephrosis:systematic review and meta-analysis[J].J Pediatr Urol,2023,19(1):66-74.DOI:10.1016/j.jpurol.2022.10.029.
[20] Meena J,Mathew G,Hari P,et al.Prevalence of bladder and bowel dysfunction in toilet-trained children with urinary tract infection and/or primary vesicoureteral reflux:a systematic review and meta-analysis[J].Front Pediatr,2020,8:84.DOI:10.3389/fped.2020.00084.
[21] Shaikh N,Hoberman A,Keren R,et al.Recurrent urinary tract infections in children with bladder and bowel dysfunction[J].Pediatrics,2016,137(1):e20152982.DOI:10.1542/peds.2015-2982.
[22] Shaikh N,Mattoo TK,Keren R,et al.Early antibiotic treatment for pediatric febrile urinary tract infection and renal scarring[J].JAMA Pediatr,2016,170(9):848-854.DOI:10.1001/jamapediatrics.2016.1181.
[23] Pohl HG,de Winter JP,Milani GP.Vesicoureteral reflux:we have yet to complete our learning[J].Eur J Pediatr,2021,180(5):1381-1382.DOI:10.1007/s00431-021-03972-w.
[24] Sillén U,Brandstr?m P,Jodal U,et al.The Swedish reflux trial in children:v.Bladder dysfunction[J].J Urol,2010,184(1):298-304.DOI:10.1016/j.juro.2010.03.063.
[25] Sj?str?m S,Bachelard M,Sixt R,et al.Change of urodynamic patterns in infants with dilating vesicoureteral reflux:3-year followup[J].J Urol,2009,182(5):2446-2453.DOI:10.1016/j.juro.2009.07.057.
[26] Joinson C,Heron J,Von Gontard A,et al.A prospective study of age at initiation of toilet training and subsequent daytime bladder control in school-age children[J].J Dev Behav Pediatr,2009,30(5):385-393.DOI:10.1097/dbp.0b013e3181ba0e77.
[27] Li X,Wen JG,Xie H,et al.Delayed in toilet training association with pediatric lower urinary tract dysfunction:a systematic review and meta-analysis[J].J Pediatr Urol,2020,16(3):352.e1-352.e8.DOI:10.1016/j.jpurol.2020.02.016.
[28] Haid B,Thüminger J,Lusuardi L,et al.Is there a need for endoscopic evaluation in symptomatic boys with an unsuspicious urethra on VCUG? A consideration of secondary radiologic signs of posterior urethral valves[J].World J Urol,2021,39(1):271-279.DOI:10.1007/s00345-020-03175-2.
[29] Nakai H,Hyuga T,Kawai S,et al.Aggressive diagnosis and treatment for posterior urethral valve as an etiology for vesicoureteral reflux or urge incontinence in children[J].Investig Clin Urol,2017,58(Suppl 1):S46-S53.DOI:10.4111/icu.2017.58.S1.S46.
[30] Nakamura S,Hyuga T,Kawai S,et al.The endoscopic morphological features of congenital posterior urethral obstructions in Boys with refractory daytime urinary incontinence and nocturnal enuresis[J].Eur J Pediatr Surg,2016,26(4):368-375.DOI:10.1055/s-0035-1563401.
[31] Marra G,Barbieri G,Dell’Agnola CA,et al.Congenital renal damage associated with primary vesicoureteral reflux detected prenatally in male infants[J].J Pediatr,1994,124(5Pt1):726-730.DOI:10.1016/s0022-3476(05)81362-9.
[32] Swerkersson S,Jodal U,Sixt R,et al.Relationship among vesicoureteral reflux,urinary tract infection and renal damage in children[J].J Urol,2007,178(2):647-651.DOI:10.1016/j.juro.2007.04.004.
[33] Craig JC,Irwig LM,Knight JF,et al.Does treatment of vesicoureteric reflux in childhood prevent end-stage renal disease attributable to reflux nephropathy?[J].Pediatrics,2000,105(6):1236-1241.DOI:10.1542/peds.105.6.1236.
[34] Peters CA,Skoog SJ,Arant BS Jr,et al.Summary of the AUA guideline on management of primary vesicoureteral reflux in children[J].J Urol,2010,184(3):1134-1144.DOI:10.1016/j.juro.2010.05.065.
[35] Hewitt I,Montini G.Vesicoureteral reflux is it important to find?[J].Pediatr Nephrol,2021,36(4):1011-1017.DOI:10.1007/s00467-020-04573-9.
[36] Thergaonkar RW,Hari P.Current management of urinary tract infection and vesicoureteral reflux[J].Indian J Pediatr,2020,87(8):625-632.DOI:10.1007/s12098-019-03099-9.
[37] Ardissino G,Daccò V,Testa S,et al.Epidemiology of chronic renal failure in children:data from the ItalKid project[J].Pediatrics,2003,111(4Pt1):e382-e387.DOI:10.1542/peds.111.4.e382.
[38] Marra G,Oppezzo C,Ardissino G,et al.Severe vesicoureteral reflux and chronic renal failure:a condition peculiar to male gender? Data from the ItalKid Project[J].J Pediatr,2004,144(5):677-681.DOI:10.1016/j.jpeds.2004.01.043.
[39] Saran R,Robinson B,Abbott KC,et al.US renal data system 2018 annual data report:epidemiology of kidney disease in the United States[J].Am J Kidney Dis,2019,73(3 Suppl 1):A7-A8.DOI:10.1053/j.ajkd.2019.01.001.
[40] Cornwell LB,Riddell JV,Mason MD.New-onset ESRD secondary to reflux nephropathy has decreased in incidence in the United States[J].J Pediatr Urol,2020,16(5):566.e1-566.e7.DOI:10.1016/j.jpurol.2020.06.023.
相似文献/References:
[1]曹国庆 汤绍涛杨瑛李时望毛永忠王勇.腹腔镜治疗直肠乙状结肠型先天性巨结肠122例疗效分析[J].临床小儿外科杂志,2011,10(01):0.
CAO Guo qing,TANG Shao tao,YANG Ying et al..The clinical analysis of laparoscopic transanal puuthrough operation for rectosigmoild Hirschsprung disease (122 cases report).[J].Journal of Clinical Pediatric Surgery,2011,10(10):0.
[2]陆良生阮双岁毕允力陆毅群王翔葛琳娟肖现民.45例两性畸形患儿的诊断及治疗分析[J].临床小儿外科杂志,2011,10(01):0.
[3]刘鸿坚杨传民祁泳波王千于丹张晋绥张强李伟李友.经肛门改良Soave术治疗先天性巨结肠80例疗效分析[J].临床小儿外科杂志,2011,10(01):0.
[4]景登攀张根领孙蔓丽.改良Snodgrass术治疗尿道下裂疗效观察[J].临床小儿外科杂志,2011,10(01):0.
[5]许瑞江
洪锡伟
于向华
李文超.大年龄儿童发育性髋脱位术后再脱位的治疗[J].临床小儿外科杂志,2010,9(02):0.
XU Rui-jiang,HONG Xi-wei,YU Xiang-hua,et al.Surgical management for redislocation after open reduction of developmental dislocation of the hip in older children[J].Journal of Clinical Pediatric Surgery,2010,9(10):0.
[6]姜 海
汪 兵
吴永涛
苗武胜
吴 革.儿童肱骨远端骨骺分离的手术治疗[J].临床小儿外科杂志,2010,9(02):0.
Jiang hai,Wang bin,Wu yongtao,et al.The operative treatment in children’s distal humeral osteoepiphysis fracture.[J].Journal of Clinical Pediatric Surgery,2010,9(10):0.
[7]姜海吴永涛苗武胜梁晓军吴革汪兵张博皓.儿童移位型股骨颈骨折16例临床分析[J].临床小儿外科杂志,2010,9(03):0.
[8]王琪.儿童髂前上棘骨折27例疗效分析[J].临床小儿外科杂志,2010,9(03):0.
[9]王鹏高翟波罗淑颖.婴幼儿室间隔缺损合并肺动脉高压的外科治疗[J].临床小儿外科杂志,2010,9(03):0.
[10]张舰范学圣.小儿脾脏外伤保守治疗47例[J].临床小儿外科杂志,2010,9(03):0.
[11]李怡,张潍平,杨庆林.儿童原发性膀胱输尿管反流手术治疗的新进展[J].临床小儿外科杂志,2019,18(10):805.[doi:10.3969/j.issn.1671-6353.2019.10.001]
Li Yi,Zhang Weiping,Yang Qinglin.Recent advances of surgery for primary vesicoureteral reflux in children[J].Journal of Clinical Pediatric Surgery,2019,18(10):805.[doi:10.3969/j.issn.1671-6353.2019.10.001]
[12]陈光杰,王晓豪,赵一俊,等.透明质酸钠凝胶注射治疗原发性膀胱输尿管反流的效果分析[J].临床小儿外科杂志,2019,18(10):820.[doi:10.3969/j.issn.1671-6353.2019.10.004]
Chen Guangjie,Wang Xiaohao,Zhao Yijun,et al.A preliminary report of endoscopic injection of dextranomer/hyaluronic acid in children with primary vesicoureteral reflux[J].Journal of Clinical Pediatric Surgery,2019,18(10):820.[doi:10.3969/j.issn.1671-6353.2019.10.004]
[13]王文杰,宋宏程,谢向辉,等.肾盂输尿管连接部梗阻合并同侧原发性膀胱输尿管反流诊治分析[J].临床小儿外科杂志,2019,18(10):835.[doi:10.3969/j.issn.1671-6353.2019.10.007]
Wang Wenjie,Song Hongcheng,Xie Xianghui,et al.Experiences of diagnosing and treating ureteropelvic junction obstruction plus ipsilateral primary ureteral reflux[J].Journal of Clinical Pediatric Surgery,2019,18(10):835.[doi:10.3969/j.issn.1671-6353.2019.10.007]
[14]李宁,张潍平,田军,等.尿动力检查评估膀胱输尿管反流患儿下尿路功能障碍的临床研究[J].临床小儿外科杂志,2023,22(02):118.[doi:10.3760/cma.j.cn101785-202210064-004]
Li Ning,Zhang Weiping,Tian Jun,et al.Urodynamic evaluations of lower urinary tract dysfunction in children with vesicoureteral reflux[J].Journal of Clinical Pediatric Surgery,2023,22(10):118.[doi:10.3760/cma.j.cn101785-202210064-004]
[15]谢华,陈方.充分认识儿童膀胱输尿管反流治疗的复杂性[J].临床小儿外科杂志,2023,22(10):908.[doi:10.3760/cma.j.cn101785-202304050-002]
Xie Hua,Chen Fang.Fully understanding the complexity of managing vesicoureteral reflux in children[J].Journal of Clinical Pediatric Surgery,2023,22(10):908.[doi:10.3760/cma.j.cn101785-202304050-002]
备注/Memo
收稿日期:2023-2-19。
基金项目:国家自然科学基金青年科学基金项目(82371722)
通讯作者:杨屹,Email:yangy2@sj-hospital.org