International Vesicoureteral Reflux Study: unsolved questions remaining

Abstract

The final report of the International Reflux Study [1] in children contains very important data for pediatricians, pediatric nephrologists and urologists. Randomized studies for such a long period of time as 10 years are rare and difficult to perform, and it is a challenging goal to obtain clear results and conclusions. The authors succeeded in achieving these goals. They concluded that the management of infants and children with severe primary vesicoureteral reflux (VUR) may be medical as well as surgical. After a follow up of 10 years the children were doing remarkably well under both managements: the number of new scars, renal growth and renal function were identical in both groups. However, the medically managed patients had more febrile infections than the patients managed surgically. As pyelonephritis and reflux may lead to new renal scars, it is surprising that an equivalent number of scars was detected in both groups. Surgical resultsA total of 151 children were treated surgically. Unilateral obstruction occurred in 10 children and VUR persisted post-operatively in another 16 patients. Unsatisfying surgical results occurred in 17% of the patients. These results are not in accordance with data in the literature. Earlier reports with large cohorts demonstrated success rates of 94-99% for open surgery for ureteral reimplantation. Recurrent pyelonephritis or obstructions were the major complications, but remained very rare (~3%) [2][3][4]. Endoscopic submucosal injection techniques have shown variable success rates (55-90%) depending on the grade of VUR and individual experience [5][6][7][8].This point will be important to consider in the future: the lower the rate of surgical failure, the higher will be the number of physicians prone to advise surgical procedure. Antibacterial prophylaxisThe medically treated patients of this protocol received continuous low-dose antibacterial prophylaxis with cotrimoxazole trimethoprim or nitrofurantoin until VUR had resolved or improved to grade I. If kidneys were unscarred, prophylaxis was usually discontinued at the age of 8 years. Was such a very long duration of treatment really necessary?Over the past few years several articles have been published leading to disturbing results [9-12]: the assumption that continuous prophylactic antimicrobial therapy is effective in reducing the incidence of reinfection and renal scarring has not been proven by a placebocontrolled study [13]. The likelihood of the eventual development of scars was independent of reflux status [14]. Reflux progress in patients managed medicallyThe rationale for not treating a child with severe reflux surgically is its resolution with time. One of the main achievements of this study was to demonstrate that 47% of high-grade reflux had disappeared over the 10-year period. At the end of the follow-up period, 53% of initial refluxes were still observed: 26.5% without dilation, but 26.5% with dilation, suggesting that at least 26.5% of the children managed medically were still receiving low-dose antibacteria...

Predictive value of clinical and laboratory variables for vesicoureteral reflux in children

“…Furthermore, as recent studies state that detection and treatment of VUR in children is not crucial for preventing renal scarring, the benefit of diagnosing VUR in children with UTI is currently under debate [7][8][9][10][11][12]. Moreover, VUR is present in only 25-40% of children with febrile UTI and is most often grade I or II [13,14].…”

Persistent renin-angiotensin system activation after anti-reflux surgery and its management

“…It was also reported that the medically managed patients had more febrile infections than the patients managed surgically. As pyelonephritis and reflux may lead to new renal scars, it is surprising that an equivalent number of scars were detected in the two groups [32].…”

Observational, medical or surgical management of vesicoureteric reflux

“…We suggest all patients with high‐grade reflux and renal scars should be followed up with regular blood pressure monitoring and microalbuminuria testing during childhood. During pregnancy, patients should be considered high risk, and nephrologists and obstetricians need to work closely together .…”