Renal growth in children with severe vesicoureteral reflux: 10-year prospective study of medical and surgical treatment: the International Reflux Study in Children (European branch)

Long term outcomes of Cohen’s cross trigonal reimplantation for primary vesicoureteral reflux in poorly functioning kidney

BACKGROUND

Open ureteric reimplantation by cross trigonal technique described by Cohen is considered a common surgical option for correction of vesicoureteral reflux (VUR). There is a lack of evidence in literature though for what happens to such kidneys, in the long run, particularly those which are poorly functioning.

AIM

To assess the long-term outcomes of ureteric reimplantation in poorly functioning kidneys in children with unilateral primary VUR.

METHODS

Children with unilateral primary VUR and a relative renal function of less than 35% who underwent open or laparoscopic ureteric reimplantation between January 2005 and January 2017 were included in the study. Patients who had a follow up of less than five years were excluded. Preoperative evaluation consisted of a voiding cystourethrogram and Dimercaptosuccinic acid (DMSA) scan. In the follow-up period, patients underwent a diuretic scan at 6 weeks and 6 months. Follow up ultrasound was done for change in grade of hydronephrosis and retrovesical ureteric diameter. Subsequent follow up was done at 6 monthly intervals with evaluation for proteinuria and hypertension and any recurrent urinary tract infection (UTI). For assessment of cortical function, DMSA was repeated annually for 5 years after surgery. A paired-samples t-test was used to test the mean difference of DMSA between pre-post observations.

RESULTS

During this period, 36 children underwent ureteric reimplantation for unilateral primary VUR. After excluding those with insufficient follow-up, 31 were included in the analysis. Most of the patients were males (n = 26/31, 83.8%). Patient’s age (mean ± SD, range) was 5.21 ± 3.71, 1-18 years. The grades of VUR were grade II (1 patient), grade III (8 patients), grade IV (10 patients), and grade V (12 patients). The pre and postoperative DMSA was 24.064 ± 12.02 and 24.06 ± 10.93, which was almost the same (statistically equal, paired-samples t-test: P = 0.873). The median (range) follow-up duration was 82 (60-120) mo. One patient had persistent reflux after surgery (preoperative: grade IV, postoperative: grade III), and the very same patient developed recurrent UTI. The difference in the preoperative and postoperative DRF was less than 10% in 29 patients. In one patient, the DRF decreased by 17% (22% to 05%) while in another patient, the DRF increased by 12% (25% to 37%) after surgery. None of the patients had an increase in scarring after surgery. 15% of patients were hypertensive before surgery and all of them continued to be hypertensive after surgery while none developed hypertension after surgery. None of the patients had significant proteinuria (> 150 mg/d) during the follow-up period.

CONCLUSION

Children with unilateral primary VUR and poorly functioning kidney maintain the renal function over the long term in most cases. Hypertension and proteinuria do not progress over time in these patients.

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.

Recurrent urinary tract infections in children: Preventive interventions other than prophylactic antibiotics

Urinary tract infection (UTI) is one of the most common childhood infections. Permanent renal cortical scarring may occur in affected children, especially with recurrent UTIs, leading to long-term complications such as hypertension and chronic renal failure. To prevent such damage, several interventions to prevent UTI recurrences have been tried. The most established and accepted prevention at present is low dose long-term antibiotic prophylaxis. However it has a risk of break through infections, adverse drug reactions and also the risk of developing antibiotic resistance. The search is therefore on-going to find a safer, effective and acceptable alternative. A recent meta-analysis did not support routine circumcision for normal boys with no risk factors. Vaccinium Macrocarpon (cranberry), commonly used against UTI in adult women, is also effective in reducing the number of recurrences and related antimicrobial use in children. Sodium pentosanpolysulfate, which prevents bacterial adherence to the uroepithelial cells in animal models, has shown conflicting results in human trials. When combined with antibiotic, Lactobacillus acidophilus (LA-5) and Bifidobacterium, by blocking the in vitro attachment of uropathogenic bacteria to uroepithelial cells, significantly reduce in the incidence of febrile UTIs. Deliberate colonization of the human urinary tract of patients with recurrent UTI with Escherichia-coli (E. coli) 83972 has resulted in subjective benefit and less UTI requiring treatment. The non-pathogenic E. coli isolate NU14 DeltawaaL is a candidate to develop live-attenuated vaccine for the treatment and prevention of acute and recurrent UTI. Diagnosing and treating dysfunctional elimination syndromes decrease the incidence of recurrent UTI. A meta-analysis found the lack of robust prospective randomized controlled trials limited the strength of the established guidelines for surgical management of vesicoureteral reflux. In conclusion, several interventions, other than antibiotic prophylaxis, for the prevention of recurrent UTI have been tried and, although showing some promise, they do not provide so far a definitive effective answer. Finding suitable alternatives still requires further high quality research of those seemingly promising interventions.

Controversy in urinary tract infection management in children: a review of new data and subsequent changes in guidelines

Controversy and lack of consensus have been encountered in the management of pediatric urinary tract infection (UTI), including its diagnosis, radiological investigations and the use of antibiotic therapy. In this review, we discuss the need for radiological investigations and the extent of their use as well as the need for prophylactic antibiotics in children with UTI and vesicoureteral reflux. Only a small proportion of children with first UTI and no history of antenatal renal abnormalities have clinically important malformations. Renal ultrasound should be performed in febrile infants and young children with UTI; a micturating cystourethrogram should not be performed routinely after the first febrile UTI. Long-term antibiotics appear to reduce the risk of recurrent symptomatic UTI in susceptible children, although the clinical benefit is marginal. Current recommendations encourage performing radiological investigations only in children at risk and discourage routine prophylactic antibiotic use.

A single-center cohort of Canadian children with VUR reveals renal phenotypes important for genetic studies

BACKGROUND

Many genes and loci have been reported in genetic studies of primary vesicoureteral reflux (VUR), but few have been reproduced in independent cohorts, perhaps because of phenotype heterogeneity. We phenotyped children with VUR who attended urology clinics so we could establish criteria to stratify patients based on the presence or absence of a renal malformation.

METHODS

History, chart review, and DNA were obtained for 200 children with VUR from 189 families to determine the grade of VUR, the mode of presentation, and the family history for each child. Kidney length measured on ultrasound (US) and technetium dimercaptosuccinic acid (DMSA) scans at the time of VUR diagnosis were used to establish the presence of a concurrent renal malformation and identify the presence of renal scarring.

RESULTS

There was an even distribution of girls and boys, and most patients were diagnosed following a urinary tract infection (UTI). Thirty-four percent of the children had severe VUR, and 25 % had undergone surgical correction. VUR is highly heritable, with 15 % of the families reporting multiple affected members. Most patients had normally formed kidneys as determined by US and DMSA imaging. Of the 93 patients who underwent DMSA imaging, 17 (18 %) showed scarring, 2 (2 %) showed scarring and diffuse reduction in uptake, and 13 (14 %) showed an isolated diffuse reduction in uptake.

CONCLUSION

Prospective long-term studies of patients with primary VUR combined with renal phenotyping using US and DMSA imaging are needed to establish the presence of a renal malformation. The majority of patients in our study had no renal malformation. This cohort is a new resource for genetic studies of children with primary VUR.

Patients with a history of infection and voiding dysfunction are at risk for recurrence after successful endoscopic treatment of vesico ureteral reflux and deserve long-term follow up

Aim of the Study:

Subureteral endoscopic injection of a bulking agent is an attractive alternative to open surgery or antibiotic prophylaxis for vesico ureteral reflux (VUR). Little information is available about long-term risk of recurrence after an initially successful treatment. Aim of this paper was to review short- and long-term success rate of endoscopic treatment in a single Center series after risk stratification of individual patients.

Materials and Methods:

The records of 126 patients who underwent Deflux injection for primary VUR were examined. Indications to treatment were an unvaried high grade VUR (IV-V) at 1 year from diagnosis and/or and recurrent urinary tract infection (UTI) on antibiotic prophylaxis even in the presence of mild grade VUR (III grade). Gender, age and mode of diagnosis, infections (UTI), voiding dysfunctions, VUR grade and side, renal function, number of treatments were correlated to outcome. Long-term evaluation was planned at a minimum of 1 year from the last negative post-injection cystogram (MCUG). A new MCUG and DMSA scan were also offered to those complaining new UTI episodes. Late recurrences were correlated to history and grade of reflux. Data were analyzed with Graph Pad Instat software; the Chi-square test was used for univariate comparisons, the Fisher's exact test for categorical variables.and multiple regression tests for factors influencing outcome.

Results:

M/F ratio was 62 to 64; median age at diagnosis was 28 months. VUR affected 198 renal units. Preinjection VUR grade was I in 1, II in 27, III in 107, IV in 59, and V in 4 units. Reduced DMSA uptake was evidenced in 51 units and scarring in 24. Median age at treatment was 34.5 months, for persistent high grade VUR (IV–V) in 55 patients and recurrent IVU in 92. Two hundred sixty seven injections were performed on 198 ureters. Complete resolution was documented by MCUG at 3-5 months in 68%, low grading < II in 20%, persistence or unsignificant reduction in 11%. Preoperative recurrent UTI, higher grade VUR, and bilaterality were correlated to a poorer surgical outcome. Among 80 successfully treated cases, 12 complained of persistent UTI. Recurrence of VUR was demonstrated in 31% of them. Deteriorated uptake or additional scarring in 25% was independent from VUR recurrence. Preoperative recurrent UTI and voiding dysfunction correlated significantly to late outcome.

Conclusions:

Preoperative recurrent IVU, together with high-grade reflux, seem to correlate to lower success rate of Deflux injection for primary VUR. Even after successful endoscopic treatment, long-term surveillance may be needed among these cases, mainly if voiding dysfunction is also recorded. Late recurring VUR must be actively excluded in case of new IVU episodes.

Vesicoureteral reflux and reflux nephropathy

Primary vesicoureteral reflux (VUR) is the commonest congenital urological abnormality in children, which has been associated with an increased risk of urinary tract infection (UTI) and renal scarring, also called reflux nephropathy (RN). In children, RN is diagnosed mostly after UTI (acquired RN) or during follow-up for antenatally diagnosed hydronephrosis with no prior UTI (congenital RN). The acquired RN is more common in female children, whereas the congenital RN is more common in male children. This observation in children might help explain the differences in the clinical presentation of RN in adults, with males presenting mostly with hypertension, proteinuria, and progressive renal failure as compared with females who present mostly with recurrent UTI and have a better outcome. Known risk factors for RN include the severity of VUR, recurrent UTI, and bladder-bowel dysfunction; younger age and delay in treatment of UTI are believed to be other risk factors. Management of VUR is controversial and includes antimicrobial prophylaxis, surgical intervention, or surveillance only. No evidence-based guidelines exist for appropriate follow-up of patients with RN.

Technical report—Diagnosis and management of an initial UTI in febrile infants and young children

OBJECTIVES

The diagnosis and management of urinary tract infections (UTIs) in young children are clinically challenging. This report was developed to inform the revised, evidence-based, clinical guideline regarding the diagnosis and management of initial UTIs in febrile infants and young children, 2 to 24 months of age, from the American Academy of Pediatrics Subcommittee on Urinary Tract Infection.

METHODS

The conceptual model presented in the 1999 technical report was updated after a comprehensive review of published literature. Studies with potentially new information or with evidence that reinforced the 1999 technical report were retained. Meta-analyses on the effectiveness of antimicrobial prophylaxis to prevent recurrent UTI were performed.

RESULTS

Review of recent literature revealed new evidence in the following areas. Certain clinical findings and new urinalysis methods can help clinicians identify febrile children at very low risk of UTI. Oral antimicrobial therapy is as effective as parenteral therapy in treating UTI. Data from published, randomized controlled trials do not support antimicrobial prophylaxis to prevent febrile UTI when vesicoureteral reflux is found through voiding cystourethrography. Ultrasonography of the urinary tract after the first UTI has poor sensitivity. Early antimicrobial treatment may decrease the risk of renal damage from UTI.

CONCLUSIONS

Recent literature agrees with most of the evidence presented in the 1999 technical report, but meta-analyses of data from recent, randomized controlled trials do not support antimicrobial prophylaxis to prevent febrile UTI. This finding argues against voiding cystourethrography after the first UTI.

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.

Congenital urological anomalies diagnosed in adulthood - management considerations

OBJECTIVE

Despite worldwide availability of prenatal ultrasound, many patients are diagnosed in adult life with congenital anomalies such as ureteropelvic junction obstruction (UPJO), undescended testicle (UDT), ureterocele, hypospadias, vesicoureteral reflux (VUR) and primary obstructing megaureter (POM). The aim of this review was to describe these clinical conditions and their suggested management based on the available medical literature.

REVIEW

Adult UPJO is not a rare condition; symptomatic patients should be treated rather than observed. Treatment options are nephrectomy for non-functioning kidneys and reconstructive surgery for functioning renal units. The adult UDT has low fertility potential and increased cancer risk; hence most of the data in the literature indicate performing an orchiectomy. Adult ureteroceles are usually related to single systems and they are intravesical and less obstructive. For symptomatic patients endoscopic incision showed high efficacy for symptom elimination with minimal side effects. Primary hypospadias correction in the adult patient is feasible, but success rates are low compared to the pediatric age group. Secondary correction, whether primary correction was performed in childhood or adulthood, is a challenging task with a high complication rate. Treatment decisions regarding adult patients with VUR are difficult to make as the available data are inconsistent; there is no strict evidence that reflux in an adult is directly related to renal growth impairment, ascending pyelonephritis, and/or embryo loss in a pregnant woman. In contrast to the pediatric age group, adult POM is usually a symptomatic condition and related to a high complication rate including infections, stone formation and renal failure. Spontaneous resolution is rare and hence active surgical management is advocated.

CONCLUSION

Congenital urological anomalies identified in adulthood are not rare and pose a management challenge to the urologist. For most of the reviewed diseases, evidence-based management direction is difficult due to a lack of randomized trials and long-term follow up.

Imaging and treatment strategies for children after first urinary tract infection

PURPOSE OF REVIEW

To highlight recent controversies regarding the rationale and effectiveness of imaging and treatment strategies for children who experience a first urinary tract infection.

RECENT FINDINGS

The yield of renal ultrasound for children who have had a first urinary tract infection is relatively low, and the most commonly identified abnormalities are of unclear clinical significance. If concerned about renal ultrasound abnormalities, clinicians should not be reassured by a normal late trimester prenatal ultrasound because its negative predictive value is not sufficiently high. Vesicoureteral reflux is neither necessary nor sufficient for developing renal scars. Some pyelonephritis and renal scarring may be related to vesicoureteral reflux that is missed by standard voiding cystourethrogram but detectable during positional instillation of contrast cystography. Dimercaptosuccinic acid scans provide important information about presence of pyelonephritis and renal scars, and have high negative predictive value for ruling out high-grade (III-V) vesicoureteral reflux. Antimicrobial prophylaxis may not be effective for preventing recurrent infections and may result in antimicrobial resistance. Endoscopic therapy (Deflux) has demonstrated moderate success in correcting vesicoureteral reflux, but little is known about its impact on recurrent infection and renal scarring.

SUMMARY

Debate continues about optimal imaging strategies after first urinary tract infection. More research is needed on the effectiveness of interventions designed to prevent recurrent infections and renal scarring.

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.

Long-term evolution of renal damage associated with unilateral vesicoureteral reflux

PURPOSE

We determined the long-term evolution of renal damage associated with vesicoureteral reflux.

MATERIALS AND METHODS

We retrospectively selected 74 consecutive children with unilateral primary vesicoureteral reflux, ipsilateral renal differential uptake less than 45% at dimercapto-succinic acid scintigraphy performed 4 to 6 months after urinary tract infection (60 patients) or shortly after diagnosis of vesicoureteral reflux investigated for prenatal hydronephrosis (14), and normal ultrasound and scintigraphic imaging of the contralateral nonrefluxing kidney. Average patient age at diagnosis was 3 years. The outcome was assessed via dimercapto-succinic acid scan at 5 to 24 years (mean 8.9).

RESULTS

In 65 patients (88%) variations of less than 5% in differential uptake were recorded. Three patients (4%) showed an increase of greater than 5% in differential uptake of the refluxing kidney. Six patients (8%) demonstrated a decrease of greater than 5%, of whom 3 had 1 and 3 had no febrile urinary tract infection during followup. A total of 18 patients had a differential uptake of 35% to 45% at the first visit, of whom 3 exhibited a decrease of 5.2% to 27% in differential uptake and had no history of febrile urinary tract infection.

CONCLUSIONS

In most cases differential uptake of the unilaterally refluxing affected kidney remains stable from early childhood to puberty despite the increase in body mass, which necessitates increasing renal work. In some patients a significant decrease in differential uptake may be observed even in the absence of recurrent febrile urinary tract infections. A mild decrease in differential uptake (35% to 45%) at diagnosis does not exclude the possibility of a subsequent significant decrease, even in the absence of febrile urinary tract infection.

[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.

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.

A MULTIVARIABLE ASSESSMENT OF RENAL SIZE AND GROWTH OF SCARRED KIDNEYS IN CHILDREN

PURPOSE

We applied a recently developed multivariable renal size nomogram to sonographic measurements of kidneys with known scarring to assess systematically their sizes and growth patterns compared to normal kidneys.

MATERIALS AND METHODS

We retrospectively reviewed renal sonograms of 138 kidneys (55 right and 83 left) with known scarring. The sizes of these scarred kidneys were compared to the 95% prediction limits calculated according to the multivariable renal size nomogram, adjusting for patient age, gender, race, weight and height. The growth of scarred kidneys was evaluated by fitting individual linear regression lines using serial sonographic measurements and comparing the results with normal predicted values.

RESULTS

The sizes of 89.1% of the right and 81.9% of the left scarred kidneys were within the 95% normal prediction limits. Only 17 of 138 of the scarred renal units showed smaller kidney sizes compared to the normal prediction limits. Serial sonographic measurements revealed that compared to normal predicted values, 24 of 60 left and 16 of 38 right scarred kidneys grew within +/- 1.0% annually of the boundaries of normal predicted values. Additionally, 8 left and 7 right scarred kidneys indicated a growth rate of more than 1% annually higher than the normal predicted values.

CONCLUSIONS

Multivariable analyses of renal sonographic measurements provided a dynamic picture of kidney well-being in children with renal scarring. We found that the majority of scarred kidneys were within the normal predicted limits, and a large proportion of these kidneys grew equally well compared to those with normal anatomy.

[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.

Effect of ureteral reimplantation on prevention of urinary tract infection and renal growth in infants with primary vesicoureteral reflux

AIM

We retrospectively reviewed the results of ureteral reimplantation in infants with primary vesicoureteral reflux (VUR) to evaluate the effect on prevention of urinary tract infection (UTI) and renal growth.

MATERIALS AND METHODS

From July 1991 to December 2001, a total of 205 infants (180 boys and 25 girls) with primary VUR underwent ureteral reimplantation at the Department of Urology, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan. Indications for surgery were high-grade reflux (grade IV-V), breakthrough UTI and non-compliance of medical treatment. Age at surgery raged from 1 to 11 months (mean, 6.4 months). Ureteral reimplantation was performed according to Cohen's method. Only two of 336 refluxing ureters required ureteral tailoring. Follow-up ranged from 12 to 110 months (mean, 64 months). Surgical outcome, frequency of UTI and individual renal growth measured by (99m)Tc-dimercaptosuccinic acid (DMSA) scintigraphy was evaluated.

RESULTS

Postoperative ultrasound and voiding cystourethrography showed neither residual reflux nor ureterovesical obstruction. Contralateral low grade reflux occurred in six of 74 patients (8.1%) who had unilateral reflux preoperatively. After reimplantation, 10 patients documented 13 febrile UTI. Eleven of the 13 episodes occurred early in the postoperative period (<6 months). Frequency of febrile UTI reduced from 0.23538 before surgery to 0.00894 and 0.00081 per patient per month at 6 and 12 months after surgery, respectively. No development of renal scarring was seen in postoperative DMSA scan. Changes of differential renal function was <0.05 in all patients.

CONCLUSION

The present results show ureteral reimplantation in infants is safe and very effective for the prevention of UTI. After surgical treatment in infancy, individual renal growth of children with primary VUR is stable.

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 to be the main cause of permanent renal parenchymal damage in children with reflux. Therefore management of these children has been directed at preventing infection by antibiotic prophylaxis and/or surgical correction of reflux. However controversy remains as to the optimum strategies for management of children with primary VUR.

OBJECTIVES

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

SEARCH STRATEGY

Published and unpublished 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.

SELECTION CRITERIA

RCTs were included if they compared any treatments of VUR including surgery (open and closed techniques), antibiotic prophylaxis of any duration, non-invasive techniques such as bladder training and any combination of therapies.

DATA COLLECTION AND ANALYSIS

Two reviewers independently searched the literature, determined trial 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

Ten trials involving 964 evaluable children comparing long-term antibiotics and surgical correction of VUR with antibiotics (seven trials), antibiotics with no treatment (one trial) and different materials for endoscopic correction of VUR (two trials) were identified. Risk of UTI by 1-2 and 5 years was not significantly different between surgical and medical groups (by 2 years RR 1.07, 95% CI 0.55 to 2.09; by 5 years RR 0.99; 95% CI 0.79 to 1.26). Combined treatment resulted in a 60% reduction in febrile UTI by 5 years (RR 0.43, 95% CI 0.27 to 0.70) but no concomitant significant reduction in risk of new or progressive renal damage at 5 years (RR 1.05, 95% CI 0.85 to 1.29). In one small study no significant differences in risk for UTI or renal damage were found between antibiotic prophylaxis and no treatment.

REVIEWERS' CONCLUSIONS

It is uncertain whether the identification and 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.

Split renal function does not change after successful treatment in children with primary vesico-ureteric reflux

OBJECTIVE

To evaluate the renal growth pattern in patients with primary vesico-ureteric reflux (VUR) using long-term measurements of split renal function with 99mTc-dimercaptosuccinic acid (DMSA) scintigraphy.

PATIENTS AND METHODS

In all, 712 children aged < 16 years (466 boys and 246 girls) with primary VUR were referred to our hospital from July 1991 to December 2000. VUR was diagnosed by voiding cysto-urethrography. The patients were treated either surgically (group 1) or conservatively (group 2) and followed with serial 99mTc-DMSA scintigraphy for up to 10 years. There were 942 examinations in 367 of 712 patients who had repeat scintigraphy. Patients with secondary VUR, VUR to a solitary or fused kidney, or upper urinary tract obstruction, were excluded. Five of 298 patients (1.7%) who had ureteric reimplantation had a febrile urinary tract infection (UTI) soon after surgery but none recurred (recurrence is an indication for surgery in children with VUR); there was no febrile UTI in the 69 patients in group 2. Planar scintigraphy with 99mTc-DMSA was used to assess the absolute uptake (AU) of each kidney, measured as a percentage of the injected dose, and the relative uptake (RU = AU of each kidney/AU of both kidneys) calculated. The initial examination was at least 4 weeks after any febrile UTI in most patients. Serial studies were conducted 1 year after surgery and then biannually in group 1. In group 2 the DMSA scan was repeated every 2-3 years. The change in split renal function was compared with the RU of the right kidney.

RESULTS

The RU of the right kidney at the initial scan correlated closely with those on repeated scans in both groups. The correlation coefficients were 0.99 in group 1 and 0.94-0.97 in group 2 at every study. The change of RU remained within 0.05 in all patients after treatment.

CONCLUSIONS

Under strict control of UTI, split renal function in children with primary VUR does not change. There may be no possibility of accelerated or compensatory growth of the kidney with reflux nephropathy, but no concern about deterioration and atrophy either.

Antibiotics and surgery for vesicoureteric reflux: a meta-analysis of randomised controlled trials

AIMS

To evaluate the benefits and harms of treatments for vesicoureteric reflux in children.

METHODS

Meta-analyses of randomised controlled trials using a random effects model. Main outcome measures were incidence of urinary tract infection (UTI), new or progressive renal damage, renal growth, hypertension, and glomerular filtration rate.

RESULTS

Eight trials involving 859 evaluable children comparing long term antibiotics with surgical correction of reflux (VUR) and antibiotics (seven trials) and antibiotics compared with no treatment (one trial) were identified. Risk of UTI by 1-2 and 5 years was not significantly different between surgical and medical groups (relative risk (RR) by 2 years 1.07; 95% confidence interval (CI) 0.55 to 2.09, RR by 5 years 0.99; 95% CI 0.79 to 1.26). Combined treatment resulted in a 60% reduction in febrile UTI by 5 years (RR 0.43; 95% CI 0.27 to 0.70) but no concomitant significant reduction in risk of new or progressive renal damage at 5 years (RR 1.05; 95% CI 0.85 to 1.29). In one small study no significant differences in risk for UTI or renal damage were found between antibiotic prophylaxis and no treatment.

CONCLUSION

It is uncertain whether the identification and 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.

Renal function in congenital anomalies of the kidney and urinary tract

Congenital anomalies of the kidneys and urinary tract are a major cause of chronic and end-stage renal failure in children. The molecular mechanisms having been elaborated, there is now growing evidence that kidney function is to a large extent determined genetically at an early stage. Assessment of kidney function is an important tool in clinical medicine and is feasible in utero. Postnatally, determination of absolute glomerular filtration rate and also of split and excretory renal function play an important role in the determination of treatment and prognosis. This is supplemented by other biochemical, molecular and interventional prognostic factors, which are of help in preservation of kidney survival by minimizing modulating factors. If chronic or terminal renal failure ensues in childhood or even in early infancy, however, improved medical care has led to encouraging results, ultimately influencing the motivation in the care of children with congenital anomalies of the kidney and urinary tract.

Medical versus surgical treatment in children with severe bilateral vesicoureteric reflux and bilateral nephropathy: a randomised trial

BACKGROUND

Nephropathy associated with vesicoureteric reflux (VUR) and urinary tract infection can result in end-stage renal failure, hypertension, or both. Whether long-term VUR contributes to these outcomes is unknown. We compared, in a randomised trial, medical with surgical management of children with bilateral severe VUR and bilateral nephropathy.

METHODS

We stratified by age and glomerular filtration rate (GFR) 25 boys and 27 girls aged 1-12 years and randomly assigned them to medical or surgical management. At enrolment and 4 years' follow-up we estimated GFR from the plasma clearance of 51Cr-labelled edetic acid (EDTA), and did intravenous urography. We also did a metastable 99mTc-labelled dimercaptosuccinic acid (DMSA) assay and contrast cystography. The change in GFR at 4 years, expressed as a percentage change between enrolment and 4 years, was available for 26 of 27 patients in the medical and 24 of 25 in the surgical group. We assessed GFR in 48 patients 10 years after enrolment.

FINDINGS

Mean GFR at enrolment was 72.4 mL/min per 1.73 m(2) (SD 24.1) in the medical and 71.7 mL/min per 1.73 m(2) (22.6) in the surgical group. The mean percentage change in GFR at 4 years was 2.4% (SE 4.5) versus 4.7% (5.0) in the medical and surgical groups, respectively. The difference in change in GFR at 4 years between the two groups was not significant (7.1%, 95% CI 6.4% to 20.6%).

INTERPRETATION

Our data do not lend support to the view that the outcome for renal function is improved by surgical correction of VUR in children with bilateral disease.