title: Surgical management of grades III and IV primary vesicoureteral reflux in children with and without acute pyelonephritis as breakthrough infections: a comparative analysis.
abstract: OBJECTIVE
  Although high grade vesicoureteral reflux associated with breakthrough infection may be an indication for surgical intervention, it remains uncertain whether acute pyelonephritis as breakthrough infection is a risk for renal scar formation and whether surgery performed without it has any advantage. We assessed the results of antireflux surgery for high grade vesicoureteral reflux in children with and without acute pyelonephritis as breakthrough infections.
  
  
  METHODS
  A total of 33 boys and 27 girls (102 refluxing units) less than 3 years old with grades III and IV vesicoureteral reflux who underwent surgical management because of breakthrough infections were retrospectively studied in a 3-year period. Of the 60 patients 30 (group 1) presented with breakthrough infections of acute pyelonephritis, although they were maintained on prophylactic antibacterials. The remaining 30 patients (group 2) underwent surgery without acute pyelonephritis as the breakthrough infections. There was no renal scar formation at the diagnosis of vesicoureteral reflux in either group. Patients with renal scars were excluded from study. There was no significant difference in patient 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 infection at the diagnosis of vesicoureteral reflux, the infection was not significantly related to the development of renal scars (p = 0.066). Of the 55 patients 12 presented with acute pyelonephritis as the initial episode of urinary tract infection. The presence of acute pyelonephritis at the diagnosis of vesicoureteral reflux was also not significantly related to renal scar formation (p = 0.207). Postoperative urinary tract infections developed in 34 patients but there was no significant correlation between postoperative urinary tract infections and renal scar formation (p = 0.235). At followup 17 group 1 and 7 group 2 patients (29 renal units) were found to have renal scars.
  
  
  CONCLUSIONS
  Renal scars were significantly more common in younger children with than without acute pyelonephritis as breakthrough infections (p = 0.010). Although breakthrough infections in high grade reflux may be an indication for antireflux surgery, the most appropriate results were achieved when acute pyelonephritis was not a breakthrough infection.
authors.affiliation: Department of Pediatric Urology, Chang Gung Medical College, Kaohsiung, Taiwan.
authors.forename: T J
authors.initials: TJ
authors.lastname: Yu
authors.forename: W F
authors.initials: WF
authors.lastname: Chen
mesh_terms: D000208:Acute Disease; D002675:Child, Preschool; D005260:Female; D006801:Humans; D007223:Infant; D008297:Male; D011704:Pyelonephritis / Q000150:complications*; D012189:Retrospective Studies; D012720:Severity of Illness Index; D014552:Urinary Tract Infections / Q000150:complications*; D014718:Vesico-Ureteral Reflux / Q000150:complications / Q000601:surgery*