International system of radiographic grading of vesicoureteric reflux. International Reflux Study in Children

The classification of grading of vesicoureteric reflux (VUR) agreed to by the participants in the International Reflux Study in Children is described. It combines two earlier classifications and is based upon the extent of filling and dilatation by VUR of the ureter, the renal pelvis and the calyces. A standardised technique of voiding cystography is also described to ensure comparability of results.

Antibiotic prophylaxis and recurrent urinary tract infection in children

BACKGROUND

Antibiotics are widely administered to children with the intention of preventing urinary tract infection, but adequately powered, placebo-controlled trials regarding efficacy are lacking. This study from four Australian centers examined whether low-dose, continuous oral antibiotic therapy prevents urinary tract infection in predisposed children.

METHODS

We randomly assigned children under the age of 18 years who had had one or more microbiologically proven urinary tract infections to receive either daily trimethoprim-sulfamethoxazole suspension (as 2 mg of trimethoprim plus 10 mg of sulfamethoxazole per kilogram of body weight) or placebo for 12 months. The primary outcome was microbiologically confirmed symptomatic urinary tract infection. Intention-to-treat analyses were performed with the use of time-to-event data.

RESULTS

From December 1998 to March 2007, a total of 576 children (of 780 planned) underwent randomization. The median age at entry was 14 months; 64% of the patients were girls, 42% had known vesicoureteral reflux (at least grade III in 53% of these patients), and 71% were enrolled after the first diagnosis of urinary tract infection. During the study, urinary tract infection developed in 36 of 288 patients (13%) in the group receiving trimethoprim-sulfamethoxazole (antibiotic group) and in 55 of 288 patients (19%) in the placebo group (hazard ratio in the antibiotic group, 0.61; 95% confidence interval, 0.40 to 0.93; P = 0.02 by the log-rank test). In the antibiotic group, the reduction in the absolute risk of urinary tract infection (6 percentage points) appeared to be consistent across all subgroups of patients (P > or = 0.20 for all interactions).

CONCLUSIONS

Long-term, low-dose trimethoprim-sulfamethoxazole was associated with a decreased number of urinary tract infections in predisposed children. The treatment effect appeared to be consistent but modest across subgroups. (Australian New Zealand Clinical Trials Registry number, ACTRN12608000470392.)

Results of a randomized clinical trial of medical versus surgical management of infants and children with grades III and IV primary vesicoureteral reflux (United States). The International Reflux Study in Children

A total of 132 infants and children with grades III and IV primary vesicoureteral reflux was entered into a prospective trial comparing medical to surgical management. Inclusion criteria were an age not exceeding 10 years and a glomerular filtration rate of at least 70 ml. per minute per 1.73 m.2. Children with significant urinary tract malformations and clinical signs/symptoms of dysfunctional voiding were not accepted into the trial. Medical therapy consisted of continuous low dose antibiotic prophylaxis until vesicoureteral reflux resolved. The type of surgical procedure used for the correction of reflux was left to the discretion of the surgeon. Outcome variables included the appearance or progression of renal lesions, rate of renal growth, recurrence rate of urinary tract infection or pyelonephritis, changes in total kidney glomerular filtration rate, development of hypertension and resolution rate of vesicoureteral reflux. Followup at 6, 18, 36 and 54 months after entry included, in addition to history and physical examination, voiding cystourethrography, excretory urography and a urine culture. Of the patients 68 were allocated to the medical group and 64 to the surgical group. They were stratified for age, sex and preexisting renal scarring. Of the patients 10% were boys, 47% were between 2 and 6 years old at entry, 93% had a history of pyelonephritis, 67% had either scarring or thinning of the parenchyma at entry, 87% had grade IV vesicoureteral reflux in at least 1 unit and 56% had bilateral reflux. There were no significant differences in the frequency distribution of entry characteristics between the patients allocated to either group. New renal scarring developed in 22% of medical and 31% of surgical patients (p < 0.4). Growth of kidneys with grade IV vesicoureteral reflux was slightly less than normal in the medical (-0.67 +/- 0.15 standard deviation) and surgical (-0.42 +/- 0.11 standard deviation) groups (p < 0.7). Pyelonephritis occurred in 15 medical patients versus 5 surgical patients (p < 0.05). There was no significant change in glomerular filtration rate within each treatment group and no difference in glomerular filtration rate between groups. No patient had hypertension during the followup period. The disappearance rate of vesicoureteral reflux in patients with grade IV reflux was approximately 8% per year. Of the medical patients 75% still had vesicoureteral reflux after 3 years of observation.(ABSTRACT TRUNCATED AT 400 WORDS)

A nonsurgical approach to the management of primary vesicoureteral reflux

We performed a retrospective review to evaluate the results of a nonsurgical approach to the management of primary vesicoureteral reflux during a 10-year period (1976 to 1986). During that interval patients with reflux were studied initially with a standard voiding cystourethrogram and either an excretory urogram or a renal scan with glomerular filtration rate and/or differential renal function determination. Height, weight, blood pressure, urine cultures and serum creatinine measurements also were obtained. Isotope cystography was used for followup examinations. A single, negative isotope cystogram was the radiological criterion for cessation of reflux. The charts of 545 children (55 per cent had bilateral reflux) with 844 refluxing ureters were reviewed. Based upon the international classification vesicoureteral reflux was grade I in 6.6 per cent of the cases, grade II in 54.2 per cent, grade III in 31.6 per cent, grade IV in 5.7 per cent and grade V in 1.9 per cent. All children were kept on long-term continuous prophylactic antibiotics and they were re-evaluated annually with isotope cystography. The followup rate for the entire group was 88 per cent. During the observation period spontaneous resolution of reflux was noted in 36 per cent of the patients and 39 per cent of the total refluxing ureters. Only 13 per cent of the entire group underwent surgical correction of reflux. Presently, 39 per cent (215) of the patients continue to be followed with reflux. Of the total group 66 patients (12 per cent) were lost to followup. In the 194 patients with spontaneous resolution of reflux the mean duration of reflux was 1.69 years, with 30 to 35 per cent resolving each year. Based on Student's t test there was a significant difference in duration of reflux in patients with grade II compared to grade III reflux (1.56 versus 1.97 years, p less than 0.04). When age at presentation was compared with duration of reflux there was a significantly shorter duration of reflux only in those patients presenting from age 0 to 12 months, compared to those 13 months and older (1.44 versus 1.85 years, p less than 0.02). Renal function was evaluated by serum creatinine, calculated glomerular filtration rate or differential diethylenetriaminepentaacetic acid scan results.(ABSTRACT TRUNCATED AT 400 WORDS)

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

A total of 401 children with severe vesicoureteral reflux (97 with grade III and 304 with grade IV) was entered into the European branch of the International Reflux Study in Children. Of these patients 37 with grade III and 43 with grade IV reflux were allocated to medical treatment as a sideline group because the reflux grade III or IV had improved to grade II or I, or it had disappeared during the preceding 2 to 6 months (median 4). Of the remaining 321 patients with persistent grade III or IV reflux 158 were randomly allocated to medical treatment of whom 3 switched to surgery. We report on 235 children treated medically (155 random medical and 80 sideline), of whom 88% had a complete 5-year followup with x-ray and/or isotope voiding cystourethrography at 6, 18, 30 and 54 months. Seven children dropped out of the study after a followup of 6 months or less, including 6 with persistent vesicoureteral reflux. Cessation of vesicoureteral reflux was observed significantly more often in children with unilateral (40 of 74, 54%) than with bilateral (18 of 154, 12%) reflux (p < 0.001). No significant difference between grades III and IV was noted. Vesicoureteral reflux ceased in 25 of 153 children (16%) from the random medical group and in 32 of 75 children (43%) in the sideline group. Of 194 children with vesicoureteral reflux detected for the first time at entry reflux resolved in 55 (28%). In only 2 of 34 children (6%) in whom vesicoureteral reflux was detected more than 1 year before entry did reflux resolve after 5 years. Among the children in whom vesicoureteral reflux either disappeared, diminished or remained unchanged the proportion with urinary tract infection recurrences was almost the same.

Medical management of mild and moderate vesicoureteral reflux: followup studies of infants and young children. A preliminary report of the Southwest Pediatric Nephrology Study Group

Mild and moderate vesicoureteral reflux is expected to resolve spontaneously in most children treated medically; however, maximum benefit or minimum risk of such therapy has not been defined. A prospective 5-year followup study of infants and children younger than 5 years at entry with primary vesicoureteral reflux (grades I to III/V) and radiographically normal kidneys after the first recognized urinary tract infection was initiated in 1984. A total of 113 patients was entered from 5 centers and 61% of the patients were less than 2 years old. Vesicoureteral reflux was unilateral in 65 cases (58%) and bilateral in 48 (42%). Of the 226 renal units reflux was grade IV in 4 (2%), III in 51 (22%), II in 81 (36%) and I in 25 (11%), and 65 (29%) had no vesicoureteral reflux. Data on 59 patients who have completed the protocol were analyzed for this report. Breakthrough urinary tract infection occurred in 20 patients. Of the 84 ureters with vesicoureteral reflux at diagnosis reflux resolved in 67%, and it was of lower grade in 22%, same grade in 8% and higher grade in 2%. Grade I vesicoureteral reflux resolved in 82%, grade II in 80% and grade III in 46% of the ureters. Resolution was better when vesicoureteral reflux was unilateral left (74%) than unilateral right (46%) or bilateral (60%). Renal scarring occurred, on average, in 10% of the kidneys without known vesicoureteral reflux or exposed only to nondilating (grades I and II) reflux and in 28% of those with dilating (grade III) reflux. Thirteen cases had breakthrough urinary tract infection but only after the scar was noted in 5. We conclude that under good medical management during 5 years of followup, even mild and moderate vesicoureteral reflux can be associated with renal injury.

Incidence and severity of vesicoureteral reflux in children related to age, gender, race and diagnosis

PURPOSE

We determine if the incidence and grade of vesicoureteral reflux (VUR) differs in children based on age, race and gender, and if the incidence and severity of VUR are related to race in girls younger than 7 years presenting for evaluation after urinary tract infection (UTI).

MATERIALS AND METHODS

The records of all children who underwent a voiding cystourethrogram or radionuclide cystogram between 1993 and 2001 were retrospectively reviewed. Age, gender, race, clinical indication and highest grade of VUR were recorded for the first voiding cystourethrogram or radionuclide cystogram. Frequency tables and logistic regression were conducted to correlate demographics to incidence and severity of VUR.

RESULTS

A total of 15,504 patients were included in the analysis. Overall, black children were a third as likely as white children (p <0.0001) and females were twice as likely as males (p <0.0001) to have VUR. Compared to children 0 to 2 years old, the occurrence of reflux was 0.5 times as likely in those 3 to 6 years old (p <0.0001), 0.3 times as likely in those 7 to 11 years old (p <0.0001) and 0.15 times as likely in those 12 to 21 years old (p <0.0001). When analyzing children with UTI, results were similar. Of the patients with VUR 65% were younger than 7 years. The incidence of VUR in black girls younger than 7 years with a diagnosis of UTI was less than 10% compared to white girls, and no black girl had high grade reflux. In young children referred for UTI the incidence and severity of VUR in black patients were significantly lower than those of white girls.

CONCLUSIONS

This study validates previous observations regarding the low incidence of VUR in black children.

Followup of conservatively treated children with high and low grade vesicoureteral reflux: a prospective study

A total of 202 children (mean age 31.5 +/- 23.3 months) with vesicoureteral reflux identified during the investigation that follows a urinary tract infection entered this prospective study dealing with the medical management of reflux. The diagnosis of vesicoureteral reflux was made significantly earlier in boys than in girls regardless of reflux grade (p < 0.001). At entry reflux nephropathy was present on a dimercaptosuccinic acid scan in 44% of 314 refluxing kidneys. There was no significant difference between boys and girls in the prevalence of reflux nephropathy. The renal lesions were more severe in boys independently of the grade of vesicoureteral reflux (p < 0.05). Breakthrough urinary tract infection was significantly more common in girls than in boys, regardless of vesicoureteral reflux grade (p < 0.05). Mean followup was 68.7 +/- 31.2 months. Patient age at the time of the first of 2 radionuclide cystograms without vesicoureteral reflux was considered the age of spontaneous resolution of reflux. Using life table estimations and analyzing data stratified to sex and grade of vesicoureteral reflux, we found that although reflux lasted longer in boys compared to girls, this difference was not statistically significant. During followup new scars developed in 7 patients related to breakthrough urinary tract infection. There was no significant difference between boys and girls in the development of new scars. To understand the natural history of vesicoureteral reflux children must be stratified by sex and grade of reflux.

Long-term followup of infants with gross vesicoureteral reflux

The majority of children (1 year old or less) with gross vesicoureteral reflux already have renal damage at the time of presentation or reflux nephropathy develops during the first few years of life. We report the long-term followup of 31 patients (16 boys) presenting in infancy with gross vesicoureteral reflux (Rolleston classification) between 1952 and 1970. They had a total of 44 grossly refluxing ureters (13 bilateral, 18 unilateral) and presented between ages 1 day and 48 weeks (mean 15.3 weeks). Of the 31 infants 5 died within the first year of life, 4 were followed for up to 11 years before being lost to followup and 1 was killed in a motor vehicle accident after 19.5 years of followup. The remaining 21 patients have been followed for 16 to 37 years (mean 23.9 years); 4 have normal kidneys, and 13 have unilateral and 4 have bilateral reflux nephropathy. Of those patients with unilateral reflux nephropathy proteinuria, hypertension and renal failure developed in 1 born with a single kidney and he is now on hemodialysis, while 2 others have a diastolic blood pressure of 90 mm. Hg or greater. Of the 4 patients with bilateral reflux nephropathy 2 have proteinuria and renal insufficiency, with 1 progressing towards end stage renal failure. Infants who present with gross vesicoureteral reflux within the first year of life appear to do well if free of severe bilateral reflux nephropathy at presentation. Patients with reflux nephropathy should remain under regular nephrological supervision with particular attention given to proteinuria, renal function and blood pressure.

The Deflux Procedure Reduces the Incidence of Urinary Tract Infections in Patients with Vesicoureteral Reflux

PURPOSE

The aim of this study was to review the experience of a single institution with the Deflux (Q-Med Scandinavia; Uppsala, Sweden) procedure and assess its effectiveness in reducing the incidence of urinary tract infections (UTIs) in children with vesicoureteric reflux (VUR).

MATERIALS AND METHODS

After institutional review board approval, the charts of 100 patients with VUR, who presented between June 2003 and June 2005, were prospectively reviewed. Data collected included: demographics, the number of preoperative and postoperative UTIs, a radiologic grade of VUR on a voiding cystourethrogram (VCUG) and the presence of VUR on a radionuclide VCUG 3 months after the procedure. Patients were continued on oral antibiotics until urine culture at 3 months was negative and no reflux was demonstrated on VCUG. The student's t test was used for data analysis.

RESULTS

The mean age was 3.8 +/- 0.3 years, and 76% were girls. From 155 ureters treated, 10 had Grade I reflux, 42 Grade II, 76 Grade III, 25 Grade IV, and 2 Grade V. A second injection was required in 22 ureters (14.2%). The overall success rate of the procedure (Grade 0 reflux at 3 months) was 77.4% after the first injection and 83.9% after a second injection. The success rate per grade was: 100% for Grade I, 88.1% for Grade II, 86.8% for Grade III, 64% for Grade IV, and 50% for Grade V. The mean follow-up was 446 +/- 20 days. The mean volume injected/ureter was 0.6 +/- 0.03 mL. Thirteen (13) patients had UTIs after the procedure, compared to 75 before. There was a 5-fold reduction in the incidence of UTIs/year, from a mean of 0.68 +/- 0.09 pre- to 0.12 +/- 0.04 postinjection (P = 0.001). The majority of UTIs were caused by Escherichia coli (74% pre- and 82% postinjection).

CONCLUSIONS

We conclude that the Deflux procedure is effective not only in eliminating VUR on radiologic studies, but also in reducing the incidence of UTIs and antibiotic use in children with VUR.

Commentary: management of children with severe vesicoureteral reflux

The main findings of the IRSC after 5 years of observation are summarized. Of the 434 children entered 128 were from centers in America and 306 from Europe. They were randomly allocated and stratified to a medical or surgical regimen. Of the children 50% had scarred kidneys at entry evenly distributed between the groups. After 5 years of observation there was no difference in outcome between the 2 treatment groups in terms of renal size and growth, the development of new radiological renal scars or areas of parenchymal thinning, or of progression of established scarring. In Europe infection recurred in equal numbers of children but pyelonephritic symptoms were more common in the medical group. Nevertheless, new scars developed in 19 of 155 children treated medically and 20 of 151 children treated surgically, including 5 and 7, respectively, with previously normal kidneys. Factors influencing the choice of treatment include patient age, availability of expert surgical care and experienced medical supervision, parental choice and compliance. Followup studies indicate that renal scarring rather than persistence of reflux determines the prognosis and, therefore, emphasis should be placed on the prevention of scarring.

Vesico-ureteral reflux in pediatric kidney transplants: clinical relevance to graft and patient outcome

From June 1985 to December 1998, 173 pediatric renal transplants were carried out in 170 patients at our center. From this pool, 73 patients (34 males and 39 females) with a follow-up of 48 months were examined. In all patients, ureteroneocystostomy was performed according to the Lich-Grégoire procedure. All patients were treated with cyclosporin A (CsA)-based immunosuppression, including prednisone and sometimes azathioprine (AZA). Six months after transplantation, voiding cystography (VCU) was performed in all patients and reflux was classified from Grade I to Grade IV. The patients were divided into two groups: those with reflux (Group A: 25 patients) and those without (Group B: 48 patients). Grade I reflux was found in four patients, Grade II in seven patients, Grade III in seven patients, and Grade IV in seven patients. All the patients with severe reflux (Grade IV) underwent a corrective surgical procedure. Both groups were examined for immunologic and non-immunologic risk factors and no significant differences were found. Analysis of patient and graft survival rates revealed no statistical differences (NS) between Groups A and B. Mean serum creatinine (mg/dL) was 1.06 +/- 0.28 and 1.12 +/- 0.41 at 4 yr in Groups A and B, respectively (NS). Mean calculated creatinine clearance (cCrC; ml/min) was 76.74 +/- 15.92 and 77.96 +/- 15.66 in Groups A and B, respectively (NS). The analysis was further extended by considering the grade of reflux (I to IV). Again, no significant differences in the above parameters emerged between the reflux sub-groups; only in the Grade IV sub-group was a slight decrease in cCrC detected, although this difference was not statistically significant when compared with the other sub-groups. In conclusion, vesico-ureteral reflux (VUR) does not seem to negatively affect graft function. However, as all severe reflux patients (Grade IV) were surgically corrected, no conclusions can be drawn with regard to the influence of Grade IV reflux on long-term graft function.

Single center experience with endoscopic subureteral dextranomer/hyaluronic acid injection as first line treatment in 1,551 children with intermediate and high grade vesicoureteral reflux

PURPOSE

In recent years the endoscopic injection of dextranomer/hyaluronic acid has become an established alternative to long-term antibiotic prophylaxis and the surgical management of vesicoureteral reflux. We determined the safety and effectiveness of the endoscopic injection of dextranomer/hyaluronic acid as first line treatment for high grade vesicoureteral reflux.

MATERIALS AND METHODS

Between 2001 and 2010, 1,551 children (496 male, 1,055 female, median age 1.6 years) underwent endoscopic correction of intermediate and high grade vesicoureteral reflux using dextranomer/hyaluronic acid soon after the diagnosis of vesicoureteral reflux on initial voiding cystourethrogram. Vesicoureteral reflux was unilateral in 761 children and bilateral in 790. Renal scarring was detected in 369 (26.7%) of the 1,384 patients who underwent dimercapto-succinic acid imaging. Reflux grade in the 2,341 ureters was II in 98 (4.2%), III in 1,340 (57.3%), IV in 818 (34.9%) and V in 85 (3.6%). Followup ultrasound and voiding cystourethrogram were performed 3 months after the outpatient procedure, and renal ultrasound was performed annually thereafter. Patients were followed for 3 months to 10 years (median 5.6 years).

RESULTS

Vesicoureteral reflux resolved after the first, second and third endoscopic injection of dextranomer/hyaluronic acid in 2,039 (87.1%), 264 (11.3%) and 38 (1.6%) ureters, respectively. Febrile urinary tract infections developed during followup in 69 (4.6%) patients. None of the patients in the series needed reimplantation of ureters or experienced any significant complications.

CONCLUSIONS

Our results confirm the safety and efficacy of the endoscopic injection of dextranomer/hyaluronic acid in the eradication of high grade vesicoureteral reflux. We recommend this 15-minute outpatient procedure as the first line of treatment for high grade vesicoureteral reflux.

Endoscopic correction of grades IV and V primary vesicoureteric reflux: six to 30 month follow-up in 42 ureters

Between March 1984 and March 1986, 31 children with 42 ureters with grades IV and V primary vesicoureteric reflux were treated by endoscopic subureteric injection of Polytef paste. Reflux ceased after a single injection in 28 ureters, after the second in six, after the third in three and after the fourth injection in one. Two ureters showed improvement to grade II reflux after two injections and no further treatment was given. Two ureters showed no change in grade of reflux after three and four injections, respectively. Twenty-seven children with successfully treated ureters have now been followed up for periods ranging from 6 to 30 months. All 38 ureters had a negative micturating cystogram following endoscopic correction. At follow-up there was no reflux in 32 (84%) ureters and recurrence in six (16%). The procedure is simple to perform and without significant complications. The follow-up results show that the endoscopic treatment is reliable and effective in correcting higher grades of vesicoureteric reflux.

Do infants with mild prenatal hydronephrosis benefit from screening for vesicoureteral reflux?

PURPOSE

Screening for vesicoureteral reflux in asymptomatic infants with low grade hydronephrosis is unjustified if this condition is benign. We present a cohort with prenatally detected hydronephrosis, some observed without voiding cystourethrography, and compare outcomes to a classic, screened group.

MATERIALS AND METHODS

A total of 206 consecutive children presenting with postnatally confirmed prenatally detected hydronephrosis (47% bilateral) were included in the study. Cases with associated renal or bladder anomalies were excluded. Children with low grade hydronephrosis either underwent screening voiding cystourethrography or did not, largely based on whether care was managed by a urologist or a nephrologist. Patients with high grade hydronephrosis routinely underwent voiding cystourethrography. Primary outcome was a symptomatic or febrile urinary tract infection. We used Mantel-Haenszel analysis to determine urinary tract infection risk factors during the first 2 years of life.

RESULTS

No urinary tract infection was observed in patients with grade I hydronephrosis. Urinary tract infections in low grade hydronephrosis were only seen in the voiding cystourethrogram group (7 patients), including 1 infection following voiding cystourethrogram. Urinary tract infection rate was 3.52 infections per 100 patient-years in children with low grade hydronephrosis and 11.1 infections per 100 patient-years in those with high grade hydronephrosis (p = 0.02). This increased risk of urinary tract infection in high grade hydronephrosis persisted after correcting for gender and circumcision status (IRR 3.17, p = 0.01). The association remained strong (IRR 2.48, 95% CI 0.96-6.44) but was not statistically significant (p = 0.053) after additionally correcting for vesicoureteral reflux status.

CONCLUSIONS

Our data suggest that children with low grade hydronephrosis and otherwise normal kidneys and bladder do not benefit from voiding cystourethrographic screening. Interestingly high grade hydronephrosis appears to carry a threefold greater risk of urinary tract infection compared to low grade hydronephrosis.

A plea for standardized grading of vesicoureteral reflux

The voiding cystourethrogram has become the accepted standard for detection and grading of vesicoureteral reflux. Although selection of treatment alternatives and interpretation of treatment results are modified by cystographic findings, no uniform grading system exists. This not only makes comparison of different series awkward, but also hampers efforts to understand the prognostic implications of reflux grading. In reviewing the grading systems available, we feel that adoption of the criteria proposed by the International Reflux Committee (originally proposed by Heikel and Parkkulainen in Europe and Dwoskin and Perlmutter in the USA) is superior in its specificity and should be adopted as an International Reflux Classification.

Endoscopic treatment of primary grades IV and V vesicoureteral reflux in children with subureteral injection of polytetrafluoroethylene

PURPOSE

We evaluated our experience with endoscopic STING (subureteral polytetrafluoroethylene injection) for grades IV and V vesicoureteral reflux.

MATERIALS AND METHODS

We reviewed the records of 221 boys and 305 girls who underwent STING for primary grades IV (430) and V (96) vesicoureteral reflux between 1984 and 2000. Median patient age at STING was 3 years (range 3 months to 14 years). Reflux was unilateral and bilateral in 335 and 191 children, respectively (717 refluxing units). Median followup was 11.6 years (range 1 to 17).

RESULTS

Reflux was corrected in 420 of the 717 refluxing units (58%) after a single injection. Reflux resolved after a second and third injection in 185 ureters (26%). High grade reflux was converted to grades I and II in 112 ureters (15%) and did not require any further treatment. STING failed to correct reflux in 7 units (0.9%), which were managed by ureteral reimplantation (5) and nephrectomy (2) due to poor renal function. Voiding cystourethrography showed recurrent vesicoureteral reflux in 9 units (1.2%), including 2 with low grade reflux for which no treatment was given. Seven ureters required repeat injection due to grades III and IV reflux. No untoward effects were noted in any patients in whom polytetrafluoroethylene was used as the injected material.

CONCLUSIONS

STING is a simple, safe and effective outpatient procedure for grades IV and V vesicoureteral reflux.

Comprehensive ultrasound versus voiding cysturethrography in the diagnosis of vesicoureteral reflux

This study evaluates the accuracy of noninvasive renal ultrasound (US) in the detection of dilative vesicoureteric reflux (VUR) compared to voiding cysturethrography (VCUG), taking both sonographic morphology and kidney length into account. The data and images of 205 paediatric patients who had renal ultrasound and VCUG performed were reviewed. Abnormalities of renal length and kidney morphology were compared with degree of reflux on VCUG for each renal unit. A total of 407 renal units were evaluated. When the sonographic diagnosis of reflux was based solely on morphological criteria and degree of dilatation, correlation with VCUG results was poor. However, the fraction of kidneys of anomalous size increased markedly with grade of reflux, from 10% of non-refluxing renal units to 50% of renal units subjected to grade 4 and 5 VUR. Taking abnormal kidney length into account as well, dilative VUR was diagnosed by ultrasound with a sensitivity of 92% (95% CI 82%-100%) and a sensitivity of 67% (95% CI 63%-72%), P<0.001.

CONCLUSION

the results of this study show that ultrasound cannot accurately diagnose vesicoureteric reflux by morphological changes alone, but requires the consideration of age-adjusted abnormalities in kidney length.

Correlation of vesicoureteral reflux with degree of hydronephrosis and the impact of antireflux surgery

PURPOSE

We correlated the degree of hydronephrosis (HN) to the grade of vesicoureteral reflux (VUR) and assessed the impact of antireflux surgery on the resolution/persistence of HN.

MATERIALS AND METHODS

Between 1997 and 2000, 308 patients (476 units) underwent antireflux surgery for primary or secondary VUR. Surgical procedures included extravesical reimplantation (291 ureters), intravesical reimplantation (48) and endoscopic polydimethylsiloxane injection (137). The degree of HN was categorized as mild (grade 1 to 2) or moderate/severe (grade 3 to 4). VUR was grade I in 44 cases, II in 145, III in 203 and IV to V in 84. Followup renal ultrasound was performed at 3 and 12 months postoperatively. Statistical analysis consisted of a contingency table and chi-square test for independence.

RESULTS

Preoperative HN existed in 123 refluxing units, and was mild in 4 (9%), 11 (7.5%), 39 (19%) and 28 (33%), and moderate/severe in 0, 2 (1.4%), 14 (7%) and 25 (30%) of grade I, II, III and IV to V VUR cases, respectively. The degree of preoperative HN correlated with VUR grade (p <0.0001). At 3 months postoperatively HN resolved in 50.4%, improved in 16.3%, persisted in 30% and worsened in 3.3% of units. At 15 months postoperatively HN resolved in 80 units (65%) and persisted in 43 (35%). Patients with preoperative moderate/severe HN constituted 56% of those with persistent HN.

CONCLUSIONS

Our data indicate that the presence and degree of preoperative hydronephrosis are closely related to VUR grade. Furthermore, antireflux surgery resulted in a high resolution rate of hydronephrosis. Persistent postoperative hydronephrosis did not require any intervention.

The interrelationship between vesico-ureteric reflux, trigonal abnormalities and a bifid pelvicalyceal collecting system: a family study

3 investigations have been undertaken to study the interrelationship between a bifid pelvicalyceal collecting system, vesico-ureteric reflux and lateral ectopia of the ureteric orifice. Firstly, in 30 families investigated to confirm the familial incidence of bifid and double ureters there were 3 families in which siblings were found with primary reflux. Secondly, reflux was found in 62 of 110 patients investigated with a duplex pelvicalyceal system. Reflux was to the ipsilateral kidney in 48 patients but occurred to the contralateral kidney, unaffected by duplicity, in 14. This high incidence of reflux is related to lateral ectopia of the ureteric orifice which may be either bilateral or unilateral. Thirdly, the incidence of a bifid pelvicalyceal system was determined in the parents and siblings of a series of 32 patients with primary reflux. The results support the hypothesis that primary reflux may be inherited by an autosomal dominant gene of variable penetrance in a manner similar to the inheritance of a duplex urinary tract. Thus there is a direct genetic relationship between primary vesico-ureteric reflux, lateral ectopia of the ureteric orifices and a duplex pelvicalyceal system.