Caione_final_Layout 1 13/10/2009 13:02 Page 86
Figure 1: Risk of Chronic Renal Failure in Infants with Figure 3: Voiding Cystourethrogram and Endoscopic
High-grade Vesico-ureteral Reflux Treatment of Left Vesico-ureteral Reflux
CRF No CRF
Among 50 infants presenting high-grade bilateral vesico-ureteral reflux (VUR) detected at
<1 year of age, 27 (54%) were at risk of long-term renal failure (chronic renal failure [CRF]).
Figure 2: Gender Distribution of Chronic Renal Failure in
50 Infants with Bilateral Gross Vesico-ureteral Reflux
Males A: Voiding cystogram of a male boy, four years of age, with recurrent febrile urinary tract
infections (UTIs): severe left vesico-ureteral reflux (VUR) with complete extravesicalisation of
At risk of CRF Not at risk
the uretero–vesical junction. B: Endoscopic treatment of the gross dilated ureteral orifice by
metallic needle and ureteral catheter to guide the endoscopic procedure. C: Modified
endoscopic view of the ureteral orifice and immediate VUR resolution.
100% on the basis of an accurate meta-analysis; seven different
treatment modalities were recommended depending on the
radiological degree of VUR and the clinical features of the
Below we present the main therapeutic options, which
are still under debate.
The basic principle of long-term antimicrobial prophylaxis assumes
that VUR tends to spontaneously regress over a three- to 10-year
period. Pending this spontaneous solution, UTIs must be prevented
by daily administration of low-dose antimicrobial drugs (50 or 30% of
At risk of CRF Not at risk
therapeutic dose) to reduce the risk of pyelonephritic episodes and
new renal scarring.
Twenty-seven of 42 males presented with chronic renal failure (CRF) (64.3%) compared with
none of the eight females.
Various medications are used. Sulphonamides and nitrofurantoine
agents have recently gained popularity. Long-term antibacterial are commonly given in northern Europe and North America. The
prophylaxis or treatment of only single episodes of UTIs are adopted advantages of these drugs are their low cost and good stability in
by different urologists and nephrologists. solution and at room temperature; however, side effects are also
described: allergic reactions, granulocytopenia and gastric
Very few randomised prospective studies have been published intolerance. They are not recommended in young infants and
comparing long-term prophylaxis with conservative observation newborns. In other countries, such as as Italy, amoxicillin with
and prompt treatment of single episodes of UTIs in order to reduce clavulanic acid and third-generation oral cephalosporins is
the frequency and severity of febrile UTIs and prevent renal preferred. However, the ‘compliance’ of children and parents to
In 1997, the American Urological long-term administration of antimicrobial medications has been
Association (AUA) processed specific guidelines for VUR treatment evaluated at less than 20%, and residual antibacterial power is less
86 EUROPEAN UROLOGICAL REVIEW