Impact of Clinical Guidelines on Voiding Cystourethrogram Use and Vesicoureteral Reflux Incidence

Correlation not Causation: Looking Back at the History of VUR

Vesicoureteral reflux (VUR) is a medical condition where urine flows retrograde from the bladder superiorly, and has traditionally been considered a risk factor for kidney damage in children. However, over the past decade and a half, several randomized controlled trials have shown the risk of kidney damage in the presence of VUR is low, and any treatment for VUR does not change that risk. Here, we review the history of VUR as a pathologic condition, how the interpretation of that history led to possibly overestimating the danger, and how current findings should be seen in the context of that history.

Update and Summary of the European Association of Urology/European Society of Paediatric Urology Paediatric Guidelines on Vesicoureteral Reflux in Children

BACKGROUND AND OBJECTIVE

The prescriptive literature on vesicoureteral reflux (VUR) is still limited and thus the level of evidence is generally low. The aim of these guidelines is to provide a practical approach to the treatment of VUR that is based on risk analysis and selective indications for both diagnostic tests and interventions. We provide a 2023 update on the chapter on VUR in children from the European Association of Urology (EAU) and European Society for Paediatric Urology (ESPU) guidelines.

METHODS

A structured literature review was performed for all relevant publications published from the last update up to March 2022.

KEY FINDINGS AND LIMITATIONS

The most important updates are as follows. Bladder and bowel dysfunction (BBD) is common in toilet-trained children presenting with urinary tract infection (UTI) with or without primary VUR and increases the risk of febrile UTI and focal uptake defects on a radionuclide scan. Continuous antibiotic prophylaxis (CAP) may not be required in every VUR patient. Although the literature does not provide any reliable information on CAP duration in VUR patients, a practical approach would be to consider CAP until there is no further BBD. Recommendations for children with febrile UTI and high-grade VUR include initial medical treatment, with surgical care reserved for CAP noncompliance, breakthrough febrile UTIs despite CAP, and symptomatic VUR that persists during long-term follow-up. Comparison of laparoscopic extravesical versus transvesicoscopic ureteral reimplantation demonstrated that both are good option in terms of resolution and complication rates. Extravesical surgery is the most common approach used for robotic reimplantation, with a wide range of variations and success rates.

CONCLUSIONS AND CLINICAL IMPLICATIONS

This summary of the updated 2023 EAU/ESPU guidelines provides practical considerations for the management and diagnostic evaluation of VUR in children.

ADVANCING PRACTICE

For children with VUR, it is important to treat BBD if present. A practical approach regarding the duration of CAP is to consider administration until BBD resolution.

PATIENT SUMMARY

We provide a summary and update of guidelines on the diagnosis and management of urinary reflux (where urine flows back up through the urinary tract) in children. Treatment of bladder and bowel dysfunction is critical, as this is common in toilet-trained children presenting with urinary tract infection.

National Trends in Voiding Cystourethrograms During Hospitalization for Young Infants With Urinary Tract Infections

OBJECTIVES

The American Academy of Pediatrics published a guideline in 2011 recommending against the routine use of voiding cystourethrogram (VCUG) in infants aged 2 to 24 months with first febrile urinary tract infection (UTI); however, the rates of VCUG for infants aged <2 months are unknown. The objective of this study was to determine the trend in VCUG performance during index hospitalization among infants aged 0 to 2 months with UTI.

METHODS

This retrospective cohort study included infants aged birth to 2 months hospitalized with a UTI from 2008 to 2019 across 38 institutions in the Pediatric Health Information System. Outcome measures included recurrent UTI within 1 year, vesicoureteral reflux diagnosis within 1 year and antiurinary reflux procedure performed within 2 years. Trends over time were compared between preguideline (2008-2011) and postguideline periods (2012-2019) using piecewise mixed-effects logistic regression.

RESULTS

The odds of VCUG decreased by 21% per year in the preguideline period (adjusted odds ratio, 0.79; 95% confidence interval, 0.77-0.81; P < .001) versus 20% (adjusted odds ratio, 0.80; 95% confidence interval, 0.77-0.83; P < .001) in the postguideline period. The preguideline and postguideline difference was not statistically significant (P = .60). There was no difference in the postguideline odds of UTI within 1 year (P = .07), whereas the odds of vesicoureteral reflux diagnosis (P < .001) and antiurinary reflux procedure performance (P < .001) decreased.

CONCLUSIONS

VCUG performance during hospitalization has declined over the past decade among young infants hospitalized with UTI. Further work is needed to determine the optimal approach to imaging in these young infants.

Predicting factors of clinically significant urological anomalies after initial urinary tract infection among 2- to 24-month-old children

AIM

To find more effective criteria to identify clinically significant urological anomalies after initial urinary tract infection among children.

METHODS

Children aged 2-24 months with an initial urinary tract infection were consecutively recruited in a Japanese hospital from 2013 to 2019. Voiding cystourethrography, 99mTc dimercaptosuccinic acid scan and ultrasound were intended to perform for all cases. Clinically significant urological anomalies were defined as high-grade vesicoureteral reflux, obstructive and abnormal urinary tract lesions, need for surgical intervention, renal hypoplasia and scarring. Using classification and regression tree analysis, we sought the associated factors. We developed new criteria with these factors, retrospectively applied them to the original data, and calculated the sensitivity and specificity.

RESULTS

One hundred sixty-seven patients were eligible, and 39 had clinically significant urological anomalies. Classification and regression tree analysis showed that the associated factors were non-E. coli infections, serum creatinine levels and ultrasound abnormalities. When the gold standards were performed on children with non-E. coli infections or serum creatinine levels ≥0.21 mg/dl, sensitivity and specificity were 0.82 and 0.68, respectively.

CONCLUSION

The criteria including non-E. coli infections and high-normal or higher serum creatinine levels may efficiently predict clinically significant urological anomalies after initial urinary tract infections.

Risk factors for renal scarring and clinical morbidity in children with high-grade and low-grade primary vesicoureteral reflux

INTRODUCTION

Primary vesicoureteral reflux (VUR) is associated with urinary tract infections (UTIs) and renal damage. However, the importance of early diagnosis of VUR has been questioned. Moreover, most studies have few patients with high-grade VUR. Hence, we retrospectively analyzed a large cohort of patients with primary high-grade and low-grade VUR and assessed risk factors for renal damage and clinical morbidity.

MATERIAL AND METHODS

We included patients (<18 years) at diagnosis with low-grade (1-3) or high-grade (4-5) primary VUR and noted their clinical history and presence of hypertension, low eGFR (<60ml/in/1.73 m²), renal scarring (focal or generalised) and reduced differential renal function (DRF; <45%). Risk factors were assessed (in patients and renal units) by logistic regression and generalised estimating equation.

RESULTS

Of 399 primary VUR patients, 255 (64%) had high-grade VUR. Indications for voiding cystourethrogram were recurrent UTI (38%), first UTI (28%) and antenatal hydronephrosis (17%). At diagnosis, 252 (65%) had renal scars (focal in 170 [44%], generalised in 82 [21%]), and 188 (47%) had reduced DRF. High-grade VUR patients were more likely than low-grade VUR patients to have renal scarring (75% vs. 49%, p < 0.01), low eGFR (23% vs. 13%, p = 0.04) and significant hypertension (26% vs. 13%, p = 0.02). High-grade VUR was associated with generalised scars (odds ratio [OR] 11, p < 0.001), focal scars (OR 3.1, p < 0.001) and reduced DRF (OR 2.3, p < 0.001) shown in the table. Male sex was a risk factor for generalised scars (OR 2.3, p = 0.005). Focal scars were associated with recurrent UTIs (OR = 1.8, p = 0.004) and reduced DRF (OR 1.4, p = 0.027). Patients with multiple focal scars were diagnosed at an older age (2 years [1,4] than those with single scars (1.5 years [1,4] or no scars (1 year [0, 3]), p = 0.04).

DISCUSSION

The prevalence of renal damage and clinical morbidity at VUR diagnosis was higher than other studies. High-grade VUR patients had a greater prevalence of renal damage, low eGFR and hypertension than low-grade VUR patients and was a risk factor for focal scars, generalised scars and reduced DRF. Focal scars were independently associated with recurrent UTI. Those with multiple scars were diagnosed later than those with single scars or no scars.

CONCLUSIONS

High-grade VUR was associated with renal damage and clinical morbidity. Our study highlights the importance of diagnosing VUR early to identify patients who may warrant long-term follow-up and intervention to minimize morbidity.

Upper urinary tract function of patients with multiple sclerosis

BACKGROUND

Neurogenic lower urinary tract dysfunction (NLUTD) is frequent in multiple sclerosis (MS) and renal prognosis is a key point of bladder management.

OBJECTIVE

To assess upper urinary tract damage risk using voiding cystourethrography (VCUG) in patients with (PwMS) and NLUTD.

METHODS

We conducted a retrospective study between 2010 and 2020. Demographic data, urinary symptoms, urinary tract infection (UTI), renal ultrasounds findings, glomerular filtration rate (GFR), VCUG data, and urodynamic parameters were collected in PwMS with NLUTD.

RESULTS

Among 325 PwMS included, 67% were female, mean age was 51.6 ± 12.0 years, and mean EDSS 4.6 ± 1.8. VCUG showed vesicoureteral reflux (VUR) in 18 patients. A link was found between VUR and progressive MS course (p = 0.04), hydronephrosis (odds ratio [OR] = 17.44; 95% confidence interval [CI] = 3.46-87.87; p = 0.001), low GFR (p < 0.001), and detrusor overactivity (p = 0.04). No association with UTIs, EDSS, detrusor sphincter dyssynergia, were elicited. On multivariate analysis, alteration of GFR was independently related to the presence of VUR (OR = 0.95; 95% CI = 0.92-0.98).

CONCLUSIONS

VUR elicited on VCUG is associated with lower GFR and hydronephrosis. However, due to the low prevalence (5.5%) of this abnormality in PwMS, VCUG should be performed in selected cases and not in routinary practice.

Changes in Clinical Presentation and Renal Outcomes among Children with Febrile Urinary Tract Infection: 2005 vs 2015

PURPOSE

Recent studies have demonstrated trends of decreasing voiding cystourethrogram utilization rates and delayed vesicoureteral reflux diagnosis in some children. It is possible that such delays could lead to more children sustaining repeated episodes of febrile urinary tract infection, and potential kidney injury, prior to diagnosis and treatment.

MATERIALS AND METHODS

Using single institutional, cross-sectional cohorts of patients in 2 time periods (2005 and 2015), we compared clinical presentation and renal outcomes among patients 13 years and younger with history of febrile urinary tract infection presenting for initial voiding cystourethrogram. Outcomes included 1) recurrent urinary tract infection, 2) presence of vesicoureteral reflux, 3) grade of vesicoureteral reflux, and 4) renal scarring. Associations between year of presentation and outcomes of recurrent urinary tract infection and vesicoureteral reflux diagnosis were evaluated using multivariable logistic regression models. For the outcome of renal scarring, a logistic regression model was fitted for propensity score matched cohorts.

RESULTS

Compared to children presenting in 2005, those in 2015 had 3 times the odds of recurrent urinary tract infection (OR 3.01, 95% CI 2.18-4.16, p <0.0001). Time period was not associated with the odds of vesicoureteral reflux (OR 0.98, 95% CI 0.77-1.23, p=0.85). Those in 2015 were more likely to present with vesicoureteral reflux grade >3 (OR 2.22, 95% CI 1.13-4.34, p=0.02) but not vesicoureteral reflux grade >2 (OR 1.11, 95% CI 0.74-1.67, p=0.60). Renal scarring was more common among children presenting in 2015 (OR 2.9, 95% CI 1.03-8.20, p=0.04).

CONCLUSIONS

Compared to 2005, children presenting in 2015 for post-urinary tract infection voiding cystourethrogram have increased likelihood of recurrent urinary tract infection and renal scarring, despite similar likelihood of vesicoureteral reflux diagnosis.

Contemporary Management of Urinary Tract Infection in Children

Urinary tract infection (UTI) is common in children, and girls are at a significantly higher risk, as compared to boys, except in early infancy. Most cases are caused by Escherichia coli Collection of an uncontaminated urine specimen is essential for accurate diagnosis. Oral antibiotic therapy for 7 to 10 days is adequate for uncomplicated cases that respond well to the treatment. A renal ultrasound examination is advised in all young children with first febrile UTI and in older children with recurrent UTI. Most children with first febrile UTI do not need a voiding cystourethrogram; it may be considered after the first UTI in children with abnormal renal and bladder ultrasound examination or a UTI caused by atypical pathogen, complex clinical course, or known renal scarring. Long-term antibiotic prophylaxis is used selectively in high-risk patients. Few patients diagnosed with vesicoureteral reflux after a UTI need surgical correction. The most consequential long-term complication of acute pyelonephritis is renal scarring, which may increase the risk of hypertension or chronic kidney disease later in life. Treatment of acute pyelonephritis with an appropriate antibiotic within 48 hours of fever onset and prevention of recurrent UTI lowers the risk of renal scarring. Pathogens causing UTI are increasingly becoming resistant to commonly used antibiotics, and their indiscriminate use in doubtful cases of UTI must be discouraged.

Trends in the surgical management of vesicoureteral reflux in Finland in 2004-2014

OBJECTIVES

Previous data on the trends of surgical treatment of vesicoureteral reflux outside USA are scarce. The aim of this study was to clarify the national trends of operative treatment of vesicoureteral reflux (VUR) in Finland.

METHODS

We analyzed national data from Finnish Care Register for Health Care on children (<16 years of age) surgically treated for VUR in 2004-2014.

RESULTS

Endoscopic injections of the ureteral orifices were primarily performed for 1212 and open ureteral reimplantation for 272 children. The use of both types of surgery decreased during the study period (p = 0.0043 and p < 0.001, respectively). The median age at surgery for VUR was lower in those treated with open ureteral reimplantation than those with endoscopic injections of the ureteral orifices [3 and 4 years, respectively] (p = 0.0001). The length of hospital stay was significantly longer (median 9.9 days) with open ureteral reimplantation compared to that (median 1.3 days) with endoscopic injections (p < 0.0001) and did not change during the study period. Reoperations were significantly more common in patients who were primarily treated with endoscopic injections (n = 146/1072, 14%) than with ureteral reimplantation (n = 7/230, 3%) (p < 0.0001).

CONCLUSIONS

While the best treatment options for VUR remain debatable, operative treatment of VUR has become less common in Finland. HIGHLIGHTS Recent data on the trends of treatment of vesicoureteral reflux outside USA are scarce. Surgical treatment for vesicoureteral reflux decreased in Finland during the study period. The length of stay was longer but reoperations were needed less often with ureteral reimplantation compared to endoscopic injections.

High incidence of abnormal imaging findings in circumcised boys diagnosed with urinary tract infections

BACKGROUND

The American Academy of Pediatrics guidelines recommend delaying voiding cystourethrogram (VCUG) until the second febrile urinary tract infection (UTI). Similarly, the NICE Guidelines do not recommend VCUG after the first febrile UTI in infants and children under three years of age. Currently, there is no good clinical indicator to determine which patients would benefit from an earlier cystogram. Here, we sought to identify clinical and bacteriologic findings that are associated with an increased risk of urinary tract anatomic anomalies in pediatric males presenting to the Emergency Department with a UTI.

METHODS

A retrospective review was performed of all urine cultures from the Emergency Department at our institution between 2006 and 2015. Males under 18 years of age with ≥50,000 CFU/mL of Proteus, Klebsiella, Escherichia coli, Staphylococcus, Streptococcus and Enterococcus were included. Clean catch, catheterized and suprapubic aspiration specimens were included. Bagged specimens and specimens from patients on intermittent catheterization were excluded. Ultrasound and cystogram images were reviewed when available. Univariate and multivariable Poisson regression with robust variance was used to calculate and compare prevalence ratios. Statistical analysis was performed with Stata software, version 15.1 MP (Stata Corporation, College Station, Texas, USA).

RESULTS

We reviewed 1585 urine cultures, of which 812 met eligibility criteria including 619 (76.2%) E. coli, 84 (10.3%) Proteus, 55 (6.8%) Klebsiella, 29 (3.6%) Staphylococcus, 13 (1.6%) Enterococcus and 12 (1.5%) Streptococcus. Median age was six months (2.4-36 months IQR). After adjusting for age, ethnicity and bacterial species, the prevalence of dilating vesicoureteral reflux (VUR, defined as grades III-V) was 5.3 times higher in circumcised males compared to uncircumcised males (95% CI: 2.4-11.4, p = 0.001). Circumcised males had a 3.1 times increased prevalence of high-grade hydronephrosis (defined as SFU grades 3 and 4) compared to uncircumcised males (prevalence ratio: 3.1, 95% CI: 1.0-10.0, p = 0.05). Among bacterial pathogens, no patients with Proteus UTI had high-grade hydronephrosis or dilating VUR. In contrast, Staphylococcal infections were associated significantly with dilating VUR (prevalence ratio 10.1, 95% CI: 2.3, 44.8; p = 0.002) and high-grade hydronephrosis (prevalence ratio 8.1, 95% CI: 1.7, 39.7; p = 0.010).

CONCLUSIONS

Circumcision status is an independent predictor of structural urinary anomalies of the bladder and upper tracts in pediatric males with UTI, therefore circumcised males should be considered for early imaging, including VCUG, after their first UTI. Furthermore, Staphylococcal infections were associated with an even higher prevalence of high-grade hydronephrosis and dilating VUR and therefore warrant early investigation with VCUG. In contrast, none of the Proteus infections, which were seen almost exclusively in uncircumcised males, were associated with dilating VUR or hydronephrosis, making initial observation more appropriate in these patients.

Printed educational materials: effects on professional practice and healthcare outcomes

BACKGROUND

Printed educational materials are widely used dissemination strategies to improve the quality of healthcare professionals' practice and patient health outcomes. Traditionally they are presented in paper formats such as monographs, publication in peer-reviewed journals and clinical guidelines. This is the fourth update of the review.

OBJECTIVES

To assess the effect of printed educational materials (PEMs) on the practice of healthcare professionals and patient health outcomes. To explore the influence of some of the characteristics of the printed educational materials (e.g. source, content, format) on their effect on healthcare professionals' practice and patient health outcomes.

SEARCH METHODS

We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), HealthStar, CINAHL, ERIC, CAB Abstracts, Global Health, and EPOC Register from their inception to 6 February 2019. We checked the reference lists of all included studies and relevant systematic reviews.

SELECTION CRITERIA

We included randomised trials (RTs), controlled before-after studies (CBAs) and interrupted time series studies (ITSs) that evaluated the impact of PEMs on healthcare professionals' practice or patient health outcomes. We included three types of comparisons: (1) PEM versus no intervention, (2) PEM versus single intervention, (3) multifaceted intervention where PEM is included versus multifaceted intervention without PEM. Any objective measure of professional practice (e.g. prescriptions for a particular drug), or patient health outcomes (e.g. blood pressure) were included.

DATA COLLECTION AND ANALYSIS

Two reviewers undertook data extraction independently. Disagreements were resolved by discussion. For analyses, we grouped the included studies according to study design, type of outcome and type of comparison. For controlled trials, we reported the median effect size for each outcome within each study, the median effect size across outcomes for each study and the median of these effect sizes across studies. Where data were available, we re-analysed the ITS studies by converting all data to a monthly basis and estimating the effect size from the change in the slope of the regression line between before and after implementation of the PEM. We reported median changes in slope for each outcome, for each study, and then across studies. We standardised all changes in slopes by their standard error, allowing comparisons and combination of different outcomes. We categorised each PEM according to potential effects modifiers related to the source of the PEMs, the channel used for their delivery, their content, and their format. We assessed the risks of bias of all the included studies.

MAIN RESULTS

We included 84 studies: 32 RTs, two CBAs and 50 ITS studies. Of the 32 RTs, 19 were cluster RTs that used various units of randomisation, such as practices, health centres, towns, or areas. The majority of the included studies (82/84) compared the effectiveness of PEMs to no intervention. Based on the RTs that provided moderate-certainty evidence, we found that PEMs distributed to healthcare professionals probably improve their practice, as measured with dichotomous variables, compared to no intervention (median absolute risk difference (ARD): 0.04; interquartile range (IQR): 0.01 to 0.09; 3,963 healthcare professionals randomised within 3073 units). We could not confirm this finding using the evidence gathered from continuous variables (standardised mean difference (SMD): 0.11; IQR: -0.16 to 0.52; 1631 healthcare professionals randomised within 1373 units ), from the ITS studies (standardised median change in slope = 0.69; 35 studies), or from the CBA study because the certainty of this evidence was very low. We also found, based on RTs that provided moderate-certainty evidence, that PEMs distributed to healthcare professionals probably make little or no difference to patient health as measured using dichotomous variables, compared to no intervention (ARD: 0.02; IQR: -0.005 to 0.09; 935,015 patients randomised within 959 units). The evidence gathered from continuous variables (SMD: 0.05; IQR: -0.12 to 0.09; 6,737 patients randomised within 594 units) or from ITS study results (standardised median change in slope = 1.12; 8 studies) do not strengthen these findings because the certainty of this evidence was very low. Two studies (a randomised trial and a CBA) compared a paper-based version to a computerised version of the same PEM. From the RT that provided evidence of low certainty, we found that PEM in computerised versions may make little or no difference to professionals' practice compared to PEM in printed versions (ARD: -0.02; IQR: -0.03 to 0.00; 139 healthcare professionals randomised individually). This finding was not strengthened by the CBA study that provided very low certainty evidence (SMD: 0.44; 32 healthcare professionals). The data gathered did not allow us to conclude which PEM characteristics influenced their effectiveness. The methodological quality of the included studies was variable. Half of the included RTs were at risk of selection bias. Most of the ITS studies were conducted retrospectively, without prespecifying the expected effect of the intervention, or acknowledging the presence of a secular trend.

AUTHORS' CONCLUSIONS

The results of this review suggest that, when used alone and compared to no intervention, PEMs may slightly improve healthcare professionals' practice outcomes and patient health outcomes. The effectiveness of PEMs compared to other interventions, or of PEMs as part of a multifaceted intervention, is uncertain.

Association of Urinary Tract Infection Guidelines With Vesicoureteral Reflux Screening

This cohort study assesses the rates of routine voiding cystourethrogram testing in children with febrile urinary tract infection before and after screening guidelines were issued by the American Academy of Pediatrics.

Primary vesicoureteral reflux; what have we learnt from the recently published randomized, controlled trials?

In recent years, progress has been made on understanding the relationship between vesicoureteral reflux (VUR) and urinary tract infection (UTI). The findings on recent prospective, randomized, controlled studies have questioned the conventional VUR clinical significance and, therefore, have challenged the traditional diagnostic and therapeutic recommendations. These new studies have redefined the pathogenic role of vesicoureteral reflux in UTI as well as have disputed the routine use of urinary antibiotic prophylaxis to prevent UTI and renal damage in VUR patients. The time to overinvestigate and treat the vast majority of otherwise healthy children who have an uncomplicated UTI with long-term antibiotic prophylaxis seems to be over. Is there a role of severe VUR in the development of chronic renal disease and renal failure? New ideas are needed to answer these questions with the goal to avoid repeating past mistakes when therapeutic choices were based on expert opinions rather than facts.

Effect of Reader and Patient Parameters on the Performance of Last-Image-Hold for Fluoroscopic Grading of Vesicoureteric Reflux

OBJECTIVE. The purpose of this study is to determine the effect of different reader and patient parameters on the degree of agreement and the rate of misclassification of vesicoureteric reflux grading on last-image-hold frames in relation to spot-exposed frames from voiding cystourethrography (VCUG) as well as to determine the nature of reflux misclassification on last-image-hold frames. MATERIALS AND METHODS. Blinded readers conducted a retrospective evaluation of last-image-hold and spot-exposed frames of the renal fossae from 191 sequential VCUG examinations performed during a five-year period. Kappa tests were used to determine the agreement between reflux gradings and to assess the impact of reader and patient parameters. Pearson product-moment correlations were used to evaluate the effect of patient parameters on reader level of certainty regarding reflux grading. RESULTS. We measured almost perfect overall agreement for more experienced readers and substantial overall agreement for less experienced readers. Point estimates of overall misclassification were less than 2% for more experienced readers and less than 4% for less experienced readers. The readers' level of certainty about reflux grading had a positive impact on agreement values and misclassification rates. Experienced readers' most common misclassification was assigning reflux a grade of 3 on a spot-exposed frame and a grade of 2 on an equivalent last-image-hold frame. Inexperienced readers' most common misclassification involved missing reflux altogether. CONCLUSION. Instances of grade 2 reflux on last-image-hold frames may warrant supplemental evaluation with spot-exposed frames. Otherwise, a reader's level of certainty regarding reflux grading on a last-image-hold frame may help determine whether a supplemental spot-exposed frame would be beneficial.

Pediatric voiding cystourethrography: An essential examination for urologists but a terrible experience for children

Voiding cystourethrography is the most important fluoroscopic examination in pediatric urology for the investigation of lower urogenital tract diseases, such as vesicoureteral reflux or urethral stricture. However, this invasive procedure imposes a significant burden on children and their parents, and recently there has been a paradigm shift in the diagnosis and treatment of vesicoureteral reflux. In the 2011 revision, the American Academy of Pediatrics guidelines on urinary tract infection recommended abandoning routine voiding cystourethrography after the first febrile urinary tract infection. In 2014, the randomized intervention for children with vesicoureteral reflux study recommended discontinuation of routine continuous antibiotic prophylaxis for vesicoureteral reflux. The time is now ripe to radically reconsider indications for voiding cystourethrography and the procedure itself.