Vesicoureteral reflux: who benefits from surgery?

Pediatric Urinary Tract Infections

Urinary tract infection (UTI) is frequent in the first year of life with bowel and bladder dysfunction, GU tract abnormalities, neurogenic bladder, and the intact prepuce conveying an increased risk. Urine culture is the gold standard for diagnosis. Antibiotics are tailored to resistance patterns. Guidelines have been established to direct the evaluation for GU anomalies but differ significantly. Bladder and bowel dysfunction is important to screen for and treat in potty-trained patients. Circumcised boys with febrile UTIs are more likely to have anatomic abnormalities than uncircumcised boys.

Higher incidence of hematuria was observed in female children with microtia

The goals of this study were to investigate the incidence and characteristics of hematuria in patients with microtia, and to clarify that more attention should be paid to renal dysfunction in patients with microtia. We conducted a retrospective cohort study of a total 9447 children diagnosed with microtia (selected as study group, 7037 children) or pigmented nevus (selected as control group, 2410 children) at the Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College from January 2009 to June 2021. All of the routine urinalysis report of these children were reviewed to assess the incidence and characteristics of hematuria in each group. No statistically significant differences were observed when analyzing the overall incidence of hematuria between the study and control groups (P > 0.05). However, after grouping by sex, the incidence of hematuria in female children with microtia was significantly higher than that in femalecontrol group and no similar results were observed in the male patients. In addition, after further grouping by age in case group, the incidence of hematuria in girls of all ages with microtia was significantly higher than that in males with microtia (age 0-10:males: Girls = 1.89%:4.14%; age 0-5: males: Girls = 1.22%:3.73%; age 6-10: males:Girls = 1.97%:4.14%,P < 0.05), while no similar results were obtained in the control group.(age 0-10:males: Girls = 1.39%:2.22%; age 0-5: males: Girls = 1.07%:1.95%; age 6-10: males: Girls = 3.38%:3.17%, P > 0.05). Higher incidence of hematuria was observed in female children with microtia.

Clinical practice in vesicoureteral reflux with respect to EAU guidelines: A multicenter study

PURPOSE

We designed a multicenter, retrospective study to investigate the current trends in initial management of reflux with respect to European Association of Urology (EAU) Guidelines in Urology clinics of our country.

MATERIALS AND METHODS

The study group consisted of 1988 renal units (RU) of 1345 patients treated surgically due to vesicoureteral reflux (VUR) (between years 2003 and 2017) in nine different institutions. Patients were divided into two groups according to time of initial treatment and also grouped according to risk factors by "EAU guidelines on VUR."

RESULTS

In this series, 1426 RUs were treated initially conservatively and 562 RUs were initially treated with surgery. In initially surgically treated group, success rates of surgery decreased significantly in low and moderate risk groups after 2013 (P = .046, P = .0001, respectively), while success rates were not significantly different in high risk group (P = .46). While 26.6% of patients in low risk group were initially surgically treated before 2013, this rate has increased to 34.6% after 2013, but the difference was not statistically significant (P = .096). However, performing surgery as the initial treatment approach increased significantly in both moderate and high risk groups (P = .000 and P = .0001, respectively) after 2013. Overall success rates of endoscopic treatments and ureteroneocystostomy (UNC) operations were 65% and 92.9% before 2013 and 60% and 78.5% after 2013, respectively. Thus, the overall success rate for surgery was 72.6%. There was significant difference between success rates of UNC operations before and after 2013 (P = .000), while the difference was not significant in the injection group (P = .076).

CONCLUSION

Current trends in management of reflux in our country do not yet follow the EAU guidelines on VUR in low and moderate risk groups despite these reliable and accepted guidelines were expected to influence our daily approach.

Relationship between Vesicoureteral Reflux and Glomerular Filtration Rate in Children

Vesicoureteral reflux (VUR) is one of the most common urinary tract anomalies in children and causes renal damage and studies focusing on the effect of VUR on renal function are rare. We recruited 35 primary VUR patients with recurrent urinary tract infection (UTI) and 10 non-VUR patients with recurrent UTI. Contrast-enhanced voiding urosonography (ceVUS) was performed for VUR grading, and renal dynamic imaging was used for evaluating glomerular filtration rate (GFR, mL/min). Standardized GFR (sGFR), namely GFR/BSA (mL·min^-1·m^-2), was calculated based on the body surface area (BSA). Total sGFR (tsGFR, mL·min^-1·m^-2) was obtained from the sum of sGFR on the left and right sides of all the children. The risk of renal regurgitation was equal in the unilateral reflux group. The sGFR of children with grade IV (45.74±18.05 mL·min^-1·m^-2) and grade V (49.67±23.63 mL·min^-1·m^-2) reflux was significantly lower than that in children with grade III (77.69 ±22.21 mL·min^-1·m^-2). The renal function compensation of contralateral non-reflux kidney increased in unilateral reflux group, which was higher than that in the control group and level II, IV and V of reflux group respectively. In VUR group of the same grade, sGFR decreased with the age at diagnosis. In unilateral grade V reflux group, the tsGFR was lower than that in the unilateral grade III reflux group (133.51±48.21 vs. 186.87±53.49 mL·min^-1·m^-2). The patients with VUR of unilateral grade II were significantly older than those with VUR of unilateral grades III and IV. This study indicates that severe VUR is significantly associated with decreased renal function. Therefore, VUR should be diagnosed early and managed individually.

Continuous Antibiotic Prophylaxis in Pediatric Urology

Continuous antibiotic prophylaxis (CAP) for urinary tract infection prevention in children with vesicoureteral reflux, hydronephrosis, and hydroureteronephrosis is reviewed. A more selective use of CAP is advocated based on a review of known individual risk factors in each of these conditions that subsequently helps identify the children most likely to benefit from CAP. Both short-term and potential long-term side effects of CAP are reviewed, including the impact of prophylactic antibiotics on bacterial resistance and the microbiome. Alternatives to continuous antibiotic prophylaxis including Vaccinium macrocarpon (Cranberry), probiotics, and vaccines are reviewed.

Controversies in the Management of Vesicoureteral Reflux

Vesicoureteral reflux (VUR) is the abnormal retrograde flow of urine from the bladder into the upper urinary tract. Diagnosis and subsequent management of VUR have become increasingly controversial, with differing opinions over which children should be evaluated for reflux, and when detected, who should undergo treatment. Management goals include prevention of recurrent febrile urinary tract infection (fUTI) and renal injury while minimizing the morbidity of treatment and follow-up. Management options include observation with or without continuous antibiotic prophylaxis and surgical correction via endoscopic, open or laparoscopic/robotic approaches. Management should be individualized and based on patient age, health, risk of subsequent renal injury, clinical course, renal function, and parental preference.

Distal ureteral diameter measurement objectively predicts vesicoureteral reflux outcome

OBJECTIVE

Vesicoureteral reflux (VUR) grading may be difficult when discrepancies exist between the degree of dilation of the pyelocalyceal system and the ureter. Resolution may be more accurately predicted by the appearance of the distal ureter. We analyzed a novel, objective method of evaluating VUR based on the diameter of the distal ureter.

METHODS

Seventy-nine voiding cystourethrograms were reviewed (18 boys; 61 girls; aged 1 month to 7.5 years). The largest ureteral diameter within the false pelvis was measured and normalized by dividing by the distance from the L1-L3 vertebral body to give the distal ureteral diameter: L1-L3 ratio (UDR). Clinical outcome was defined as spontaneous resolution or surgical correction.

RESULTS

A significant association between grade and UDR existed (p < 0.0001). Mean UDR was significantly greater in those who underwent surgical correction (0.34 ± 0.02 vs 0.18 ± 0.02; p < 0.0001). Logistic regression analysis demonstrated a significant association of UDR with outcome controlling for grade (p = 0.001). Grade effect on outcome when controlling for UDR was not significant (p = 0.76). Odds ratio for surgical correction corresponding to a 0.1 increase in UDR equaled 2.25 (95% CI: 1.39, 3.64).

CONCLUSION

UDR provides an objective measurement of VUR and appears more predictive of clinical outcome than grade in this series.

Individualizing management of vesicoureteral reflux

BACKGROUND

Approaches to the management of vesicoureteral reflux (VUR) in children have changed rapidly in recent years. Multiple studies published over the last decade have contributed to these changes by challenging the dogma that all children with reflux require and benefit from continuous antibiotic prophylaxis. The advent and wide acceptance of endoscopic treatment for VUR has also contributed to these changes. Although new guidelines for VUR management have recently been proposed, they are broad and relatively non-specific. Many physicians and parents remain unsure which children are at risk from their VUR, and which would benefit from antibiotic prophylaxis or surgical intervention.

MATERIALS AND METHODS

A literature search, followed by an additional search based on bibliographies, was performed for articles reporting on VUR and the utility of antibiotic prophylaxis for its treatment, as well as the chance of spontaneous resolution.

RESULTS

Articles selected for review included those that provided information to assist physicians in determining if a child with VUR is at increased risk of pyelonephritis or persistent VUR, and would benefit from intervention. Particular emphasis was placed on recent prospective, randomized trials in children with VUR.

CONCLUSIONS

Because of the multiple factors affecting risk in a child with VUR, specific guidelines for intervention cannot be provided. However, an accurate understanding of these risk factors will help the physician and parents to develop a more individualized management plan for a child with VUR.

Bladder Dysfunction in Infants with Primary Vesicoureteric Reflux

There is growing evidence that bladder dysfunction is a negative prognostic factor for spontaneous resolution of vesicoureteric reflux (VUR). This study evaluated the prevalence of urodynamic abnormalities in infants with primary VUR who were referred over a 4-year period. The urodynamic evaluations and medical records of 54 infants with primary VUR (79 ureters with reflux) were reviewed prospectively. Urodynamic dysfunction was observed in 46.3% ( n = 25) of infants with primary VUR; 35.2% ( n = 19) had a low bladder capacity and 11.1% ( n = 6) had a large bladder capacity. All infants with large bladder capacities also had high grade (IV-V) VUR. In conclusion, there was a close relationship between bladder dysfunction and primary VUR. For that reason, urodynamic testing of infants with primary VUR should be performed as part of routine clinical evaluations.

Diagnosis and management of vesicoureteral reflux in children

Critical evaluation of previously accepted dogma regarding the evaluation and treatment of vesicoureteral reflux (VUR) has raised significant questions regarding all aspects of VUR management. Whereas the standard of care previously consisted of antibiotic prophylaxis for any child with VUR, it is now unclear which children, if any, truly benefit from antibiotic prophylaxis. Operative intervention for VUR constitutes overtreatment in many children, yet there are limited data available to indicate which children benefit from VUR correction through decreased rates of adverse long-term clinical sequelae. Studies with longer follow-up demonstrate decreased efficacy of endoscopic therapy that was previously hoped to approach the success of ureteroneocystostomy. Prospective studies might identify risk factors for pyelonephritis and renal scarring without antibiotic prophylaxis. Careful retrospective reviews of adults with a history of reflux might allow childhood risk factors for adverse sequelae to be characterized. Through analysis of multiple characteristics, better clinical management of VUR on an individualized basis will become the new standard of care.

Current status of Gil-Vernet trigonoplasty technique

Significant controversy exists regarding vesicoureteral reflux (VUR) management, due to lack of sufficient prospective studies. The rationale for surgical management is that VUR can cause recurrent episodes of pyelonephritis and long-term renal damage. Several surgical techniques have been introduced during the past decades. Open anti-reflux operations have high success rate, exceeding 95%, and long durability. The goal of this article is to review the Gil-Vernet trigonoplasty technique, which is a simple and highly successful technique but has not gained the attention it deserves. The mainstay of this technique is approximation of medial aspects of ureteral orifices to midline by one mattress suture. A unique advantage of Gil-Vernet trigonoplasty is its bilateral nature, which results in prevention from contralateral new reflux. Regarding not altering the normal course of the ureter in Gil-Vernet procedure, later catheterization of and retrograde access to the ureter can be performed normally. There is no report of ureterovesical junction obstruction following Gil-Vernet procedure. Gil-Vernet trigonoplasty can be performed without inserting a bladder catheter and drain on an outpatient setting. Several exclusive advantages of Gil-Vernet trigonoplasty make it necessary to reconsider the technique role in VUR management.