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Primärer vesikoureteraler Reflux

Primary vesicoureteral reflux

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  • 5 Citations

Zusammenfassung

Die derzeitige Diskussion zum vesikoureteralen Reflux (VUR) bewegt sich zwischen diagnostischem Nihilismus und invasiver Therapie und erinnert an den Disput um das Prostatakarzinom im Erwachsenenalter. Gemeinsames Ziel aller derzeit konkurrierenden diagnostischen Strategien und Therapieansätze ist es, pyelonephritische Nierenschädigungen mit dem wirksamsten und gleichzeitig am wenigsten belastenden Konzept zu verhindern.

Der VUR kann konventionell radiologisch, sonographisch, nuklearmedizinisch oder auch mittels Magnetresonanztomographie (MRT) verifiziert werden. In den Leitlinien der „European Association of Urology“/“European Society for Paediatric Urology“ (EAU/ESPU) wird die Refluxprüfung nach der ersten fieberhaften Harnweginfektion (HWI) im Säuglings- und Kleinkindesalter gefordert. Rezidivierende HWI und Parenchymnarben stellen wesentliche Risikofaktoren bei Patienten mit einem VUR dar. Diese Patienten sollten einer patienten- und risikoadaptierten Therapie zugeführt werden. Säuglinge mit einem dilatierenden Reflux haben ein höheres Risiko für Nierenschädigungen als diejenigen ohne eine Nierenbeckendilatation. Blasenfunktionsstörungen bzw. die Entleerungsstörungen (Blase und Darm) stellen in Kombination mit einem Reflux einen altbekannten jedoch früher sehr vernachlässigten Risikofaktor dar. Bei Patienten mit Blasenfunktionsstörungen sollten diese vor jedweder Intervention abgeklärt und – wenn möglich – behandelt werden.

Aktuelle Behandlungsstrategien berücksichtigen neben Alter und Geschlecht, das Vorhandensein dysplastischer oder pyelonephritischer Nierenparenchymdefekte, die klinische Symptomatik, Blasenfunktionsstörungen und die Häufigkeit bzw. Schwere rezidivierender HWI als Kriterien für die Therapieentscheidung. Die endoskopische Therapie kann für Patienten mit niedriggradigem VUR eine Alternative zur antibakteriellen Prophylaxe oder zu einer rein abwartenden Haltung sein. Bei Patienten mit einem dilatierenden VUR kann eine endoskopische Therapie angeboten werden, wenn eine antibakterielle Prophylaxe nicht infrage kommt. Allerdings sollten die Eltern zuvor über die deutlich schlechtere Erfolgsquote gegenüber offen operativen Verfahren aufgeklärt werden. Die offen operativen Techniken sind bei weitem nicht in jedem Fall durch die subureterale Implantation von „bulking agents“ ersetzbar. Sie garantieren die höchsten operativen Erfolgsraten und sollten nach wie vor bei Patienten mit einem dilatierenden VUR und hohem renalem Schädigungsrisiko zum Einsatz kommen.

Abstract

The never ending discussion about the diagnostics and treatment of vesicoureteral reflux (VUR) now includes arguments for diagnostic nihilism as well as invasive diagnostics and therapy, which is reminiscent of the debate on prostate cancer in adulthood. The common goal of all currently competing diagnostic strategies and approaches is the prevention of renal scars by the most effective and least burdensome approach. There is a difference between acquired pyelonephritic scars with VUR (acquired reflux nephropathy) and congenital reflux nephropathy (primary dysplasia) which cannot be influenced by any therapy.

The VUR can be verified by conventional radiological voiding cystourethrography (VCUG), by urosonography, radionuclide cystography or even by magnetic resonance imaging (MRI). The guidelines of the European Association of Urology/European Society for Paediatric Urology (EAU/ESPU) recommend radiological screening for VUR after the first febrile urinary tract infection. Significant risk factors in patients with VUR are recurrent urinary tract infections (UTI) and parenchymal scarring and the patients should undergo patient and risk-adapted therapy. Infants with dilating reflux have a higher risk of renal scarring than those without dilatation of the renal pelvis. Bladder dysfunction or dysfunctional elimination syndrome represents a well-known but previously neglected risk factor in combination with VUR and should be treated prior to any surgical intervention as far as is possible.

Certainly not every patient with VUR needs therapy. The current treatment strategies take into account age and gender, the presence of dysplastic or pyelonephritic renal scars, the clinical symptoms, bladder dysfunction and frequency and severity of recurrent UTI as criteria for the therapy decision. The use of an antibacterial prophylaxis as well as the duration is controversially discussed. Endoscopic therapy can be a good alternative to antibacterial prophylaxis or a surveillance strategy in patients with low grade VUR. In patients with dilating VUR and given indications for surgery, endoscopic treatment can be offered. However, parents should be completely informed about the significantly lower success rate of endoscopic therapy compared to open surgical procedures. The open surgical techniques guarantee the highest success rates and should be used in patients with a dilating VUR and high risk of renal damage.

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Correspondence to Prof. Dr. R. Stein.

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Stein, R., Ziesel, C., Rubenwolf, P. et al. Primärer vesikoureteraler Reflux. Urologe 52, 39–47 (2013). https://doi.org/10.1007/s00120-012-3079-z

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Schlüsselwörter

  • Reflux, vesikoureteraler
  • Refluxprüfung
  • Prophylaxe, antibakterielle
  • Refluxtherapie, endoskopische
  • Blasenfunktionsstörungen

Keywords

  • Reflux, vesicoureteral
  • Voiding cystourethrography
  • Prophylaxis, antibacterial
  • Endoscopic therapy
  • Dysfunctional elimination syndrome