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Paediatric Urology
Vesico-ureteral Reflux in Paediatric Patients – Update on Treatment
Paolo Caione
Chief, Division of Paediatric Urology, and Head, Department of Nephrology-Urology, ‘Bambino Gesù’ Children’s Hospital, Rome
Abstract
The pathogenesis and the appropriate treatment of vesico-ureteral reflux (VUR) and correlated nephropathy is still very controversial,
despite its frequence in infancy and childhood. We reviewed the pathogenetic hypothesis and the current management options of VUR and
related nephropathy. VUR prevalence is estimated at up to 1% of children within three years of age. In newborns and infants, VUR is more
severe and frequent in male gender compared with pre-school and school-age girls with recurrent urinary tract infections (UTIs). Renal
damage occurs in 40–45% of VUR as a consequence of acquired renal scarring secondary to febrile acending UTIs. Recently, pre-natally
determined renal hypodysplasia has been recognised as congenital nephropathy associated with VUR. Appropriate VUR treatment is still
not defined, as long-term antimicrobial prophylaxis and early surgery by open or laparoscopic techniques have classically been adopted.
Endoscopic treatment by subureteral bulking agents (i.e. dextranomer in jaluronic acid) has recently gained popularity. The role of
antimicrobial prophylaxis in presenting UTIs and new renal damage has been discussed and no prophylactic treatment has been
advocated. In conclusion, definitive results on the different therapeutic options are still lacking. Correct information and minimally invasive,
early endoscopic treatment should be offered, taking into account the preference of the parents. Dysfunctional elimination syndrome
requires appropriate urotherapy in any toilet-trained child with abnormal voiding habits.
Keywords
Vesico-ureteral reflux, reflux nephropathy, endoscopic treatment, antimicrobial prophylaxis, urinary tract Infections (UTIs), ureteral re-implantation
Disclosure: The author has no conflicts of interest to declare.
Received: 13 May 2009 Accepted: 10 July 2009
Correspondence: Paolo Caione, Primario Divisione Chirurgia Urologica, Direttore Di Dipartimento Nefrologia-Urologia, Ospedale Pediatrico Bambino Gesù, IRCCS,
Piazza S Onofrio, 4, 00165 Rome, Italy. E:
caione@opbg.net
Vesico-ureteral Reflux and Related high intravesical pressure occurs during dysfunctional voiding has
Nephropathy in Infants and Children led researchers to consider that VUR may develop in high-pressure
The optimal management of vesico-ureteral reflux (VUR) in infants emptying bladders.
3
So far, disorders of the lower urinary tract and
and children remains one of the most controversial questions in VUR have been considered from a functional rather than a
paediatric urology. A wide spectrum of therapeutic strategies have structural point of view.
been proposed, adopted and sometimes discouraged over the last
two to three decades. The new clinical approach to VUR treatment The ‘Reflux Nephropathy’
is the result of a significant evolution of new concepts in bladder Renal damage is present in about 40–45% of VUR in pre-school-age
and lower urinary tract pathophysiology and new knowledge of children. It was considered a consequence of acquired renal
renal parenchyma damage concerning acquired and congenital scarring secondary to febrile ascending UTI. Recent studies have
reflux nephropathy. demonstrated that VUR is often associated with congenital
nephropathy (renal hypodysplasia), which is determined pre-
VUR is a well-recognised urological abnormality characterised by natally
6,7
(see Figure 1). Any febrile acute intravenous urography (IVU)
retrograde urine flow from the bladder to the kidneys through the that might occur in a child with VUR could cause only limited further
ureters. Its prevalence is estimated to be up to 1% of children in the parenchymal damage. Males are at greater risk compared with
first three years of life, with differences between males and females females
7
(see Figure 2).
in infancy and school age.
1–4
The significance of VUR in paediatrics
has been strongly debated in the last few years. Very few Management of Vesico-ureteral Reflux
randomised controlled studies have been available until now to Just as the pathogenesis of the consequences of VUR on renal
confirm the role of VUR in the pathogenesis of recurrent urinary parenchyma is controversial, the appropriate treatment of children
tract infections (UTIs), febrile ascending pyelonephritis and the with VUR is still debated. Some physicians take a completely non-
onset of renal scars.
1,4,5
The refluxing uretero–vesical junction was treatment approach to VUR, while other urologists suggest early
initially considered only as a consequence of a structural defect of surgical intervention using open techniques, and, lastly, minimally
the uretero–trigonal junction. More recently, the observation that invasive procedures such as endoscopic treatment by bulking
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