Figure 1 Bilateral VUR

Marie-Klaire Farrugia MD MD(Res) FRCS(Paed.Surg)

Consultant Paediatric Urologist

 Until recently, common clinical practice has been that all children diagnosed with vesicoureteric reflux (VUR) are maintained on prophylactic antibiotics for an undefined length of time or subjected to aggressive surgical management in the hope that this would prevent further infection and scarring from recurrent pyelonephritis. However, a long-term Australian study has shown that rates of renal disease secondary to VUR have remained unchanged for 3 decades, suggesting that the identification and treatment of reflux have not reduced the incidence of clinically-significant reflux nephropathy. In an era of healthy living and minimally-invasive techniques, parents often question the indication for long-term antibiotics or the suggestion of open surgery. The literature, and the aggressive management of VUR, has therefore been questioned and the management of VUR literally turned on its head.

It has become clear that high-grade reflux (International Reflux Classification III-V – Figure 1) and renal dysplasia/ scarring often co-exist and are the result of a congenital urinary tract “field-defect” during embryological development. One does not necessarily lead to the other, especially in the absence of infection. Moreover, aggressive treatment of VUR will not change the outcome of the scarred or poorly-functioning kidney: therefore investigation and intervention has become more selective and aimed at preventing symptoms rather than cure. Decision-making is complex and is best managed by a specialist Paediatric Urologist.

In a nut-shell:

  • There is no correlation between the presence and degree of prenatal hydronephrosis and the postnatal diagnosis of VUR. In spite of extensive prenatal scanning, VUR still most commonly presents with a febrile UTI in children who have normal prenatal scans. Therefore invasive investigation of mild prenatal hydronephrosis with an MCUG is not warranted.
  • Low-grade (I-II) VUR does not require prophylaxis and is rarely symptomatic. No follow-up is required.
  • Resolution of high-grade (III-V) VUR is spontaneous in only 38% of cases maintained on prophylactic antibiotics alone. The presence of a renal abnormality on ultrasound (duplex system or para-ureteric diverticulum), renal scarring, break-through UTI’s and underlying bladder dysfunction are the major risk-factors for non-resolution.
  • An ongoing-prospective study by our group showed that the presence of renal scarring on DMSA (a nuclear medicine study which shows the differential kidney function and the presence of cortical defects) was the most significant predictor of progression to surgical intervention – whereas VUR grade, patient age, gender, laterality, diagnosis following prenatal hydronephrosis, presence of duplex or para-ureteric diverticula and timing of reflux did not reach statistical significance.
  • A consensus session by the British Association of Pediatric Urologists (www.bapu.org.uk) concluded that surgical intervention is indicated after the first break-through UTI, and after underlying bladder dysfunction has been addressed. First-line treatment should be endoscopic injection (most commonly with Deflux, a biodegradable compound injected into the base of the refluxing ureteric orifice via cystoscopy) – performed as a day-case – with success rates of up to 95% (Figure 2). Endoscopic injection may be repeated 2-3 times before a ureteric reimplantation is considered.
  • Boys with VUR also benefit from a circumcision, which has been shown to reduce infection rates ten-fold. This procedure may be performed under the same anaesthetic as an endoscopic injection.

In conclusion, VUR is a spectrum and its management depends on a number of anatomical and functional factors. Please seek advice early and avoid a viscous cycle of recurrent infections and antibiotic courses: there is a light at the end of the (ureteric) tunnel!

References have been omitted in the interest of space but may be requested from Miss Farrugia ([email protected]). More information may be found on www.kidsurology.co.uk.

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Legends:

Figure 2 Endoscopic injection

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