Cessation of vesicoureteral reflux for 5 years in infants and children allocated to medical treatment. The International Reflux Study in Children

Primary vesicoureteral reflux

Primary vesicoureteral reflux (VUR) is one of the most common urological abnormalities in infants and children. The association of VUR, urinary tract infection (UTI) and renal parenchymal damage is well established. The most serious complications of VUR-associated reflux nephropathy are hypertension and proteinuria with chronic kidney disease. Over the past two decades, our understanding of the natural history of VUR has improved, which has helped to identify patients at increased risk of both VUR and VUR-associated renal injury. The main goals in the treatment of paediatric patients with VUR are the prevention of recurrent UTIs and minimizing the risk of renal scarring and long-term renal impairment. Currently, there are four options for managing primary VUR in infants and children: surveillance or intermittent treatment of UTIs with management of bladder and bowel dysfunction; continuous antibiotic prophylaxis; endoscopic subureteral injection of tissue-augmenting substances; and ureteral reimplantation via open, laparoscopic or robotic-assisted surgery. Current debates regarding key aspects of management include when to perform diagnostic imaging and how to best identify the paediatric patients that will benefit from continuous antibiotic prophylaxis or surgical intervention, including endoscopic injection therapy and minimally invasive ureteral reimplantation. Evolving technologies, such as artificial intelligence, have the potential to assist clinicians in the decision-making process and in the individualization of diagnostic imaging and treatment of infants and children with VUR in the future.

[Voiding cystourethrography : Indications, fluoroscopy technique and radiation protection]

BACKGROUND

Voiding cystourethrography continues to be the gold standard in the diagnostics of a wide range of diseases of the urinary tract in children.

MATERIAL AND METHODS

Indications, implementation of voiding cystourethrography in terms of preparation, materials used, dealing with the child and the parents as well as the standardized examination technique are presented. In particular, the technical aspects of fluoroscopy devices and criteria for good image quality are discussed. Case studies are used to illustrate the problems of frequent urological diseases.

DISCUSSION

The three standard examinations for the detection of vesicoureteral reflux (VUR), radionuclide cystography, contrast-enhanced voiding urosonography and voiding cystourethrography are compared. Their potential for detecting VUR and additional urological pathologies is discussed in detail. Furthermore, the optimized examination technique of voiding cystourethrography is presented. The applicability of the current dose reference values of the German Federal Office for Radiation Protection (BfS) in the daily routine is discussed and the feasibility of the dose reference values is explained.

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.

Susceptibility of the Index Urinary Tract Infection to Prophylactic Antibiotics Is a Predictive Factor of Breakthrough Urinary Tract Infection in Children with Primary Vesicoureteral Reflux Receiving Continuous Antibiotic Prophylaxis

BACKGROUND

Few studies have reported on breakthrough urinary tract infection (UTI) associated with the susceptibility of index UTI to prophylactic antibiotics in children with primary vesicoureteral reflux (VUR) receiving continuous antibiotic prophylaxis (CAP). We assessed the impact of the susceptibility of index UTI to prophylactic antibiotics in breakthrough UTIs in children with primary VUR receiving CAP.

METHODS

We retrospectively reviewed the medical records of 81 children with primary VUR who were diagnosed after febrile or symptomatic UTI and subsequently received trimethoprim-sulfamethoxazole (TMP-SMX) as CAP between January 2010 and December 2013. We allocated children to a susceptible group or a resistant group based on the susceptibility of index UTI to TMP-SMX. We evaluated patient demographics and clinical outcomes after CAP according to the susceptibility of index UTI to TMP-SMX. Multivariate analysis was used to identify the predictive factors for breakthrough UTI.

RESULTS

Of the 81 children, 42 were classified into the susceptible group and 39 into the resistant group. The proportion of breakthrough UTI was 31.0% (13/42) in the susceptible group and 53.8% (21/39) in the resistant group (P = 0.037). Progression of renal scarring was observed in 0% of children in the susceptible group and 15% in the resistant group (P = 0.053). Multivariate analysis showed that TMP-SMX resistance and initial renal scarring were significant predictors of breakthrough UTI.

CONCLUSION

Susceptibility of index UTI to prophylactic antibiotics is a risk factor of breakthrough UTI and is associated with poor clinical outcomes in children with primary VUR receiving CAP.

Interventions for primary vesicoureteric reflux

BACKGROUND

Vesicoureteric reflux (VUR) results in urine passing retrograde up the ureter. Urinary tract infections (UTI) associated with VUR have been considered a cause of permanent renal parenchymal damage in children with VUR. Management has been directed at preventing UTI by antibiotic prophylaxis and/or surgical correction of VUR. This is an update of a review first published in 2004 and updated in 2007 and 2011.

OBJECTIVES

The aim of this review was to evaluate the available evidence for both benefits and harms of the currently available treatment options for primary VUR: operative, non-operative or no intervention.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Specialised Register to 3 May 2018 through contact with the Information Specialist using search terms relevant to this review. Studies contained in the Specialised Register are identified through search strategies specifically designed for CENTRAL, MEDLINE, and EMBASE; handsearching conference proceedings, and searching the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov.

SELECTION CRITERIA

RCTs in any language comparing any treatment of VUR and any combination of therapies.

DATA COLLECTION AND ANALYSIS

Two authors independently determined study eligibility, assessed quality and extracted data. Dichotomous outcomes were expressed as risk ratios (RR) with 95% confidence intervals (CI) and continuous data as mean differences (MD) with 95% CI. Data were pooled using the random effects model.

MAIN RESULTS

Thirty four studies involving 4001 children were included. Interventions included; long-term low-dose antibiotics, surgical reimplantation of ureters, endoscopic injection treatment, probiotics, cranberry products, circumcision, and oxybutynin. Interventions were used alone and in combinations. The quality of conduct and reporting of these studies was variable, with many studies omitting crucial methodological information used to assess the risk of bias. Only four of the 34 studies were considered at low risk of bias across all fields of study quality. The majority of studies had many areas of uncertainty in the risk of bias fields, reflecting missing detail rather than stated poor design.Low-dose antibiotic prophylaxis compared to no treatment/placebo may make little or no difference to the risk of repeat symptomatic UTI (9 studies, 1667 children: RR 0.77, 95% CI 0.54 to 1.09; low certainty evidence) and febrile UTI (RR 0.83, 95% CI 0.56 to 1.21; low certainty evidence) at one to two years. At one to three years, antibiotic prophylaxis made little or no difference to the risk of new or progressive renal damage on DMSA scan (8 studies, 1503 children: RR 0.73, 95% CI 0.33 to 1.61; low certainty evidence). Adverse events were reported in four studies with little or no difference between treatment groups (1056 children: RR 0.94, 95% CI 0.81 to 1.08; ), but antibiotics increased the likelihood of bacterial drug resistance threefold (187 UTIs: RR 2.97, 95% CI 1.54 to 5.74; moderate certainty evidence).Seven studies compared long-term antibiotic prophylaxis alone with surgical reimplantation of ureters plus antibiotics, but only two reported the outcome febrile UTI (429 children). Surgery plus antibiotic treatment may reduce the risk of repeat febrile UTI by 57% (RR 0.43, 95% CI 0.27 to 0.70; moderate certainty evidence). There was little or no difference in the risk of new kidney defects detected using intravenous pyelogram at 4 to 5 years (4 studies, 572 children, RR 1.09, 95% CI 0.79 to 1.49; moderate certainty evidence)Four studies compared endoscopic injection with antibiotics alone and three reported the outcome febrile UTI. This analysis showed little or no difference in the risk of febrile UTI with endoscopic injection compared to antibiotics (RR 0.74, 95% CI 0.31 to 1.78; low certainty evidence). Four studies involving 425 children compared two different materials for endoscopic injection under the ureters (polydimethylsiloxane (Macroplastique) versus dextranomer/hyaluronic acid polymer (Deflux), glutaraldehyde cross-linked (GAX) collagen (GAX) 35 versus GAX 65 and Deflux versus polyacrylate polyalcohol copolymer (VANTRIS)) but only one study (255 children, low certainty evidence) had the outcome of febrile UTI and it reported no difference between the materials. All four studies reported rates of resolution of VUR, and the two studies comparing Macroplastique with Deflux showed that Macroplastique was probably superior to dextranomer/hyaluronic acid polymer (3 months: RR 0.50, 95% CI 0.33 to 0.78; 12 months: RR 0.54 95% CI 0.35 to 0.83; low certainty evidence)Two studies compared probiotic treatment with antibiotics and showed little or no difference in risk of repeat symptomatic UTI (RR 0.82 95% CI 0.56 to 1.21; low certainty evidence)Single studies compared circumcision with antibiotics, cranberry products with no treatment, oxybutynin with placebo, two different surgical techniques and endoscopic injection with no treatment.

AUTHORS' CONCLUSIONS

Compared with no treatment, the use of long-term, low-dose antibiotics may make little or no difference to the number of repeat symptomatic and febrile UTIs in children with VUR (low certainty evidence). Considerable variation in the study designs and subsequent findings prevented drawing firm conclusions on efficacy of antibiotic treatment.The added benefit of surgical or endoscopic correction of VUR over antibiotic treatment alone remains unclear since few studies comparing the same treatment and with relevant clinical outcomes were available for analysis.

The RIVUR study: a review of its findings

BACKGROUND

The conclusion drawn by the authors of the Randomized Intervention for Children with Vesicoureteral Reflux (RIVUR) trial is that antimicrobial prophylaxis reduces the risk of recurrent urinary tract infection (UTI)-but not of renal scarring-in patients with vesicoureteral reflux (VUR).

RESULTS

A review of the findings showed that the decreased recurrent UTI rate was only present at the end of the 2-year follow-up period and was only slightly increased (12.3%) above the 10% cutoff for statistical significance. The difference was not observed in children younger than two years of age with VUR grade III and IV. In addition, the rate of new renal scarring was not statistically different between the prophylaxis and placebo groups (8.2 vs. 8.4%, respectively). A high rate of uropathogen antibiotic resistance was observed in the prophylaxis group (68.4 vs. 24.6%, respectively).

CONCLUSION

The analysis of the RIVUR findings questions the validity of its authors suggestion that the results may warrant reconsideration of the current recommendations by the American Academy of Pediatrics on obtaining a voiding cystourethrogram after the first febrile UTI and the use of urinary antibiotic prophylaxis in VUR patients.

Efficacy of antibiotic prophylaxis in children with vesicoureteral reflux: systematic review and meta-analysis

PURPOSE

Controversy exists regarding the use of continuous antibiotic prophylaxis vs observation in the management of children with vesicoureteral reflux. The reported effectiveness of continuous antibiotic prophylaxis in children with reflux varies widely. We determined whether the aggregated evidence supports use of continuous antibiotic prophylaxis in children with vesicoureteral reflux.

MATERIALS AND METHODS

We searched the Cochrane Controlled Trials Register, clinicaltrials.gov, MEDLINE(®), EMBASE(®), Google Scholar and recently presented meeting abstracts for reports in any language. Bibliographies of included studies were then hand searched for any missed articles. The study protocol was prospectively registered at PROSPERO (No. CRD42014009639). Reports were assessed and data abstracted in duplicate, with differences resolved by consensus. Risk of bias was assessed using standardized instruments.

RESULTS

We identified 1,547 studies, of which 8 are included in the meta-analysis. Pooled results demonstrated that continuous antibiotic prophylaxis significantly reduced the risk of recurrent febrile or symptomatic urinary tract infection (pooled OR 0.63, 95% CI 0.42-0.96) but, if urinary tract infection occurred, increased the risk of antibiotic resistant organism (pooled OR 8.75, 95% CI 3.52-21.73). A decrease in new renal scarring was not associated with continuous antibiotic prophylaxis use. Adverse events were similar between the 2 groups. Significant heterogeneity existed between studies (I(2) 50%, p = 0.03), specifically between those trials with significant risk of bias (eg unclear protocol descriptions and/or lack of blinding).

CONCLUSIONS

Compared to no treatment, continuous antibiotic prophylaxis significantly reduced the risk of febrile and symptomatic urinary tract infections in children with vesicoureteral reflux, although it increased the risk of infection due to antibiotic resistant bacteria. Continuous antibiotic prophylaxis did not significantly impact the occurrence of new renal scarring or reported adverse events.

A unique presentation, and management, of acute urinary retention in a young boy with underlying vesicoureteral reflux

Vesicoureteral reflux (VUR) affects ∼1% of children. We present an unusual case of urinary retention secondary to an obstructing urethral stone, underlying reflux, and its management. A 7-year-old boy presenting with acute urinary retention had a palpable penile shaft swelling and patent urethral meatus on examination. Cysto-urethroscopy with a 6.6Fr ureteroscope, due to unavailability of paediatric instruments, revealed an obstructing calculus impacted in the navicular fossa. This was laser fragmented and extracted. Cystoscopy revealed multiple bladder calculi with a patulous right ureteric orifice. Post-operative investigations revealed a small, scarred right kidney (ultrasound), bilateral ureteric reflux (micturating-cystourethrogram), 4 cm by 0.8 cm right ureteric calculus (CT-KUB) and 4% right split renal function (DMSA). Right laparoscopic nephroureterectomy was subsequently performed. Our case highlights the variety with which VUR can present and the effectiveness of a ureteroscope in an emergency setting as an alternative to a paediatric cystoscope to visualize the urethra and the bladder.

[Primary vesicoureteral reflux]

The never ending discussion about the diagnostics and treatment of vesicoureteral reflux (VUR) now includes arguments for diagnostic nihilism as well as invasive diagnostics and therapy, which is reminiscent of the debate on prostate cancer in adulthood. The common goal of all currently competing diagnostic strategies and approaches is the prevention of renal scars by the most effective and least burdensome approach. There is a difference between acquired pyelonephritic scars with VUR (acquired reflux nephropathy) and congenital reflux nephropathy (primary dysplasia) which cannot be influenced by any therapy.The VUR can be verified by conventional radiological voiding cystourethrography (VCUG), by urosonography, radionuclide cystography or even by magnetic resonance imaging (MRI). The guidelines of the European Association of Urology/European Society for Paediatric Urology (EAU/ESPU) recommend radiological screening for VUR after the first febrile urinary tract infection. Significant risk factors in patients with VUR are recurrent urinary tract infections (UTI) and parenchymal scarring and the patients should undergo patient and risk-adapted therapy. Infants with dilating reflux have a higher risk of renal scarring than those without dilatation of the renal pelvis. Bladder dysfunction or dysfunctional elimination syndrome represents a well-known but previously neglected risk factor in combination with VUR and should be treated prior to any surgical intervention as far as is possible.Certainly not every patient with VUR needs therapy. The current treatment strategies take into account age and gender, the presence of dysplastic or pyelonephritic renal scars, the clinical symptoms, bladder dysfunction and frequency and severity of recurrent UTI as criteria for the therapy decision. The use of an antibacterial prophylaxis as well as the duration is controversially discussed. Endoscopic therapy can be a good alternative to antibacterial prophylaxis or a surveillance strategy in patients with low grade VUR. In patients with dilating VUR and given indications for surgery, endoscopic treatment can be offered. However, parents should be completely informed about the significantly lower success rate of endoscopic therapy compared to open surgical procedures. The open surgical techniques guarantee the highest success rates and should be used in patients with a dilating VUR and high risk of renal damage.

The RIVUR voiding cystourethrogram pilot study: experience with radiologic reading concordance

PURPOSE

Two reference radiologists independently review voiding cystourethrograms for the National Institutes of Health sponsored RIVUR (Randomized Intervention for Children with Vesicoureteral Reflux) trial for children with vesicoureteral reflux. A pilot study was required from all clinical centers before enrolling patients.

MATERIALS AND METHODS

Digital images were reviewed. Responses were compared and discrepancies adjudicated by teleconference to a final assessment.

RESULTS

A total of 75 studies from 19 sites were reviewed. Discrepancies in vesicoureteral reflux grade level were noted on the left and right side in 11 (15%, kappa 0.85) and 12 (16%, kappa 0.83) ureters, respectively. Other areas of disagreement were the presence of paraureteral diverticulum (left 11%, kappa 0.31; right 9%, kappa 0.34), urethral anatomy (15%, kappa 0.33), whether the child voided (8%, kappa 0.21), the presence of ureteral duplication (left 7%, kappa 0.64; right 3%, kappa 0.78) and the presence of bladder trabeculation (5%, kappa 0.32). Of 83 ureters in which reflux was seen there was grade disagreement about 23 (28%). Of 61 ureters initially assessed as grade II or III reflux by both readers, there was disagreement on 9 (15%). Of these 9 discrepancies 7 (78%) were adjudicated to the higher grade (grade III).

CONCLUSIONS

Discrepancies in the assessment of intermediate grade vesicoureteral reflux were noteworthy. Recommendations for patients with grade II or III reflux advanced by studies which rely on a single reading, which categorize only grade III or higher reflux as significant, may not be valid.

A systematic review on renal and bladder dysfunction after endoscopic treatment of infravesical obstruction in boys

Background

Posterior urethral valves (PUV) may cause subtle to severe obstruction of the urethra, resulting in a broad clinical spectrum. PUV are the most common cause of chronic renal disease in boys. Our purpose was to report the incidences of kidney and bladder dysfunction in boys treated with endoscopic valve resection for PUV.

Methodology

We searched MEDLINE and EMBASE databases until 1st of July 2011, to identify original papers that described outcome of endoscopic valve resection (EVR) in boys. We extracted information on (1) patient characteristics and clinical presentation of PUV related to outcomes and (2) the post-treatment absolute risks for kidney and bladder dysfunction.

Principal findings

Thirty-four studies describing renal function, vesicoureteral reflux (VUR), incontinence, and urodynamic bladder function after EVR in 1474 patients were retrieved. Patients treated for PUV show high percentages of chronic kidney disease (CKD) or end stage renal disease (ESRD), 22% (0–32%) and 11% (0–20%), respectively. Elevated nadir serum creatinine was the only independent factor associated with renal failure. Before treatment, VUR was present in 43% of boys and after EVR, VUR was present in 22%. Post treatment, 19% (0–70%) was reported to suffer from urinary incontinence. Urodynamic bladder dysfunction was seen in many patients (55%, 0–72%) after treatment of PUV.

Conclusions

The reported cumulative incidence of renal and bladder dysfunction in patients with PUV after endoscopic PUV treatment varies widely. This may reflect a broad clinical spectrum, which relates to the lack of a standardised quantification of obstruction and its severity. Moreover, the risk of bias is rather high, and therefore we put little confidence in the reported estimates of effect. We found elevated nadir serum creatinine as a predictor for renal dysfunction. In order to be able to predict outcomes for patients with PUV, an objective classification of severity of obstruction is mandatory.

Endoscopic treatment of vesicoureteral reflux in children with subureteral dextranomer/hyaluronic acid injection: a single-centre, 7-year experience

BACKGROUND

The goals of medical intervention in patients with vesicoureteral reflux are to allow normal renal growth, prevent infections and pyelonephritis, and prevent renal failure. We present our experience with endoscopic treatment of vesicoureteral reflux in children by subureteral dextranomer/hyaluronic acid copolymer injection.

METHODS

Under cystoscopic guidance, dextranomer/hyaluronic acid copolymer underneath the intravesical portion of the ureter in a subureteral or submucosal location was injected in patients undergoing endoscopic correction of vesicoureteral reflux.

RESULTS

A total of 282 patients (120 boys and 162 girls) underwent the procedure. There were 396 refluxed ureters altogether. The mean age of patients was 4.9 years. The mean overall follow-up period was 44 months. Among the 396 ureters treated, 76% were cured with a single injection. A second and third injection raised the cure rate to 93% and 94%, respectively. Twenty-two (6%) ureters failed all 3 injections, and were converted to open surgery.

CONCLUSION

Endoscopic treatment of vesicoureteral reflux can be recommended as a first-line therapy for most cases of vesicoureteral reflux, because of the short hospital stay, absence of complications and the high success rate.

The impact of vesicoureteral reflux treatment on the incidence of urinary tract infection

Vesicoureteral reflux (VUR) is a heterogeneous disease and its management remains one of the most controversial topics in pediatrics. Management options include surveillance, antibiotics, and surgery. The approval of dextranomer/hyaluronic acid (DHA) as a bulking agent by the Food and Drug Administration was followed by wide acceptance of endoscopic techniques as a major tool in the management of reflux. Pyelonephritis rather than VUR is the most common cause of kidney damage in children. It should be emphasized that the primary goal of diagnosing and treating VUR should be preventing this complication. There are no sufficient data in the literature to address the impact of the different treatment modalities on the incidence of febrile urinary tract infections (feb-UTIs) denoting pyelonephritis, with very few studies evaluating endoscopic treatment in light of this clear and well-defined outcome. The fact that we can correct the anatomy at the vesicoureteral junction with a simple and relatively safe outpatient procedure does not justify offering it to all patients. In this review, we attempt to critically evaluate the available literature pertaining to the impact of different treatment modalities on reducing the incidence of febrile UTIs and kidney damage, with a special emphasis on endoscopic treatment.

Analysis of indications for ureteral reimplantation in 3738 children with vesicoureteral reflux: a single institutional cohort

PURPOSE

No method exists for predicting which child with vesicoureteral reflux (VUR) will have surgery. Our goals were to analyze practice patterns at a major pediatric center and to identify factors predisposing children to surgery for specific indications.

MATERIALS AND METHODS

We analyzed a cohort of 3738 children presenting with primary VUR (1996-2005). Surgical indications included: 1) breakthrough urinary tract infection (UTI), 2) non-resolution over 3 years, 3) renal scan abnormality and 4) parent/surgeon preference. Logistic regression was applied to a random 60% subset of children. Validation in the remaining 40% was done using receiver operating characteristic curve analysis and the Hosmer and Lemeshow goodness-of-fit test.

RESULTS

Independent predictors of surgery included higher age at presentation, antenatal hydronephrosis (ANH), bilateral VUR and VUR grade. Predictors of surgery for a breakthrough UTI included female gender, increasing age, and bilateral and high-grade VUR. Girls were less likely than boys to be operated for renal scan abnormality or parent/surgeon preference. ANH was a predictor of surgery for decreased function and parent/surgeon preference. The model had fair discrimination (c-statistic = 0.68-0.76) and high calibration (p ≥ 0.24). Probabilities of surgery were calculated.

CONCLUSIONS

Higher age at presentation, being followed for ANH, and bilateral and high-grade VUR are independent predictors of VUR-corrective surgery. Predictors of surgery vary with indication. Our methods allow comparison of urological practice patterns and outcomes between institutions by taking into account indications for surgery.

Embryology and anatomy of the vesicoureteric junction with special reference to the etiology of vesicoureteral reflux

Concerning the ureterovesical junction - the region most important for the anti-reflux mechanism - there is still a lot of misunderstanding and misinterpretation with regard to normal fetal development. Data are scarce on possible causes of primary vesicoureteral reflux and on involved mechanisms of the so-called maturation process of refluxing ureteral endings. The ratio of the intravesical ureteral length to the ureteral diameter is obviously lower than assumed so far, as clearly revealed by some studies. Therefore it can be doubted that the length and course of the intravesical ureter is of sole importance in the prevention of reflux. Additionally refluxing intravesical ureteral endings present with dysplasia, atrophy, and architectural derangement of smooth muscle fibers. Besides, a pathologically increased matrix remodeling combined with deprivation of the intramural nerve supply has been confirmed. Consequently, symmetrical narrowing of the very distal ureteral smooth muscle coat creating the active valve mechanism to defend reflux is not achievable. It is apparent that primary congenital vesicoureteral reflux seems to be the result of an abnormality within the ureterovesical junction with an insufficient muscular wrap. Nature is believed to establish much more sophisticated mechanisms than the so-called passive anti-reflux mechanism. Remodeling processes within the ureterovesical junction of refluxing ureteral endings support that maturation itself is nothing else than wound or defect healing and not a restitution of a morphological normal ureterovesical junction. Lacking the nerve supply a restoration of any muscular structure can not be achieved.

In vitro analysis of the bactericidal activity of Escherichia coli Nissle 1917 against pediatric uropathogens

PURPOSE

The usefulness of prophylactic antibiotics to prevent recurrent urinary tract infections in children was recently questioned. Some groups have attempted to use probiotics, most commonly lactobacillus, to prevent recurrent infections by altering the intestinal bacterial reservoir with variable results. Mutaflor® is a possible alternative probiotic in which the active agent is Nissle 1917. Nissle 1917 is a commensal Escherichia coli strain that eradicates pathogenic bacteria from the gastrointestinal tract. Due to its ability to alter the intestinal biome we hypothesized that Mutaflor may have the potential to prevent recurrent urinary tract infections. Thus, we used an in vitro assay to analyze the effectiveness of Nissle 1917 for eradicating pediatric uropathogens.

MATERIALS AND METHODS

We established a collection of 43 bacterial pediatric uropathogens. With each isolate a microcin-type assay was performed to determine the effectiveness of Nissle 1917 on bacterial growth inhibition and competitive overgrowth.

RESULTS

Nissle 1917 adversely affected the growth of 34 of the 43 isolates (79%) isolates. It inhibited the growth of 21 isolates and overgrew 13. The percent of species adversely affected by Nissle 1917 was 40% for Pseudomonas, 50% for E. coli, Enterococcus and Staphylococcus, 100% for Klebsiella and Enterobacter, and 0% for Citrobacter and Serratia.

CONCLUSIONS

Nissle 1917, the active agent in Mutaflor, inhibited or out competed most bacterial isolates. These mechanisms could be used in vivo to eradicate uropathogens from the gastrointestinal tract. Further study is needed to determine whether Mutaflor can prevent recurrent urinary tract infections in children.

Concomitant vesicoureteral reflux and gastroesophageal reflux: an analytic cross-sectional study

PURPOSE

Vesicoureteral reflux (VUR) and Gastroesophageal reflux (GER) are both common disorders in children and could be associated with significant morbidities. Although they appear to be separate entities, their natural history and underlying pathophysiology are the same and they both tend to resolve over time. We aimed to appraise their concurrent occurrence and prevalence of GER in VUR patients to understand whether they can be considered different manifestations of a syndrome mainly caused by developmental delay resulting in dysfunction of the sphincters.

METHODS

Totally, 174 children ≤ 2 years of age were enrolled and 87 of them with primary VUR constituted patients group. The rest of the cases with the same age and sex distribution entered control group. All the study population underwent ultrasonographic evaluation to detect GER.

RESULTS

GER was more frequent in patients with primary VUR. GER was more prevalent in higher grades of VUR. We observed higher prevalence of GER and higher grades of VUR in younger infants demonstrating the tendency of both conditions to resolve overtime. Bilateral VUR was more prevalent among patients with higher grades of VUR. GER was more prevalent in patients with bilateral VUR and Prevalence of bilateral VUR decreased with increase in age. These findings show that the chance of concomitant GER and VUR is higher in children with more severe developmental defect of sphincters.

CONCLUSIONS

Regarding the higher prevalence of GER among VUR patients and correlation of VUR severity with co-occurrence of GER, besides the natural tendency of both conditions to resolve overtime, they may be considered parts of developmental delay syndrome of sphincters.

Interventions for primary vesicoureteric reflux

BACKGROUND

Vesicoureteric reflux (VUR) results in urine passing retrograde up the ureter. Urinary tract infections (UTI) associated with VUR have been considered a cause of permanent renal parenchymal damage in children with VUR. Management of these children has been directed at preventing UTI by antibiotic prophylaxis and/or surgical correction of VUR. The optimum strategy is not clear.

OBJECTIVES

To evaluate the benefits and harms of different treatment options for primary VUR.

SEARCH STRATEGY

In August 2010 we searched CENTRAL, MEDLINE and EMBASE and screened reference lists of papers and abstracts from conference proceedings.

SELECTION CRITERIA

RCTs in any language comparing any treatment of VUR including surgical or endoscopic correction, antibiotic prophylaxis, non-invasive non-pharmacological techniques and any combination of therapies.

DATA COLLECTION AND ANALYSIS

Two authors independently searched the literature, determined study eligibility, assessed quality, extracted and entered data. We expressed dichotomous outcomes as risk ratios (RR) and their 95% confidence intervals (CI) and continuous data as mean differences (MD) and their 95% CI's Data were pooled using the random effects model.

MAIN RESULTS

Twenty RCTs (2324 children) were included. Long-term low-dose antibiotic prophylaxis compared to no treatment/placebo did not significantly reduce repeat symptomatic UTI (846 children: RR 0.68, 95% CI 0.39 to 1.17) or febrile UTI (946 children: RR 0.77, 95% CI 0.47 to 1.24) at two years. There was considerable heterogeneity in the analyses and only one study was adequately blinded. At one to three years, antibiotic prophylaxis reduced the risk of new or progressive renal damage on DMSA scan (446 children: RR 0.35, 95% CI 0.15 to 0.80). Side effects were infrequent when reported, but antibiotics increased the likelihood of bacterial drug resistance threefold (132 UTIs: RR 2.94, 95% CI 1.39 to 6.25).When long-term antibiotic prophylaxis was compared with surgical or endoscopic correction of VUR plus antibiotics for one to 24 months (10 studies, 1141 children), the risk of symptomatic UTI was not significantly different at any time point. Combined surgical and antibiotic treatment caused a 57% reduction in febrile UTI by five years (2 studies, 449 children: RR 0.43, 95% CI 0.27 to 0.70) but did not decrease the risk of new or progressive renal damage at any time point. Postoperative obstruction was seen in 0% and 7% of children in two surgical studies and 0% in one endoscopic study.

AUTHORS' CONCLUSIONS

Compared with no treatment, use of long-term, low-dose antibiotics did not significantly reduce the number of repeat symptomatic and febrile UTIs in children with VUR. Considerable heterogeneity in the analyses and inclusion of only one adequately blinded study, made drawing firm conclusions challenging. Antibiotic prophylaxis significantly reduced the risk of developing new or progressive renal damage, but assuming an 8% baseline risk, 33 children would need long-term antibiotic prophylaxis to prevent one more child developing kidney damage over the course of two to three years.The added benefit of surgical or endoscopic correction of VUR over antibiotic treatment alone remains unclear. Eight children would require combined surgical and antibiotic treatment to prevent one additional child developing febrile UTI by five years, but it would not cause fewer children developing renal damage.

Is antibiotic prophylaxis effective in preventing urinary tract infections in patients with vesicoureteral reflux?

The main concern in the management of children with vesicoureteral reflux (VUR) is the prevention of urinary tract infections and avoidance of renal damage. Medical management has been recommended or preferentially suggested over surgery in all but a few select clinical situations. Prophylactic antibiotics are prescribed routinely in the management of young children with radiological evidence of VUR following an episode of acute pyelonephritis. Prophylaxis is generally maintained until the VUR resolves spontaneously or is corrected surgically. Although the administration of prophylactic antibiotics has been universal in children with VUR, some authors have reported that long-term antibiotic prophylaxis does not fully prevent urinary tract infections or scarring, that antibiotic-related adverse events are known to occur, and that the incidence of pyelonephritis does not increase in spite of prophylactic antibiotic cessation. Recently, four prospective, randomized, controlled trials of antibiotic prophylaxis for preventing pyelonephritis and renal scarring were reported and some placebo-controlled, double-blind prospective studies are ongoing. The goal of this review is to evaluate the treatment of VUR using antibiotic prophylaxis, and its advantages and disadvantages based on appropriate descriptions and studies in the literature.

The value of estimation of distal ureteral dilatation in primary vesicoureteral reflux

Purpose

Recently, several studies have suggested that distal ureteral dilatation is an important factor influencing the spontaneous resolution of primary vesicoureteral reflux (VUR). We evaluated the relationship between distal ureteral dilatation and the spontaneous resolution of primary VUR.

Materials and Methods

The medical records of 114 patients with primary VUR maintained on prophylactic antibiotics from April 1999 to August 2008 were retrospectively reviewed. The patients' mean age was 24.2 months (range, 6-108 months). There were 66 male patients and 48 female patients. The mean follow-up was 37.6 months (range, 12-102 months). We analyzed various factors including age, gender, grade of reflux, laterality, and ureteral diameter ratio (UDR; the largest ureteral diameter was divided by the distance from the L1-4 vertebral body to minimize the differences in diameter by age) to determine whether these factors influenced the spontaneous resolution of primary VUR.

Results

Unilateral, low-grade reflux and low UDR were significantly associated with the spontaneous resolution of reflux (p=0.048, p<0.001, and p<0.001, respectively). The multivariate analysis revealed that the spontaneous resolution rate of primary reflux was significantly higher in patients with low UDR than in patients with high UDR (p<0.001).

Conclusions

The degree of distal ureteral dilatation is expected to be another important factor in determining therapeutic course and predicting the spontaneous resolution of VUR.

Evaluation of Renal Resistivity Index Before and After Voiding Cystoureterography Examination in Patients With Vesicoureteral Reflux

Vesicoureteral reflux (VUR) occurs commonly in children and can cause significant renal damage. The purpose of this study is to assess the changes in renal vasculature with spectral Doppler sonography in patients with VUR. In addition, the possible effects of voiding cystoureterography (VCU) on the kidneys in patients with VUR are investigated by calculating renal resistivity index (RI) values before and after VCU using spectral Doppler sonography. In this prospective study, 114 kidneys of 58 children ages 0 to 16 years were included. The RI values that were calculated before and after VCU and RI values in different grades of VUR were compared statistically. In patients with VUR, the renal parenchymal RI values before and after VCU were significantly higher than those in patients without VUR ( P < .05). The mean pre-VCU RI values were 0.68 ± 0.03 and 0.65 ± 0.05 in patients with VUR and in the control group, respectively, and the mean post-VCU RI values were 0.68 ± 0.03 and 0.65 ± 0.04 in patients with VUR and in the control group, respectively. Calculating renal RI values from arcuate or interlobar renal arteries with spectral Doppler sonography while the patients are in a supine or lateral decubitus position is a useful technique in patients with VUR, being significantly higher in high-grade VUR patients than in low-grade VUR patients. There is no significant effect of the contrast agent reaching the renal calycial system during VCU examination on renal RI values.

Update on childhood urinary tract infection and vesicoureteral reflux

Urinary tract infection (UTI) is a leading cause of serious bacterial infection in young children. Vesicoureteral reflux (VUR), a common pediatric urologic disorder, is believed to predispose to UTI, and both are associated with renal scarring. The complex interaction of bacterial virulence factors and host defense mechanisms influence renal damage. However, some renal parenchymal abnormalities associated with VUR are noninfectious in origin. Long-term, renal parenchymal injury may be associated with hypertension, pregnancy complications, proteinuria, and renal insufficiency. Optimal management of VUR and UTI is controversial because of the paucity of appropriate randomized controlled trials; there is a need for well-designed studies. The recently launched Randomized Intervention for children with VesicoUreteral Reflux (RIVUR) study hopefully will provide insight into the role of antimicrobial prophylaxis of UTI in children with VUR.

Are prophylactic antibiotics indicated after a urinary tract infection?

PURPOSE OF REVIEW

Many children with urinary tract infection (UTI) and urinary tract abnormality such as vesicoureteral reflux (VUR) are given prophylactic antibiotic to prevent recurrence of UTI and permanent kidney damage. Occasionally, children with normal urinary tract receive prophylactic antibiotic to alleviate the patient suffering and family inconvenience associated with recurrent symptomatic UTI. These recommendations are mostly opinion-based and are derived from studies that were not randomized and were done before the current renal imaging modalities became available. The purpose of this review is to discuss these recommendations in the context of recent research findings.

RECENT FINDINGS

Recent studies have raised serious doubts about the role of antibiotic prophylaxis after UTI by demonstrating the presence of preexisting renal scars without UTI in some patients, systematic reviews of published literature on UTI and VUR, and by comparing randomized patients with VUR who received antibiotic prophylaxis with those who did not receive any prophylaxis. However, the new knowledge has also highlighted that,apart from skillful management of individual patients, well designed studies are needed to answer the questions on antibiotic prophylaxis across the spectrum of UTI in different clinical situations. One such study currently underway is the Randomized Intervention for Children With Vesicoureteral Reflux (RIVUR) study, which will evaluate the role of antibiotic prophylaxis in preventing recurrent UTI and renal scarring in young children with VUR.

SUMMARY

It is advisable that, until the results of more appropriately designed studies become available, UTI in young children is considered as a risk factor for renal scarring and each patient is treated with prudence.

Vesicoureteral reflux, a benign condition

The combination of urinary tract infection (UTI) and vesicoureteral reflux (VUR) is commonly thought to predispose the child to pyelonephritis, renal scarring and, later in life, to hypertension or end-stage renal disease (ESRD). This paradigm has led to the active search, follow-up and treatment of VUR, and also prevention of recurrent UTI in children. The causality of VUR and ESRD is controversial, however. According to recent meta-analyses it is uncertain whether we can prevent renal scarring or ESRD by treating VUR. Studies on VUR are abundant, but the findings and conclusions are confounding. Because of the lack of evidence of the role of VUR, reasonable doubt has recently been presented on the rationale of imaging all children with UTI and treating the children with VUR. The overall importance of VUR is confounded because of the natural tendency of VUR to resolve spontaneously, its dynamic nature, and its different grades in children. The historical studies showing that VUR is much more common, even among healthy children, than usually claimed, have been forgotten. Since it seems that we are referring too many healthy children to unpleasant and possibly unnecessary imaging tests for VUR, we are uncertain when and what kind of VUR-if any-we should treat, and whether our present rationale of addressing VUR truly makes any difference to renal scarring or ESRD in children, we should critically revisit the subject of VUR.

Predictors of renal scar in children with urinary infection and vesicoureteral reflux

We evaluated the predictors of renal scar in children with urinary tract infections (UTIs) having primary vesicoureteral reflux (VUR). Data of patients who were examined by dimercaptosuccinic acid (DMSA) scintigraphy between 1995 and 2005 were evaluated retrospectively. Gender, age, reflux grade, presence/development of scarring, breakthrough UTIs, and resolution of reflux, were recorded. The relation of gender, age and VUR grade to preformed scarring and the relation of gender, age, VUR grade, presence of preformed scarring, number of breakthrough UTIs and reflux resolution to new scarring were assessed. There were 138 patients [male/female (M/F) 53/85]. Multivariate analysis showed that male gender [odds ratio (OR) 2.5], age > or = 27 months in girls (OR 4.2) and grades IV-V reflux (OR 12.4) were independent indicators of renal scarring. On the other hand, only the presence of previous renal scarring was found to be an independent indicator for the development of new renal scar (OR 13.4). In conclusion, while the most predictive variables for the presence of renal scarring among children presenting with a UTI were male gender, age > or = 27 months in girls, and grades IV-V reflux, the best predictor of new scar formation was presence of previous renal scarring.

The current evidence based medical management of vesicoureteral reflux: The Sickkids protocol

Vesicoureteral reflux is a common clinical entity and is one of the keystones of the establishment of pediatric urology as a urological subspeciality. There has been continued evolution in the management of vesicoureteral reflux as new insights are gained on its role in renal damage. The optimal treatment algorithm remains controversial. This review aims to highlight the current literature on VUR and its association with urinary tract infections and renal damage. The protocol of management of a child with VUR followed at The Hospital for Sick Children, Toronto is described.

Interventions for primary vesicoureteric reflux

BACKGROUND

Vesicoureteric reflux (VUR) results in urine passing, in a retrograde manner, up the ureter. Urinary tract infections (UTIs) have been considered the main cause of permanent renal parenchymal damage in children with reflux. Management of these children has been directed at preventing infection by antibiotic prophylaxis and/or surgical correction of reflux. Controversy remains as to the optimum strategies.

OBJECTIVES

To evaluate the benefits and harms of different treatment options for primary VUR.

SEARCH STRATEGY

Randomised controlled trials (RCTs) were identified from the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, reference lists of articles and abstracts from conference proceedings. Date of last search: June 2006

SELECTION CRITERIA

Any treatment of VUR including surgery, antibiotic prophylaxis of any duration, non-invasive techniques and any combination of therapies.

DATA COLLECTION AND ANALYSIS

Two authors independently searched the literature, determined study eligibility, assessed quality, extracted and entered data. For dichotomous outcomes, results were expressed as relative risk (RR) and 95% confidence intervals (CI). Data were pooled using the random effects model.

MAIN RESULTS

Eleven studies (1148 children) were identified. Seven compared correction of VUR (by surgery or endoscope) plus antibiotics for 1-24 months with antibiotics alone, two compared antibiotics with no treatment and two compared different materials for endoscopic correction of VUR. Risk of UTI by 2, 5 and 10 years was not significantly different between surgical and medical groups (2 years RR 1.07, 95% CI 0.32 to 2.09; 5 years RR 0.99, 95% CI 0.79 to 1.26; 10 years RR 1.06, 95% CI 0.78 to 1.44). Combined treatment resulted in a 50% reduction in febrile UTI by 10 years (RR 0.54, 95% CI 0.55 to 0.92) but no concomitant reduction in risk of new or progressive renal damage by 10 years (RR 1.03, 95% CI 0.53 to 2.00). In two small studies no significant differences in risk for UTI (RR 0.75, 95% CI 0.15 to 3.84) or renal damage (RR 1.70, 95% CI 0.36 to 8.07) were found between antibiotic prophylaxis and no treatment.

AUTHORS' CONCLUSIONS

It is uncertain whether the treatment of children with VUR confers clinically important benefit. The additional benefit of surgery over antibiotics alone is small at best. Assuming a UTI rate of 20% for children with VUR on antibiotics for five years, nine reimplantations would be required to prevent one febrile UTI, with no reduction in the number of children developing any UTI or renal damage.

Spontaneous resolution rates of vesicoureteral reflux in Brazilian children: a 30-year experience

OBJECTIVE

We evaluated clinical characteristics of primary vesicoureteral reflux (VUR) in infants in a 30-year period in Brazil with special reference to the relation of renal parenchymal damage to urinary tract infection and gender.

MATERIALS AND METHODS

From 1975 through 2005, 417 girls (81.6%) and 94 boys (18.4%) with all grades of reflux were retrospectively reviewed. Patients were categorized by the worst grade of reflux, maintained on antibiotic prophylaxis and underwent yearly voiding cystourethrography until the reflux was resolved. VUR was considered resolved when a follow-up cystogram demonstrated no reflux. Surgical correction was recommended for those who fail medical therapy, severe renal scarring or persistent VUR.

RESULTS

Grades I to V VUR resolved in 87.5%, 77.6%, 52.8%, 12.2% and 4.3%, respectively. Renal scars were present at presentation in 98 patients (19.2%). Neither gender nor bilaterality versus unilaterality was a helpful predictor of resolution. The significant difference was found among the curves using the log rank (p<0.001) or Wilcoxon (p<0.001) test.

CONCLUSION

Despite the current use of screening prenatal ultrasound, many infants are still diagnosed as having vesicoureteral reflux only after the occurrence of urinary tract infection in our country. Scarring may be associated to any reflux grade and it may be initially diagnosed at any age but half of the scars are noted with higher grades of reflux (IV and V). The incidence of reflux related morbidity in children has significantly diminished over the last three decades.

Medical management of vesicoureteral reflux--quiz within the article. Don't overlook placebos

Vesicoureteral reflux (VUR) in children is associated with increased risk of urinary tract infection (UTI). Recurrent UTI in the presence of the VUR is believed to cause renal scarring, which carries a risk of subsequent hypertension, toxemia of pregnancy, and significant renal damage, including end-stage renal disease. The natural history of VUR is to improve or resolve completely with time in most of the patients. The traditional management consists of prompt treatment of UTI, long-term anti-microbial prophylaxis until the VUR resolves, or surgical intervention in those with persistent high grade VUR, recurrent UTI in spite of prophylaxis with anti-microbial agent, allergy to anti-microbial agents, and patient/parent non-compliance with the medical management. Voiding dysfunction and constipation play an important role, and their diagnosis and appropriate management helps reduce the frequency of UTI and promote the resolution of the VUR. Patients with renal scarring need to be monitored for potential complications such as hypertension, proteinuria, and progression of the renal damage. In patients with hypertension and/or proteinuria, angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) are the drugs of choice, because of their reno-protective properties. Recent studies have revealed that there is no convincing evidence that UTI in the presence of VUR predicts renal injury or that the use of long-term anti-microbial prophylaxis or surgical intervention prevents renal scarring or its progression. However, until proven otherwise by a prospective, placebo-controlled, randomized study, it is advisable to err on the side of caution and consider VUR and UTI risk factors for renal scarring and treat each patient on individual basis.

Meta-analysis of vesicoureteral reflux and urinary tract infection in children

OBJECTIVE

We evaluated the efficacy of medical and surgical treatment of vesicoureteral reflux (VUR) in children by means of a meta-analysis, using the recurrence of urinary tract infections (UTIs), renal growth and renal scarring as endpoints.

MATERIAL AND METHODS

We performed a MEDLINE search for articles published in the English language between 1966 and 2002. Of 639 relevant articles found, 139 were chosen for a close review and the main database was supplemented with some additional articles derived from the references of these reviewed articles. Five studies were found acceptable for a meta-analysis. We reviewed all articles independently. All reviewers had to approve the accepted articles and data that were used in this meta-analysis.

RESULTS

Operative treatment of VUR was better than medical treatment in terms of abolishing reflux (OR = 0.033; 95% CI 0.010-0.107). We found no statistically significant differences between surgically and medically treated patients in terms of kidney growth (OR = 2.46; 95% CI 0.74-8.16), scarring (OR = 1.05; 95% CI 0.71-1.55) or recurrence of UTIs (OR = 0.80; 95% CI 0.49-1.29). We could not evaluate possible differences in the parameters monitored between boys and girls because of a lack of data.

CONCLUSIONS

Although surgical treatment of VUR is a common pediatric urologic procedure, the data relating to it are scanty. We found no clinically significant differences between surgical and medical treatment for VUR other than in the resolution of VUR itself. On the basis of present evidence we suggest that a child with UTI and significant VUR should be treated conservatively at first and that surgical treatment should be reserved for children who experience problems with antimicrobials or persistent clinically significant VUR after several years of follow-up.

Reference Ranges for Cystographic Bladder Capacity in Children—With Special Attention to Vesicoureteral Reflux

PURPOSE

Linear correlations for cystometric/cystographic bladder capacity with age universally serve as clinical yardsticks in pediatric urology and nephrology. However, these correlations do not account for growth or the range in values, as the relation of cystometric/cystographic bladder capacity with age is nonlinear. Also, vesicoureteral reflux might influence the size of cystometric/cystographic bladder capacity, since small and large bladder capacities have been reported in conjunction with reflux. We decided to use the data sets of the International Reflux Study in Children to construct full reference ranges for cystometric/cystographic bladder capacity and age, for comparison with existing reference ranges in normal children, and to study the relation between bladder capacity and refluxing volume.

MATERIALS AND METHODS

In the International Reflux Study in Children 386 patients with grade III or IV vesicoureteral reflux were followed with isotope cystography for 10 years. To follow the grade of reflux, x-ray cystography was also used at 60-month intervals. The 386 children, who were 1 month to 12 years old, were randomized into 2 groups-those undergoing surgery and those receiving medical treatment. For both groups data were available on cystometric/cystographic bladder capacity, refluxing volume, reflux grade and reflux outcome.

RESULTS

The distribution of cystometric/cystographic bladder capacity vs age is logarithmic, with a wide range between the 5th and 95th percentiles, and a clear nonlinear relation between bladder capacity and age (p < 0.001). Gender has no influence on cystometric/cystographic bladder capacity. No difference in bladder capacity exists between persistence or resolution of vesicoureteral reflux (p < 0.78), between grade III and grade IV reflux (p < 0.94), or between unilateral and bilateral reflux (p < 0.74). Thus, refluxing volume correlated only with reflux grade, not with cystometric/cystographic bladder capacity or age.

CONCLUSIONS

With or without vesicoureteral reflux values for cystometric/cystographic bladder capacity range widely in children, and correlate logarithmically with age. For clinical decisions the full reference range for age, flanked by the 5th and 95th percentiles, should be used to assess individual values for cystometric/cystographic bladder capacity, rather than linear functions.

[Evidence-based medicine and vesicoureteral reflux]

Vesicoureteral reflux (VUR) remains one of the most controversial subjects in paediatric urology. Much literature has been published on VUR, making the understanding of this anomaly and its treatments quite opaque. Evidence-Based Medicine (EBM) should be helpful to clarify the various VUR approaches contained in the 6224 titles found on Medline using the keywords "vesicoureteral reflux" and "vesicoureteric reflux". These articles were critically reviewed and graded according to EBM scorings, with regard to their methodological designs. This review of VUR literature suggests that most of our knowledge is based on publications with a low level of evidence, and that EBM lacks arguments to support recommendations for VUR diagnostic and treatment. It appears yet that antenatal dilatation of the urinary tract and symptomatic urinary tract infections (UTI) justify VUR screening. Surgery should be discussed in recurrent UTIs or deterioration of renal function. There is no consensus in case of persistent asymptomatic VUR regarding indication and duration of antibio-prophylaxis, and selection of radical treatment.

Vesicoureteric reflux and urinary tract infection in children

An association between vesicoureteric reflux (VUR) and renal damage was found in 1960. In 1973, the term reflux nephropathy (RN) was first used to describe the renal damage caused by VUR. Follow up studies show that about 10%-20% of children with RN develop hypertension or end stage renal disease. It is now evident that there is a sex difference in the development of RN. In most males with RN, the kidneys are congenitally abnormal. In females it is an acquired condition, the most severe damage being sustained by recurrent urinary tract infections (UTIs). The purpose of current UTI guidelines is to identify VUR or any other abnormality of the urinary tract. Since the advent of routine antenatal ultrasonography, there is no longer a need to identify an abnormality of the urinary tract after the first reported UTI. Routine investigations are not required. Recurrent UTIs and a family history of VUR need further evaluation. There is also an urgent need to establish the long term value of prophylactic antibiotics in children with VUR.

Predictive factors of resolution of primary vesico-ureteric reflux: a multivariate analysis

OBJECTIVE

To identify independent factors predicting the resolution of primary vesico-ureteric reflux (VUR) in a cohort of medically managed children.

PATIENTS AND METHODS

Between 1977 and 2003, 506 children were diagnosed with VUR and were conservatively managed and prospectively followed. All of the children were maintained on antibiotic prophylaxis. Follow-up imaging consisted of voiding cysto-urethrography (VCUG) or a direct isotope cystogram at intervals of 2-3 years. The predictive factors used are based on the patient data at the time of entry in the protocol. The dependent variable was VUR resolution. The criterion for resolution was based on a single negative VCUG or direct isotope cystogram. A survival analysis identified variables significantly associated with VUR resolution. Cox's regression model was applied to identify variables independently associated with the dependent variable.

RESULTS

After adjustment, four variables remained as independent predictors of VUR resolution: nonwhite race, relative risk (95% confidence interval) of 1.5 (1.1-1.9; P = 0.009); mild grade of VUR, 3.3 (2.1-5.3; P < 0.001); absence of renal damage, 3.3 (2.4-4.5; P < 0.001); and absence of dysfunctional voiding, 2.0 (1.4-3.1; P < 0.001). For mild VUR, three variables were significantly associated: male gender, 1.7 (1.1-2.6; P = 0.012); absence of renal damage, 3.4 (1.8-6.4; P < 0.001); and unilateral VUR, 1.6 (1.1-2.3; P = 0.004). For moderate/severe VUR, three variables were significantly associated: nonwhite race, 1.7 (1.1-2.6; P = 0.01); absence of renal damage, 3.0 (2.0-4.4; P < 0.001); and absence of dysfunctional voiding, 2.8 (1.4-5.5; P = 0.004).

CONCLUSION

Few factors are amenable to intervention to modify the natural history of VUR. According to our findings, there are only two possible interventions: avoiding renal scars and managing voiding dysfunction.

Ten-year results of randomized treatment of children with severe vesicoureteral reflux. Final report of the International Reflux Study in Children

For the comparison of long-term outcome of the management of medical or surgical treatment of children with severe vesicoureteral reflux (VUR), children aged <11 years with non-obstructive grade III/IV reflux, previous urinary tract infection (UTI) and glomerular filtration rate (GFR) >or=70 ml/min per 1.73 m2 body surface area were recruited, and 306 were randomly allocated to receive antimicrobial prophylaxis or ureteral reimplantation. Primary endpoints were new renal scars and renal growth. Follow up, originally planned for 5 years, was extended to 10 years for 252 children, 223 of whom had follow-up imaging. Up to 5 years, 40 new urographic scars (medical 19, surgical 21) were seen. Between 5 years and 10 years, only two further scars were observed. Renal growth and UTI recurrence rate were similar, except that medically treated patients had more febrile infections. There was no difference in somatic growth, radionuclide imaging or renal function. A GFR <70 ml/min per 1.73 m2 was found in only one patient. Three patients developed hypertension requiring treatment. We conclude that, with close supervision and prompt treatment of recurrences, children entering the study with GFR >or=70 ml/min per 1.73 m2 progressed remarkably well under either medical or surgical management, emphasizing the importance of continued supervision and the entry level of renal function.

Vesicoureteral reflux

Vesicoureteral reflux, the abnormal flow of urine from the bladder into the ureter, is one of the most common congenital anomalies found in children. The association of vesicoureteral reflux with urinary tract infections and renal scarring has important clinical implications. New insights into pathogenesis and new surgical techniques are changing the approach to the management of this disorder.

Permanent renal parenchymal defects after febrile UTI are closely associated with vesicoureteric reflux

The finding of scintigraphic renal defects in children with febrile urinary tract infection (UTI) even in the absence of vesicoureteric reflux (VUR) has led to the conclusion that VUR is a weak predictor of renal defects in these patients. We used isotopic cystography (IC) for diagnosis of VUR in children with febrile UTI. Dimercaptosuccinic acid renal scintigraphy was performed 6 months after cure of the last UTI. Renal defects were defined by the finding of focal defects of radionuclide uptake and/or by a split renal function <43%. The study included 206 children with primary VUR and 77 without VUR. Among the subjects with and without VUR, respectively, renal defects were found in 40 and 6% (p=0.0001), focal uptake defects in 33 and 5% (p=0.0001) and split renal function <43% in 26 and 5% (p=0.0001). Permanent renal defects in children with febrile UTI are closely associated with VUR. The possibility that a child will have permanent renal defects can reasonably be ruled out on the basis of the absence of VUR by IC.

[Vesicorenal reflux]

For vesicorenal reflux an incidence of 16 to 17% is described. In 85% girls are affected except in the antenately detected reflux. Ascending infections are the pathomechanism. A reflux can be diagnosed in up to 70% of children with febrile urinary tract infection. The probability of spontaneous maturation is highest in low grade and unilateral reflux as well as during the first year of life. During time to maturation antibiotic prophylaxis can avoid urinary tract infections (conservative treatment). Break-through infections, high grade reflux, loss of kidney function, associated malformations and bad patients compliance represent indications for operative reflux repair. Surgery should more often be considered in girls (higher risk for urinary tract infections, pregnancy). Success rates of reflux surgery are high (>90%). Endoscopy is quoted to be an alternative, however, success rates are lower and long-term results of the new substances are still lacking.

[Primary vesicoureteral reflux treatment in childhood: comparsion of two systematic review]

Many medical practices are being carried out unawares of their efficiency, or of their actual impact on the health of the patients, therefore it is necessary to consider the support of professional recommendations with scientific evidence.

THE PRIMARY OBJECTIVE

To perform a systematic review (SR) of the therapeutic management of primary VUR in pediatric urology.

MATERIAL AND METHODS

A systematic review has been performed, including scientific evidence-based medicine criteria, of the articles published in all of the available databases. Inclusion criteria concerning basic quality of the articles were considered essential, as well as exclusion criteria to be able to reject the articles.

RESULTS AND DISCUSSION

Subsequently, and following the critic reading of greater than 320 articles, statistical study of the grouped data was performed according to the type of treatment and to the benefits contributed by each treatment, and also to their undesirable effects. Finally we have made a comparison between our results and recent Cochrane Systematic Review. The following Conclusions were drawn from the results obtained and from the analysis of the texts. Both medical and surgical treatment present with similar effectiveness concerning resolution of grades I, II and III of VUR, and the former one is the recommended initial treatment following diagnosis. Endoscopic treatment is exactly as effective as open surgery for grades I, II and III with fewer undesirable effects secondary. There are no differences concerning the efficacy of the different injected substances. Not enough evidences exist for degrees IV and V that may recommend or advise against any of the treatments. In any degree of VUR, open surgical treatment is superior as far as medical treatment is concerned only regarding the number of acute pyelonephritis episodes during followup. This conclusion cannot be applied on endoscopic treatment.

Timing of follow-up voiding cystourethrogram in children with primary vesicoureteral reflux: development and application of a clinical algorithm

BACKGROUND AND OBJECTIVES

Of children diagnosed with urinary tract infection, 30% to 40% have primary vesicoureteral reflux (VUR). For the majority of these children, treatment involves long-term prophylactic antibiotics (ABX) and a periodic voiding cystourethrogram (VCUG) until resolution of VUR as detected by VCUG. Radiation exposure and considerable discomfort have been associated with VCUG. To date, no clear guidelines exist regarding the timing of follow-up VCUGs. The objective of this study was to develop a clinically applicable algorithm for the optimal timing of repeat VCUGs and validate this algorithm in a retrospective cohort of children with VUR.

METHODS

Based on previously published data regarding the probability of resolution of VUR over time, a decision-tree model (DTM) was developed. The DTM compared the differential impact of 3 timing schedules of VCUGs (yearly, every 2 years, and every 3 years) on the average numbers of VCUGs performed, years of ABX exposure, and overall costs. Based on the DTM, an algorithm optimizing the timing of VCUG was developed. The algorithm then was validated in a retrospective cohort of patients at an urban pediatric referral center. Data were extracted from the medical records regarding number of VCUGs, time of ABX prophylaxis, and complications associated with either. VUR in patients in the cohort was grouped into mild VUR (grades I and II and unilateral grade III for those < or =2 years old), and moderate/severe VUR (other grade III and grade IV). Kaplan-Meier survival curves were created from the cohort data. From the survival curves, the median times to resolution of VUR were determined for the cohort, and these times were compared with the median times to VUR resolution of the data used for the DTM. The numbers of VCUGs performed, time of ABX exposure, and costs in the cohort were compared with those that would have occurred if the algorithm had been applied to both mild and moderate/severe VUR groups.

RESULTS

Using an algorithm that results in a recommendation of VCUGs every 2 years in mild VUR would reduce the average number of VCUGs by 42% and costs by 33%, with an increase in ABX exposure of 16%, compared with a schedule of yearly VCUGs. For moderate/severe VUR, a VCUG performed every 3 years would reduce the average number of VCUGs by 63% and costs by 51%, with an increase in ABX exposure of 10%. Applying this algorithm to the retrospective cohort consisting of 76 patients (between 1 month and 10 years old) with primary VUR would have reduced overall VCUGs by 19% and costs by 6%, with an increase in ABX exposure of 26%. The patterns of VUR resolution, age distribution, and prevalence of severity of VUR were comparable between previously published results and the retrospective cohort.

CONCLUSIONS

Delaying the schedule of VCUG from yearly to every 2 years in children with mild VUR and every 3 years in children with moderate/severe VUR yields substantial reductions in the average numbers of VCUGs and costs, with a modest subsequent increase in ABX exposure.