Treatment of vesicoureteric reflux. Preliminary report of a prospective study

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.

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.

[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.

Dysfunctional voiding syndromes and vesicoureteral reflux

Micturition disorders simulating neurogenic bladder disease have been loosely termed "dysfunctional voiding". No underlying neuropathy can be found. A variety of voiding disturbances have been identified since the early 1970s, each with its own characteristics and clinical relevance. We have classified voiding dysfunctions into mild, moderate and severe, according to their potential impact on the upper tracts. Bladder instability, the Hinman syndrome and the Ochoa syndrome are the only dysfunctional voiding syndromes that are associated with reflux or ureterovesical obstruction. Each syndrome is briefly described.

Prevalence of hypertension in children with primary vesicoureteral reflux

This study was undertaken to determine the prevalence of hypertension in children with primary, uncomplicated vesicoureteral reflux (VUR) and to evaluate the relationship between blood pressure (BP), grade and duration of reflux, and renal scarring. Subjects were identified retrospectively during a 17-year period; of 146 subjects who agreed to participate, 129 (88.4%) were female. Mean age at diagnosis was 5.0 years (range, 1 month to 16 years), and at follow-up was 14.4 years (range, 5 months to 21 years). Mean duration of follow-up was 9.6 years. Renal scarring was detected in 34.3% of patients by intravenous pyelogram, ultrasonography, or both. The BP at diagnosis was linearly related to the grade of reflux, but values were not higher than expected norms for age. At follow-up, mean systolic and diastolic BP were at the 41.6 percentile and the 18.7 percentile, respectively. No patient's BP was above the 55th percentile. After a mean follow-up period of 10 years, we conclude that primary, uncomplicated VUR, regardless of the number of documented urinary tract infections, duration and severity of reflux, modality of therapy, presence of renal scarring, and duration of follow-up, is not associated with the development of hypertension. Hypertension does not appear to be a complication of VUR and urinary tract infection unless there is preexisting dysplasia.

Treatment of vesicoureteric reflux. Results of a prospective study

Between 1982 and 1986, 96 children with non-obstructive vesicoureteric reflux were included in a prospective study. Three patients withdrew from the study and results are therefore presented on 93 children with 135 refluxing ureters who were followed up for at least 5 years. Initially, all children with reflux grade III or less received antibiotic treatment only. Those with reflux grade IV were randomised to antibiotic treatment alone versus surgery plus antibiotic treatment; the primary treatment of reflux grade V was reimplantation. In 85 ureters treated by antibiotics only, reflux disappeared in 64 cases and was reduced in 12. In 50 ureters treated by reimplantation, reflux was cured in 46 cases and no severe ureteric obstruction was seen. Conservative management of reflux grade IV was less successful than surgery. The results of conservative, non-surgical treatment of reflux grades I-III were satisfactory, but for grades IV and V surgery should be the treatment of choice if detrusor instability has been excluded.

Surgical results in the International Reflux Study in Children (Europe)

In the European part of the International Reflux Study in Children (7 participating centers) 151 infants and children were randomly allocated to surgical treatment of primary grades III and IV vesicoureteral reflux. Reimplantation was performed unilaterally in 65 patients and bilaterally in 86, for a total of 237 ureters reimplanted. The patients were followed at regular intervals for 5 years. Reflux was absent in 231 of the reimplanted ureters (97.5%) at the end of 5 years. No patient underwent reoperation for reflux. In 10 ureters (4.2%, 10 patients) obstruction developed postoperatively and 7 needed reoperation. All reoperations were performed on the left side. Of the obstructed kidneys new scars developed in 6 during the 5-year followup. Including these cases, the number of new renal scars was equal in the surgical and medical groups (20 each). The number of pyelonephritic episodes during followup was significantly less in the surgical group (without chemoprophylaxis) than in the medical group (on chemoprophylaxis). No kidneys were lost and no child became hypertensive. If voiding cystourethrography and excretory urography were normal 6 months postoperatively, the reflux had been permanently eradicated and postoperative obstruction could be ruled out. In this study the patients who underwent reimplantation had a 74% (112 of 151) chance of an uncomplicated postoperative course (no persisting reflux, obstruction, pyelonephritis or severe renal damage).

Methodologic limitations in the literature on vesicoureteral reflux: a critical review

We analyzed studies concerned with four important aspects of vesicoureteral reflux in infancy and childhood: the imaging procedures for the evaluation of vesicoureteral reflux, the treatment of reflux, and the correlation between reflux and later development of hypertension and end-stage kidney disease. The objectives of the study were to evaluate the validity and reliability of the current literature, to draw conclusions, and to recommend future studies for unresolved issues. We reached the following conclusions: (1) Retrograde cystography should be the gold standard for diagnosing vesicoureteral reflux. When ultrasonography and cystography are performed together, all clinically important abnormalities in the urinary system are detected. Intravenous pyelography is needed only when either or both of these studies are abnormal. (2) Other than abolishing reflux, surgery offers no short-term advantages (in terms of preventing breakthrough urinary tract infections, improving renal function, or preventing the development of new scars, hypertension, or end-stage kidney disease) over medical management. (3) The short periods of follow-up and methodologic flaws encountered in the reviewed studies make determination of the incidence of hypertension in children with vesicoureteral reflux impossible. (4) Although indications for an association between vesicoureteral reflux and end-stage kidney disease exist, the strength of this association has not been determined.

High grade vesicoureteral reflux: analysis of observational therapy

Between 1981 and 1987, 300 patients with high grade (III, IV and V international classification) vesicoureteral reflux were treated at a single pediatric hospital. Only patients with primary vesicoureteral reflux were included in the study. The guiding principle during this period was that all patients with high grade vesicoureteral reflux would be observed on prophylactic antibiotics (observational therapy) and surgical correction would be reserved for specific indications. Of the 300 patients 132 received observational therapy alone and 168 required surgical correction for specific indications after varying periods of observation. In both groups the duration of persistent reflux was analyzed using a life-table method. In patients with grade V reflux we observed resolution in 3 patients whereas 23 required surgical correction. Of those patients in the observation group with grade IV reflux 83% had persistent reflux at 2 years and 70% still had reflux at 5 years. For those with grade III reflux the persistence rate was 83% and 50%, respectively. Neither age, sex nor side of reflux had a correlation with the rate of resolution. When tested grade of reflux correlated loosely (p = 0.07). During the period of observational therapy new renal scars developed in 23 patients (8%). We conclude that high grade vesicoureteral reflux can resolve in a minority of patients over a protracted interval. On the basis of this analysis, we advocate consideration of surgical correction in these patients after a 4-year period of observational therapy and for specific indications.

The role of videourodynamic studies in diagnosis and treatment of vesicoureteral reflux

From January 1986 to January 1988, 63 children with 95 refluxing ureters have been studied in a prospective study with videourodynamic examination. All children with reflux grades I, II, and III received antibacterial treatment. Surgical treatment was adopted for reflux grades IV and V, provided detrusor instability had been excluded. However, if there was detrusor instability, anticholinergic drugs and antibacterial treatment were given in all grades of reflux and videourodynamic examination was repeated after 3 to 6 months and after 12 months of therapy. Bilateral reflux was found in 22 of 38 patients with a stable bladder, and reimplantation was performed in 11 patients with 18 refluxing ureters. In 25 children with 35 refluxing ureters of various grades of reflux, detrusor instability was found and unilateral reflux was noted more frequently than bilateral reflux. Surgery was necessary for only five children, because in the majority of the patients detrusor instability and reflux could be treated by anticholinergic drugs and antibacterial treatment. For the decision as to which treatment should be given in vesicoureteral reflux, a videourodynamic study is mandatory.

Results of surgical treatment of severe vesicoureteric reflux. Retrospective study of reflux grades 4 and 5

A series of 80 children underwent surgery in the Sophia Children's Hospital for gross reflux grades 4 and 5. In this retrospective study the success rate for ureteric reimplantation was 90%. Analysis of growth showed that after surgery the children tended to fall within the normal ranges for height and weight. Deterioration in renal function was progressive in 3 children. New renal scars developed in 13% of renal units. Initially non-refluxing kidneys showed no further deterioration. Moderate hypertension was found in only 4 patients.