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Paediatric Urology
expert hands due to refinement of the techniques means that we do prophylaxis was chosen by 5% and open surgery by 2%; 13% of the
not routinely perform voiding cystourethrogram after treatment; it is parents did not express any preference (see Table 2). If the results of
requested only if UTIs or ultrasound signs are present. The morbidity different therapeutic options are similar, we have to consider the
is minimal, with the procedure performed on an outpatient basis. patient’s/parents’ preference.
23
Dysuria and side effects are minimal, and the child returns to normal
activities within one day. The risk of ureteral obstruction is very rare These results suggest the need for a new algorithm for VUR
(fewer than 0.5% of cases) and transient (see Figure 3). management in children based on endoscopic treatment as the first
choice for intermediate- to high-grade VUR as an efficacious and
In expert hands, Deflux endoscopic treatment today presents similar safe alternative to open surgery. In lower-grade VUR, if the patient is
positive results to open surgery, with minimal invasiveness and symptomatic with recurrent febrile UTIs, endoscopic treatment
discomfort and without the severe adverse effects of open surgery. represents a valid alternative to long-term antimicrobial prophylaxis
Compared with antimicrobial prophylaxis, endoscopic treatment or occasional antibiotic administration (see Figure 4).
with Deflux was demonstrated in our randomised study to be
superior (8–10 versus 22%) in terms of the prevention of febrile Conclusion
UTIs
12
(see Table 1). The best treatment for VUR has still not been determined. In our
opinion, immediate treatment of VUR in infants and children using
No Prophylactic Treatment but Antimicrobial subureteric injection of Deflux is a fascinating new concept. It
Therapy for Febrile Urinary Tract Infections allows successful repair at the diagnosis of VUR with minimally
This strategy is based on recent observations of long-term invasive morbidity, and significantly reduces the rate of newly
antimicrobial prophylaxis.
10,11
Daily intake of an antimicrobial drug for developed febrile pyelonephritis, renal scarring, annual testing and
a long period presents low compliance, especially in children. In a use of prophylactic antimicrobials. These advantages are more
recent study by Hensle,
11
most children took antibiotics for less than evident within the first two years of life. Anxiety and stress on the
half the year (41.4% of the year). Subtherapeutic doses of family and invasive procedures on the child are also greatly
antimicrobial drugs could contribute to the onset of bacterial decreased.
23
Accurate medical and behavioural treatment of
resistance. Garin
4
observed a higher incidence of acute bladder and bowel dysfunction is necessary if abnormal voiding
pyelonephritis and new renal scarring in children supposed to habits (daytime incontinence, urgency, frequency) and constipation
receive long-term antimicrobial prophylaxis (12.9 and 9.0%, are present in toilet-trained children.
24,25
respectively) compared with those treated occasionally for acute
episodes (1.7 and 3.4%, respectively). However, a critical review of The urological and nephological approach to the child with VUR has
the literature data by the Cochrane Renal Group showed no greatly changed in recent years and is still evolving. Congenital
significant difference in terms of the risk of symptomatic IVU or renal hypodysplasia is well recognised, and we can reduce the risk
renal damage comparing antimicrobial prophylaxis versus no of symptomatic UTIs and new renal scarring.
26
The advent of
treatment. A bias of the study could be the small number of enrolled minimally invasive and cost-effective endoscopic treatment is
patients.
6
A similar experience was recently reported by an Italian strongly modifying the natural history of children suffering from
multicentre, randomised, prospective study.
5
congenital VUR and recurrent febrile UTIs. Dysfunctional elimination
syndrome is well recognised in school-age children and requires
In conclusion, although definitive confirmation is required, the role appropriate uropathy. n
of antimicrobial prophylaxis in preventing UTIs and new renal
scarring is now under discussion.
Paolo Caione is Chief of the Division of Paediatric
Urology and Head of the Nephrology-Urology
A New Therapeutic Algorithm Department at ‘Bambino Gesù’ Children’s Hospital in
In the absence of definitive results for the different therapeutic
Rome. He is President of the Italian Society of Paediatric
Urology (SIUP) and a member of several scientific
options in grade 3–4 VUR, we must offer children and their parents
societies, including the European Society for Paediatric
correct information on the different options and consider their Urology (ESPU), the Italian Society of Urology (SIU), the
preference. At our institution,
23
we provide detailed information on
Italian Society of Paediatric Surgery (SICP), the American
Academy of Pediatrics (AAP) urology section and the
the mechanism of action, cure rate, possible complications and pros
International Continence Society (ICS). Dr Caione has published more than 550 articles,
and cons of the different therapeutic options. The great majority of and is Editor or Co-editor of three monographs on paediatric urology.
parents (80%) prefer endoscopic treatment, whereas antibacterial
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1837–41. 716–22. 19. Shu T, Cisek LJ Jr, Moore RG, J Endourol, 2004;18:441–6.
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2006;117(3):626–32. 11. Hensle TW, Grogg AL, Eaddy M, Nat Clin Pract Urol, 22. Capozza N, Lais A, Nappo S, Caione P, J Urol,
5. Montini G, Rigon L, Zucchetta P, et al., Pediatrics, 2007;4(9):462–3. 2004;172:1626–9.
2008;122(5):1064–71. 12. Capozza N, Caione P, J Pediatr, 2002;140(2):230–34. 23. Capozza N, Lais A, Matarazzo E, BJU Int, 2003;92(3):285–8.
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Cochrane Library, 2007;3. 2006;21(6):785–92. 25. Capozza N, Lais A, Matarazzo E, et al., J Urol, 2002;168(4 Pt
7. Caione P, Villa M, Capozza N, et al., BJU Int, 14. Greenfield SP, Expert Opin Pharmacother, 2003;4(11):1959–66. 2):1695–8.
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