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Paediatric Urology
Interventional Treatment for Children with Vesicoureteral Reflux
a report by
Saul P Greenfield
Professor of Urology, School of Medicine and Biomedical Sciences, State University of New York at Buffalo, and
Director, Pediatric Urology, Women and Children’s Hospital of Buffalo
Until recently it was recommended that all children who present with Roussey published a study purporting to show that antibiotic prophylaxis
a urinary tract infection (UTI) must be evaluated for vesicoureteral in infant boys and girls with low-grade (I, II and III) reflux offers
reflux with a cystourethrogram (VCUG). The aetiological association little therapeutic advantage.
10
The average age of entrance into the study
between reflux and infection was assumed, as up to 40% of children was around one year, and two groups – equally matched for gender and
with infection are found to have reflux. Evidence from the 1960s reflux grade – were observed on either trimethoprim/sulfamethoxazole
appeared to demonstrate that the diagnosis and treatment of (TMP/SMZ) or no drug for 18 months. The end-point was UTI. Cultures
reflux were necessary to prevent further infection and renal scarring were obtained for fever or urinary symptoms in the presence of abnormal
from pyelonephritis. urinary dipstick findings. Urine specimens were obtained by collection bag
in non-toilet-trained children, which can result in many false-positive
This literature is now being questioned and conventional diagnostic cultures in boys and girls. None of the boys were circumcised. DMSA renal
and therapeutic recommendations are being challenged. Some scans were not routinely performed at entry or exit from the study. Slightly
specialists now allege that the radiographic detection of reflux is not more children in the non-prophylaxis group (26%) had UTIs than in the
necessary in all children after an infection. In 2007, the National Health medicated group (17%), but this was not statistically significant. One-
Service (NHS) in the UK recommended that a VCUG not be routinely quarter of children with UTIs in the prophylaxis group had organisms that
performed after a UTI.
1
However, this recommendation has been were sensitive to medication, suggesting non-compliance. However, boys
severely criticised.
2
Furthermore, when reflux is detected, the with grade III reflux appeared to fare much better on prophylaxis. Despite
recommendations for treatment are controversial and contradictory. these weaknesses, the authors concluded that antibiotic prophylaxis
Depending on the consultant, a child with reflux may be placed on confers little benefit for most children with low-grade reflux, and
long-term antibiotic prophylaxis, be observed off prophylaxis or suggested that a VCUG may not be necessary or appropriate after an
undergo a surgical procedure, such a cystoscopic deflux injection or an episode of pyelonephritis.
openintra-vesical, extra-vesical or laparoscopic ureteral reimplantation.
In a study of a group of infants with grade II–IV reflux, Pennesi similarly
Paediatric urologists have been basing their recommendations on three concluded that continuous antibiotic prophylaxis was ineffective in
decades of poorly controlled studies. These studies suggested that reducing the rate of pyelonephritis compared with controls who were not
episodic treatment of infections in patients with known reflux resulted prophylaxed.
11
Again, the boys were not circumcised and bagged
in unacceptably high rates of new renal damage.
3,4
These older studies specimens were accepted. The study was not blinded or placebo-
were not blinded or controlled, relied on intravenous pyelograms to controlled, compliance with a medical regimen was not assessed or
detect scarring instead of radionuclide imaging and did not use an enforced and DMSA scans were not performed in all patients.
international classification system. The few prospective studies that
were controlled compared surgery with continuous prophylaxis, such as Rates of renal disease secondary to reflux have remained unchanged over
the International Reflux Study or the Birmingham Co-operative Study, three decades in one Australian study, suggesting that the identification
but did not have an observation arm.
5,6
Cooper and Thompson and treatment of reflux has not reduced the incidence of clinically
prospectively observed children with reflux on and off prophylaxis, and significant ‘reflux nephropathy’.
12
On the other hand, data from the US
found similar rates of infection.
7,8
However, in these two studies show a significant decrease in both reflux-related paediatric end-stage
scarring was often assessed by renal ultrasounds, not renal disease and hypertension.
13,14
In a recent meta-analysis, only eight
dimercaptosuccinic acid (DMSA) renal scans, and voiding function was
not routinely or prospectively measured.
Saul P Greenfield is a Professor of Urology at the State
University of New York at Buffalo and Director of Pediatric
A number of more recently published studies have also concluded that Urology at the Women and Children’s Hospital of Buffalo.
antibiotic prophylaxis was not useful in children with reflux. However,
He is a member of the American Urological Association
(AUA) and a Fellow of the American Academy of Pediatrics
they all have significant flaws. Garin looked at a small group of
(AAP) and the American College of Surgeons (ACS). Dr
children with reflux off prophylaxis, and after one year their rate
Greenfield graduated from the University of Pennsylvania
School of Medicine. He trained in urology at the Columbia-
of infection was similar to those on medication.
9
The data were
Presbyterian Medical Center in New York, and completed a
unclear regarding sex, grade, circumcision status or voiding fellowship in paediatric urology at the Women and Children’s Hospital of Buffalo. He is
dysfunction in those with breakthrough infection. There was also a
certified in urology and paediatric urology by the American Board of Urology (ABU).
very wide age distribution – up to 18 years – and we know that E: spg@acsu.buffalo.edu
infections are less likely in older children.
© TOUCH BRIEFINGS 2008 125