Vesicoureteral reflux: practical aspects of evaluation and management

Abstract

The efficacy of both medical and surgical therapy for vesicoureteral reflux (VUR) has been well established. Controversy remains, however, regarding who should be evaluated for the presence of VUR, who should undergo corrective surgery, who should be treated medically and for how long. Medical treatment requires many years of continuous antibiotic prophylaxis, so compliance with therapy is essential. Many children are lost to followup, however, and remain untreated after a medical regimen is started. This large number of untreated children raises issues of the appropriateness of blanket therapeutic recommendations for all children with VUR and challenges the clinician to devise more effective treatment strategies.

Study of Association of Primary Vesicoureteric Reflux in Children Suffering from Urinary Tract Infection

“…But they failed to show any document and no prenatal diagnosis was done in any patient in present study. Greenfield & Wan (1996) showed that reflux is the most common underlying cause of antenatally detected hydronephrosis 15 . The advantage of identifying children antenatally is that treatment, either prophylaxis or surgery, can be instituted early and further scarring can be prevented.…”

Discrepancy between power-Doppler voiding urosonography and voiding cystourethrography is not relevant for the management of primary vesicoureteric reflux

“…Over the last two decades, pediatric urologists have learned to be more and more conservative in treating VUR [12]. Evidence suggests that low-grade VURs usually cease spontaneously over time, whereas renal damage is mostly congenital in children with high-grade VUR undergoing renal function deterioration while on conservative treatment [13].…”

“…Hence, outcome is largely independent from surgery [14] and a nonoperative treatment has become the first-line approach to VUR, no matter what grade or laterality [1,[12][13][14][15]. Surgery seems indicated only on a clinical ground, potential indications for reimplantation being breakthrough UTIs, appearance of new renal scars or worsening in renal function during follow-up, and parents' noncompliance with long-term prophylaxis [1,12]. Accordingly, accuracy of the imaging modality in grading VUR seems no longer paramount.…”

“…Reflux grading may still be considered relevant only whether lack of improvement or progression of VUR grade, in a patient otherwise asymptomatic, is considered an indication for surgery too. However, actual association among VUR degree, renal damage, and need for surgery remains controversial as well as the real need to treat persistent VUR [12,16]. Furthermore, with a routine use of PD-VUS, comparison would be done among multiple PD-VUSs, increasing consistency.…”

“…Jequier and Jequier [5] reported that an additional 4% of patients can show VUR after a third cycle. Greenfield and Wan [12] reported a reappearance of reflux after a negative VCUG in 27% of patients followed on prophylaxis suggesting that probably VCUG overlooked an intermittent VUR in one fourth of their patients. Similar data were reported for DRVC [17].…”