Management of Vesicoureteral Reflux: What Have We Learned Over the Last 20 Years?

Vesicoureteral reflux (VUR) is associated with increased risks of urinary tract infection, renal scarring and reflux nephropathy. We review advancements over the last two decades in our understanding and management of VUR. Over time, the condition may resolve spontaneously but it can persist for many years and bladder/bowel dysfunction is often involved. Some factors that increase the likelihood of persistence (e.g., high grade) also increase the risk of renal scarring. Voiding cystourethrography (VCUG) is generally considered the definitive method for diagnosing VUR, and helpful in determining the need for treatment. However, this procedure causes distress and radiation exposure. Therefore, strategies to reduce clinicians' reliance upon VCUG (e.g., after a VUR treatment procedure) have been developed. There are several options for managing patients with VUR. Observation is suitable only for patients at low risk of renal injury. Antibiotic prophylaxis can reduce the incidence of UTIs, but drawbacks such as antibiotic resistance and incomplete adherence mean that this option is not viable for long-term use. Long-term studies of endoscopic injection have helped us understand factors influencing use and the effectiveness of this procedure. Ureteral reimplantation is still performed commonly, and robot-assisted laparoscopic methods are gaining popularity. Over the last 20 years, there has been a shift toward more conservative management of VUR with an individualized, risk-based approach. For continued treatment improvement, better identification of children at risk of renal scarring, robust evidence regarding the available interventions, and an improved VUR grading system are needed.

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The role of voiding cystourethrography in the investigation of children with urinary tract infections

Canadian Urological Association Journal ◽

10.5489/cuaj.3610 ◽

2016 ◽

Vol 10 (5-6) ◽

pp. 210 ◽

Cited By ~ 5

Author(s):

Linda C. Lee ◽

Armando J. Lorenzo ◽

Martin A. Koyle

Keyword(s):

Urinary Tract ◽

Vesicoureteral Reflux ◽

Urinary Tract Infections ◽

Renal Scarring ◽

High Rate ◽

Voiding Cystourethrography ◽

Low Grade ◽

Endoscopic Injection ◽

Febrile Uti ◽

Tract Infections

Urinary tract infections (UTIs) represent a common bacterial cause of febrile illness in children. Of children presenting with a febrile UTI, 25‒40% are found to have vesicoureteral reflux (VUR). Historically, the concern regarding VUR was that it could lead to recurrent pyelonephritis, renal scarring, hypertension, and chronic kidney disease. As a result, many children underwent invasive surgical procedures to correct VUR. We now know that many cases of VUR are low-grade and have a high rate of spontaneous resolution. The roles of surveillance, antibiotic prophylaxis, endoscopic injection, and ureteral reimplantation surgery also continue to evolve. In turn, these factors have influenced the investigation of febrile UTIs.Voiding cystourethrography (VCUG) is the radiographic test of choice to diagnose VUR. Due to its invasive nature and questionable benefit in many cases, the American Academy of Pediatrics (AAP) no longer recommends VCUG routinely after an initial febrile UTI. Nevertheless, these guidelines pre-date the landmark Randomized Intervention of Children with Vesicoureteral Reflux (RIVUR) trial and there continues to be controversy regarding the diagnosis and management of VUR. This paper discusses the current literature regarding radiographic testing in children with febrile UTIs and presents a practical risk-based approach for deciding when to obtain a VCUG.

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The Diagnosis and Treatment of Vesicoureteral Reflux: An Update

The Open Urology & Nephrology Journal ◽

10.2174/1874303x01508010096 ◽

2015 ◽

Vol 8 (1) ◽

pp. 96-103 ◽

Cited By ~ 1

Author(s):

Adam Rensing ◽

Paul Austin

Keyword(s):

Urinary Tract ◽

Vesicoureteral Reflux ◽

Renal Scarring ◽

Reflux Nephropathy ◽

Bowel Dysfunction ◽

Alternative Approach ◽

Febrile Uti ◽

Febrile Urinary Tract Infections ◽

Tract Infections ◽

Pediatric Providers

Vesicoureteral reflux [VUR] remains a common problem seen by pediatric providers. Despite a great deal of research, the debate regarding how to screen and treat patients reremains tense and controversial. This review seeks to summarize the management of VUR with emphasis on recent published findings in the literature and how they contribute to this debate. The goals of managing VUR include preventing future febrile urinary tract infections [FUTI], renal scarring, reflux nephropathy and hypertension. The topdown approach with upper tract imaging and selective vesicocystourethrogram [VCUG] is an emerging alternative approach in the evaluation of children after their first FUTI. The elimination of bladder and bowel dysfunction [BBD] is an important management strategy to prevent further FUTIs, regardless of treatment choice. Antibiotic prophylaxis is a safe and effective modality to sterilize the urinary tract. Endoscopic treatment of VUR is an attractive modality in select patients, although some concerns remain regarding its effectiveness and durability as compared to to the gold standard of open or laparoscopic ureteroneocystostomy. Lastly, further research is required to determine the most effective algorithm to evaluate the pediatric patient after the first febrile UTI.

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Bladder/bowel dysfunction at school age is seen in children with high‐grade vesicoureteral reflux and lower urinary tract dysfunction in infancy

Acta Paediatrica ◽

10.1111/apa.14973 ◽

2019 ◽

Vol 109 (2) ◽

pp. 388-395 ◽

Cited By ~ 1

Author(s):

Sofia Sjöström ◽

Helena Ekdahl ◽

Kate Abrahamsson ◽

Ulla Sillén

Keyword(s):

Urinary Tract ◽

Vesicoureteral Reflux ◽

Lower Urinary Tract ◽

Bowel Dysfunction ◽

Lower Urinary Tract Dysfunction ◽

School Age ◽

High Grade ◽

Bladder Bowel Dysfunction ◽

Lower Urinary

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Biomarkers in vesicoureteral reflux: an overview

Biomarkers in Medicine ◽

10.2217/bmm-2019-0378 ◽

2020 ◽

Vol 14 (8) ◽

pp. 683-696

Author(s):

Flávia C Valério ◽

Renata D Lemos ◽

Ana L de C Reis ◽

Letícia P Pimenta ◽

Érica LM Vieira ◽

...

Keyword(s):

Vesicoureteral Reflux ◽

Renal Scarring ◽

Reflux Nephropathy ◽

Serum Levels ◽

Cellular Adhesion ◽

High Grade ◽

Epigenetic Factors ◽

Cellular Adhesion Molecules ◽

Potential Biomarkers

Aim: This article aimed to review the role of cytokines, chemokines, growth factors and cellular adhesion molecules as biomarkers for vesicoureteral reflux (VUR) and reflux nephropathy (RN). Methods: We reviewed articles from 1979 onward by searching PubMed and Scopus utilizing the combination of words: ‘VUR’ or ‘RN’ and each one of the biomarkers. Results: Genetic, inflammatory, fibrogenic, environmental and epigenetic factors responsible for renal scarring need to be better understood. TGF-β, IL-10, IL-6, IL-8 and TNF seem to exert a role in VUR particularly in RN based on the current literature. Serum levels of procalcitonin have been also associated with high-grade VUR and RN. These molecules should be more intensively evaluated as potential biomarkers for renal scarring in VUR. Conclusion: Further studies are necessary to define which molecules will really be of utility in clinical decisions and as therapeutic targets for VUR and RN.

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LONG-TERM FOLLOW-UP OF REFLUX NEPHROPATHY IN ADULTS WITH VESICOURETERAL REFLUX - RADIOLOGICAL AND PATHOANATOMICAL ANALYSIS

Acta Radiologica ◽

10.1034/j.1600-0455.2001.420403.x ◽

2001 ◽

Vol 42 (4) ◽

pp. 355-364 ◽

Cited By ~ 1

Author(s):

J. Kohler ◽

H. Thysell ◽

J. Tencer ◽

L. Forsberg ◽

M. Hellstrom

Keyword(s):

Vesicoureteral Reflux ◽

Reflux Nephropathy ◽

Long Term Follow Up

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Endoscopic Injection of Dextranomer/Hyaluronic Acid as First Line Treatment in 851 Consecutive Children with High Grade Vesicoureteral Reflux: Efficacy and Long-Term Results

The Journal of Urology ◽

10.1016/j.juro.2018.03.074 ◽

2018 ◽

Vol 200 (3) ◽

pp. 650-655 ◽

Cited By ~ 9

Author(s):

Florian Friedmacher ◽

Eric Colhoun ◽

Prem Puri

Keyword(s):

Hyaluronic Acid ◽

Vesicoureteral Reflux ◽

Long Term Results ◽

High Grade ◽

Line Treatment ◽

First Line ◽

Endoscopic Injection ◽

First Line Treatment

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Adherence to Antibiotic Prophylaxis in Children with Vesicoureteral Reflux

Advances in Urology ◽

10.1155/2011/134127 ◽

2011 ◽

Vol 2011 ◽

pp. 1-6 ◽

Cited By ~ 5

Author(s):

Esequiel Rodriguez ◽

Dana A. Weiss ◽

Hillary L. Copp

Keyword(s):

Clinical Trial ◽

Antibiotic Prophylaxis ◽

Vesicoureteral Reflux ◽

Low Dose ◽

Renal Scarring ◽

Healthcare Providers ◽

Trial Outcomes ◽

Treatment Changes ◽

Antibiotic Failure

Vesicoureteral reflux (VUR) affects approximately 1% of children and may predispose a child with a bladder infection to develop pyelonephritis and renal scarring. To prevent these potential sequelae, one accepted treatment option for VUR includes low-dose continuous antibiotic prophylaxis (CAP) to maintain urine sterility until the condition resolves. Despite the widespread use of CAP, little data exists regarding adherence to long-term antibiotic therapy. Not only will poor adherence to CAP potentially preclude the intended benefit, but also nonadherence with antibiotic regimens may carry untoward effects including unnecessary treatment changes for presumed antibiotic failure, emergence of resistant organisms, and compromised clinical trial outcomes. We present an overview of medication adherence in children with VUR, discuss possible consequences of nonadherence to antibiotic prophylaxis, and suggest ways to improve adherence. We raise awareness of issues related to nonadherence relevant to healthcare providers, investigators, and the community.

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