Antireflux-Operation im ersten Lebensjahr, wenn ja, wann und wie? Kontra OP

Zusammenfassung

Das Management des vesikoureteralen Refluxes (VUR) im Säuglingsalter bleibt auch weiterhin ein überaus kontrovers diskutiertes Thema in der Kinderurologie. Hohe Spontanmaturationsraten selbst bei dilatierenden Refluxen von bis zu 45 %, der hohe Anteil an Jungen mit hohen Refluxgraden und oft assoziierter Nierenhypoplasie/Nierendysplasie von bis zu 30 % sowie die noch unreife Blasenfunktion kennzeichnen das Krankheitsbild in diesem Alter. Der Reflux per se hat in diesem Kontext eher an Bedeutung verloren. Umso erstaunlicher ist es, dass in letzter Zeit vermehrt Publikationen erscheinen, die eine endoskopische Therapie nicht nur als Alternative bei Durchbruchsinfektionen unter der Langzeittherapie, sondern auch als primäre Alternative zur Chemoprophylaxe empfehlen. Keine der bislang vorliegenden Metaanalysen konnte jedoch eine Evidenz für die Überlegenheit der endoskopischen Therapie gegenüber der Langzeitantibiose im Hinblick auf die Infekthäufigkeit oder die Entstehung neuer Parenchymnarben belegen. Demgegenüber stehen Nachteile dieser Methode wie die Notwendigkeit einer Narkose, die häufige Refluxpersistenz und das Obstruktionsrisiko sowohl postoperativ als auch im Langzeitverlauf. Die klassischen operativen Antireflux-Techniken sollten trotz moderner minimal invasiver Techniken aufgrund der hohen Spontanmaturationsrate und der in diesem Alter noch nicht abgeschlossenen Blasenfunktionsausreifung (sog. immature Blasenfunktion) auch weiterhin routinemäßig nicht zur Anwendung kommen und nur Einzelfällen vorbehalten bleiben

Abstract

The current management of vesicoureteral reflux (VUR) in infants remains controversial. Parameters such as high spontaneous resolution rates even in high-grade reflux in up to 45 %, associated renal hypo-/dysplasia in boys in up to 30 % and immature bladder function characterise the condition in early life. In this context, the reflux per se has become less important. This makes it all the more surprising that endoscopic treatment is recommended in recent papers to eliminate or downgrade the reflux in infants as an alternative to conservative treatment regimes. Compared with antibiotic prophylaxis, there is no difference in outcomes regarding new episodes of urinary tract infections or renal scarring. On the other hand, the necessity of anaesthesia, considerable reflux recurrence rates and the risk of obstruction in the short and long-term follow-up must be taken into consideration. Minimally-invasive anti-reflux surgery techniques are feasible also in infants. However, in due consideration of the high spontaneous resolution rates of reflux during the first 12 to 15 months of life and the fact that bladder function is still immature at that age, they should not be used as routine interventions.

Schlüsselwörter

vesikoureteraler Reflux - Spontanmaturation - Antibiotikaprophylaxe - Säuglingsalter - endoskopische Refluxoperation

Keywords

vesicoureteral reflux - spontaneous resolution - antibiotic prophylaxis - endoscopic treatment - infant

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