Editorial: Risk of Urinary Tract Infections in Adults Surgically Treated for Vesicoureteral Reflux in Childhood

Evaluating and measuring the outcome of treatments are not only important but extremely valuable. Such data collection is difficult and takes a dedicated and significant effort on the part of researchers. These studies are undertaken when the disease impact is obvious, the occurrence is frequent and the outcome has a significant effect on life. The long-term research in cancer has been invaluable. If urologists consider how ill-prepared we would be to take care of prostate cancer without 15-year longitudinal studies, the impact can easily be seen. Unfortunately, long-term studies of nonmalignant diagnoses are few and far between but in my opinion no less valuable. Common problems without life and death outcomes still need long-term followup to document improvement and evaluate treatments so appropriate changes can be made. Otherwise, well respected treatments will continue with presumed benefits and little opportunity for improvement. Long-term clinical studies are extremely difficult to perform. Such efforts may require more than 1 generation of investigators to initiate these studies, follow through with similar criteria and perform periodic assessments. Many of these studies require more than 1 discipline, such that if pathological procedures change or progress is made, than the original criteria for patient selection may be inaccurate. Older radiological techniques have been supplanted by current techniques, and many times documentation of reviewing initial radiographic findings or verification by investigators reviewing the actual films has become impossible. Until recently, data bases on nonmalignant diseases have been rare, yet valuable information can be obtained through a cooperative effort. Such has been done with the multicystic kidney registry. In our own setting dedicated coworkers made great efforts to identify patients from past records and group them by available criteria.1, 2 We divided patients with vesicoureteral reflux into 2 groups based on whether they were treated with corrective surgery or observation. The criteria which the original urologists used to make the recommendations of treatment were not available to us. I presume that the recommendations were based on excretory urography scarring but these data nor the actual films were available for review because of the time that had passed. This example demonstrates the difficulty of collecting such long-term data. I believe interpretation of long-term results must be tempered with a cautious eye toward missing data or assumptions made by the investigators. This caution does not in any way diminish the value of the long-term followup data but readers should be aware of the different attention that these reports demand. Beetz et al (page 704) should be congratulated on their dedication to collect this information and their persistence in locating so many patients after an average of 20 years from the time of the ureteral reimplant surgery. There are many pearls that I will take away from this study, such as the incidence of urinary tract infections increases with each decade. Presumably, the second decade after surgery would be the years of sexual activity onset which may account for this increase. There is no increase in pyelonephritis incidence with years of followup. The finding of the International Reflux Study Group that pyelonephritis after reimplantation is diminished continues to be valid with time. Most patients during followup had multiple urinary tract infections (only 18% had just 1). There was no correlation between preoperative urinary tract infections, grade of reflux or the likelihood of subsequent urinary tract infections with time. Approximately 10% of initial urinary tract infections occurred during the second decade following surgery, suggesting that longterm followup may be necessary. The findings presented in table 1 by Beetz et al show the risks of pregnancy complicated by urinary tract infections after childhood reimplants, which raises the question of whether prophylactic antibiotics should be used during pregnancy. We also would like to know whether there is progressive kidney damage in the long term in these patients but because few dimercapto-succinic acid scans were performed 2 decades ago, these data are not available. It would be of interest to note whether the infections, especially the febrile infections, had significant morbidity. It is my conviction that good patient care is predicated on fundamental understanding of the disease process and outcome data that either validate the treatment or provide opportunity for improvement and change with time. Reevaluation is an important part of what provides urological progress. Researchers should be encouraged to look at their own data collection to determine if long-term outcome research can be gleaned so improvements in not only cancer treatments, but in treatment of all varieties of urological diseases may be validated and improved. It is hoped that others with the opportunity to perform long-term followup studies will be able to add further data and clarify these and many other urological issues.