Mujdem Nur AZILI, Tugrul TIRYAKI, Gülsah KABACAM BAYRAM, Halil ATAYURT, Dogus CALISKAN

DMSA Bulguları Primer Vezikoüreteral Reflülü Çocuklarda Sting Prosedürünün Başarısızlığını Önceden Belirleyen Bir Faktör Müdür? 132 Olgunun Değerlendirilmesi

Amaç: Vezikoüreteral reflülü (VUR) olgularda endoskopik tedavi komplikasyonsuz, kolay uygulanabilir ve tekrarlanabilir olması nedeni ile pek çok hastada ilk tedavi seçeneği olarak görülmektedir. VUR’lu olgularda DMSA sintigrafi sonuçları ile idrar yolu enfeksiyonunun tekrarlaması arasında ilişki olduğu yapılan çalışmalarda gösterilmiştir. Çalışmamızda primer VUR’lu olgularda DMSA ile belirlenen renal fonksiyonlar ile STING uygulamasının başarısı arasında ilişki olup olmadığının araştırılması amaçlandı. Materyal ve Metod: Kliniğimizde 2002 ile 2009 yılları arasında primer VUR nedeni ile STING uygulaması yapılan 132 olgu hastane kayıtlarından geriye dönük olarak değerlendirmeye alındı. Bu araştırmada olguların yaşı, cinsiyeti, reflünün tek ya da çift taraflı olması, reflünün derecesi, başvuru anındaki bulguları ve ilk DMSA sintigrafi bulgusundaki hasarlanma derecesi ile STING uygulaması ile VUR iyileşmesi arasındaki ilişki araştırıldı. Bulgular: Çalışmamıza yaşları 5 ay ile 16 yaş (ortalama 6.59+3.23) arasında değişen 36 erkek (%27), 96 kız (%73) toplam 132 olgu alındı. 113 olgumuz (%86) tekrarlayan idrar yolu enfeksiyonu yakınması ile başvururken, 14 (%10) olgu enürezis nedeni ile yapılan araştırma sırasında, 5 olgu (%4) prenatal saptanan hidronefroz bulgusunun araştırılması sırasında tanı aldı. Reflü 62 (%47) olguda bilateral, 29 olguda (%22) sağ, 41 olguda (%31) sol tarafta belirlendi. 132 olguda toplam 194 üreterde reflü saptandı. Başlangıçta 10 olguda grade 2 VUR ( %5.1), 79 olguda grade 3 VUR (%40.8), 63 olguda grade 4 VUR (%32.4), 42 olguda grade 5 (%21.7) VUR saptandı. İlk enjeksiyon sonrası 105 üreterde iyileşme saptandı (%54.68). İkinci enjeksiyon 82 üretere uygulandı. İkinci enjeksiyon sonrası 22 üreterde iyileşme saptandı. 50 olguya yapılan üçüncü enjeksiyon sonrası 11 üreterde daha iyileşme izlendi. Başlangıçta %54.68 olan başarı oranı, tekrarlanan enjeksiyonlar ile % 71.13’e kadar ulaştı. 24 olgumuzdaki 32 üretere STING uygulamasına yanıt alınamadığı için açık cerrahi girişim uygulandı. 19 olguda (%14) DMSA sintigrafisi normal iken, 113 olguda (%86) anormal olarak bulundu. STING ile iyileşen ya da açık cerrahi uygulamasına alınan olgularımız yaş, cinsiyet, VUR’un tek yada bilateral olması, başlangıç bulguları ve başlangıç DMSA bulguları açısından karşılaştırıldığında anlamlı herhangi bir fark bulunmadı. Reflü derecesi ile STING sonrası iyileşme arasında ise negatif corelasyon mevcuttu (p<0.001). Aynı grade’deki olgularda DMSA bulguları arasındaki farkın STING uygulamasına yanıtı etkilemediği görüldü (p>0.05). Sonuç: Ortalama 42 aylık izlem sonuçlarının irdelendiği serimizde endoskopik ilk enjeksiyon sonrası üreterlerin % 54’ünde reflünün iyileştiği saptanırken, üçüncü enjeksiyon sonrası bu oranın % 71’e yükseldiği görüldü. Bu çalışmanın sonuçlarına göre STING uygulaması ile reflünün düzelmesinde anlamlı olan tek parametre reflünün derecesi olduğu ve başlangıç DMSA incelemesinde saptanan fonksiyon bozukluğu ile STING uygulaması başarısı arasında herhangi bir ilişki olmadığı saptandı.

Anahtar Kelimeler:

Vezikoüreteral reflü, DMSA

MAY DMSA FINDINGS BE PREDICTIVE OF STING PROCEDURE FAILURE IN CHILDREN WITH PRIMARY VESICOURETERAL REFLUX? (AN EVALUATION OF 132 CASES)

Purpose: Endoscopic treatment seems to be the first choice of therapy in most of the patients with vesicoureteral reflux (VUR) since it is easily applicable and repeatable without complication. Existence of relation between the DMSA results and recurrence of urinary tract infection in cases with VUR has been demonstrated in previous studies. We aimed to search a relation between the renal functions set by DMSA and the success of STING procedure in patients with primary VUR.Material And Method: 132 patients on whom STING procedure has been applied for primary VUR at our clinic between the years 2002 to 2009 were evaluated retrospectively in this study. Initial findings of DMSA scintigraphy of the patients in relation to scarring degree at the hospital admission and their improvement after STING procedure were evaluated.Findings: 132 cases were included in our study consisting of 36 (27%) males and 96 females (73%) in between the ages of 5 months to 16 years (mean 6,59±3,23). 113 cases (86%) referred for the complaints of recurrent urinary tract infection, 14 cases (10%) had enuresis and 5 cases (4%) diagnosed as prenatal hydronephrosis. VUR was detected in 194 ureters of the 132 patients. VUR was bilateral in 62 (47%) patients, on the right side in 29 (22%) patients and on the left side in 41 (31%) patients. Initially, grade II VUR in 10 (5, 1%) cases, grade III VUR in 79 (40,8%), grade IV VUR in 63 (32,4%) cases and grade V VUR in 42 (21,7%) cases were confirmed. Recovery was determined in 105 (54,68%) ureters after the first injection. Second injection was applied to 82 ureters resulting with recovery in 22 ureters. Additional recovery was achieved in 11 ureters after the application of third injection to 50 patients. Thus the initial success rate of 54,68% reached to a success rate of 71,13% with repeated injections. Open surgery was applied to 32 ureters of 24 patients in whom no positive response was noted after STING procedure. DMSA findings were normal in 19 (14%) patients and abnormal in 113 (86%) patients at the initial hospital admission. A significant negative correlation was detected between the grade of VUR and the recovery after STING procedure (p>0,001). DMSA findings were not predictive in the success of STING procedure in children with primary VUR on the same degree category (p>0,05).Conclusion: Follow-up results are evaluated on an average of 42 month period in our study. VUR was treated in 54% of the ureters following the first injection and the recovery rate reached to 71% after the third injection. The results of this study revealed that the single meaningful parameter in estimating the recovery by STING application is the degree of VUR. There was no correlation between the initial DMSA findings and the success of STING procedure

Keywords:

Vesicoureteral reflux, DMSA,

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