PMCCPMCCPMCC

Search tips
Search criteria 

Advanced

 
Logo of cuajLink to Publisher's site
 
Can Urol Assoc J. 2010 August; 4(4): 276–278.
PMCID: PMC2910775

Medical versus surgical management for vesicoureteric reflux: the case for medical management

Armando J. Lorenzo, MD, MSc, FRCSC, FAAP

Many scientists have recently written about the virtues of different approaches to manage children with vesicoureteral reflux (VUR).117 Nevertheless, the topic often departs from evidence-based medicine, moving towards more subjective (and difficult to challenge) arenas.18 Unfortunately, the available level of evidence is rather modest, and we continue to practice based on limited data, which mostly address short-term and relatively meaningless outcomes.19 Isn’t it surprising that the time-honoured practice of antibiotic prophylaxis (ABP) has not been seriously subjected to rigorous evaluation through randomized controlled trials until relatively recently?2024 Comparative analyses including conservative (i.e., no intervention or medical management) versus different surgical treatments, as well as evaluation of important issues (such as the development of complications during later pregnancy, hypertension or chronic kidney disease) lag far behind. Even though ongoing efforts are encouraging, such as the Randomized Intervention for Children With Vesicoureteral Reflux (RIVUR) trial,2527 with all the deficiencies and shortcomings of the current knowledge, it is difficult to confidently debate for or against any reasonable treatment option.

What’s more, the basic assumption that there should be a favoured approach underscores a serious flaw in the way we view VUR. Arguably, not all patients with reflux are the same, and our ultimate goal should not be to broadly contend with strategies, but to better risk-stratify patients and offer the best treatment option(s) for each particular case. This is the case for other conditions, many of which have been studied in a more rigorous fashion, such as myocardial infarction; these patients are offered treatment options based on characteristics that go beyond the presence of a diseased coronary artery.28 Nevertheless, in consideration to the task at hand, I will support the role of medical management, which I have taken the liberty to expand and include other non-surgical interventions beyond ABP (time, patience, family education about appropriate evaluation and management of a febrile illness, treatment of constipation and dysfunctional elimination disorders and the optimization of fluid intake).

A quick look at the bigger picture would remind us that children without documented reflux get pyelonephritis, scarring and recurrences.29 These patients deserve a similar degree of concern as the ones who matter in this debate, yet the absence of a surgical treatment excludes them. I would argue that reflux or not, the presence of recurrent infections reflects the complex interaction between host and bacteria; reflux is an additional risk factor in the process that seems to get a lot of attention, partly because it is amenable to surgical correction. Moreover, surgical management focuses on the mechanical problem, while medical management attempts to attack from alternative angles: bacterial colonization (regular bladder emptying), time (spontaneous resolution), damage prevention (ABP, early treatment of infections) and selective invasive intervention (allowing the natural history of the disease dictate which ones may deserve a more aggressive approach). Indeed, as well-stated by Snodgrass, “we treat many to prevent problems in a few.”30 If so, is overtreatment best carried out with a scalpel, scope & needle or with a medicine bottle and some advice? Even though I often question the “need” to treat, if we feel compelled to do so, why not employ the least invasive interventions first? Unfortunately, conservative management entails a more labour-intensive and less of a quick fix solution to the problem. Seen from a different perspective, surgical correction alone carries the risk of disregarding important risk factors leading to problems down the road despite the initial radiological “success.”13,31,32 Addressing pelvic floor dynamics, fluid intake and elimination habits3336 can carry more weight (and potentially have a longer duration of benefit) than some of the surgical procedures we offer.

There is little argument that primary reflux is associated with the presence of upper tract abnormalities and, in the setting of upper tract infections, is associated with acquired renal scars.37 The issue is not so much the association, but the impact our treatment has on decreasing or eliminating the risk of future lesions and minimizing morbidity. I hope our readers will agree that the main question is how to best approach this patient population when we lack the tools to differentiate those at risk from the ones who will do well no matter what. Long-term, the important consequences of infection are limited to a subgroup. Is it reasonable to assume superiority of surgical management in the prevention of adverse outcomes related to VUR in these children? Some of the best long-term evidence does not heavily favour surgery over medical treatment, particularly for important long-term issues.3840 Furthermore, we sometimes promulgate surgery not considering that some of the best data is rather old (International Reflux Study [IRS] trial), and reflects the “gold standard” of surgery (open ureteral reimplantation).4143 The more recently introduced and widely embraced approach, endoscopic injection, has a more uncertain track record, particularly in terms of preventing long-term complications and durability.31,33,4446 Moreover, the patient population has changed and increasingly includes children diagnosed based on the presence of antenatal hydronephrosis with a potentially lower risk of progressive renal damage (the “diagnostic shift” recently discussed by Peters30). Accordingly, I would propose to opt for the non-invasive option until we categorically prove superiority or become wise at selecting those who need no treatment, those who will do fine with ABP and those who benefit from early surgery. In the meantime, we can at least agree that drinking adequate amounts of water, voiding regularly, avoiding constipation and educating families about early evaluation and management of a febrile illness or lower urinary tract symptoms are wise recommendations with little downside and lots of potential benefits.

I foresee a few criticisms to medical management, namely the questionable efficacy of ABP,24,41 problems with compliance47 and the worrisome development of resistance.48,49 These are valid points that highlight the need for better treatment options and predictive tools. The leap comes when we use these limitations to advocate for early or upfront surgical intervention.50 Is it because we feel we must do something? I would argue that if daily antibiotics are indeed a poor prophylactic measure, then many patients have historically done fairly well without much treatment. We may then accept that little treatment is needed for many, opt for medical management first, and try to minimize as much as possible the diagnostic and therapeutic plan. Growing evidence suggests that we can decrease the use of antibiotics without resorting to invasive interventions.5153 The “top-down” approach and the National Institute for Health and Clinical Excellence (NICE) guidelines already call for a less invasive evaluation.54 Why? It is likely because not being aware of a reflux that has a low potential of causing harm is probably better than finding out about a process where the cure can be worse than the disease. Again, the concept of risk-stratification comes into play.

So, dear reader, who won the debate? I hope no one. Sadly, regardless of the spin placed on the problem, besides overtreating we may still be undertreating, or can’t really do much, for those who already have marginal kidneys or significant damage.55 This forum highlights limitations in our knowledge and should serve as an irritant making us so uncomfortable with the current approach that it has the potential to revolutionize management by critically questioning our standards of care, seriously embracing the issue, focusing on disease modification that translates into lower morbidity, less anxiety and better long-term outcomes. We must continue to review our diagnostic and treatment paradigms following a sound conceptual framework (Fig. 1).

Fig. 1
Proposed conceptual framework for diagnostic and treatment strategies in patients with urinary tract infections. DES: dysfunctional elimination syndrome; Tx: treatment; UTIs: urinary tract infections; VUR: vesicoureteral reflux.

Footnotes

Competing interests: None declared.

This paper has been peer-reviewed.

References

1. Aaronson IA. Does deflux alter the paradigm for the management of children with vesicoureteral reflux? Curr Urol Rep. 2005;6:152–6. [PubMed]
2. Canning DA. Deflux for vesicoureteral reflux: pro--the case for endoscopic correction. Urology. 2006;68:239–41. [PubMed]
3. Cendron M. Endoscopic treatment for vesicoureteral reflux: let’s not get carried away! Urology. 2006;68:242–3. [PubMed]
4. Cendron M. Antibiotic prophylaxis in the management of vesicoureteral reflux. Adv Urol. 2008;825475 [PMC free article] [PubMed]
5. Cooper CS. Diagnosis and management of vesicoureteral reflux in children. Nat Rev Urol. 2009;6:481–9. [PubMed]
6. Cooper CS, Austin JC. Vesicoureteral reflux: who benefits from surgery? Urol Clin North Am. 2004;31:535–41. x. [PubMed]
7. Dave S, Khoury AE. The current evidence based medical management of vesicoureteral reflux: The Sickkids protocol. Indian J Urol. 2007;23:403–13. [PMC free article] [PubMed]
8. Elder JS, Shah MB, Batiste LR, et al. Part 3: Endoscopic injection versus antibiotic prophylaxis in the reduction of urinary tract infections in patients with vesicoureteral reflux. Curr Med Res Opin. 2007;23:S15–20. [PubMed]
9. Escribano Subias J, Fraga Rodriguez G. Conservative versus interventional treatment of primary vesicoureteral reflux in children (article in Spanish) Arch Esp Urol. 2008;61:229–35. [PubMed]
10. Faust WC, Pohl HG. Role of prophylaxis in vesicoureteral reflux. Curr Opin Urol. 2007;17:252–6. [PubMed]
11. Greenfield SP. Management of vesicoureteral reflux in children. Curr Urol Rep. 2001;2:113–21. [PubMed]
12. Herndon CD, DeCambre M, McKenna PH. Changing concepts concerning the management of vesicoureteral reflux. J Urol. 2001;166:1439–43. [PubMed]
13. Lorenzo AJ, Khoury AE. Endoscopic treatment of reflux: management pros and cons. Curr Opin Urol. 2006;16:299–304. [PubMed]
14. MacNeily AE. Pediatric urinary tract infections: current controversies. Can J Urol. 2001;8(Suppl1):18–23. [PubMed]
15. McLorie GA. Vesicoureteral reflux: where have we been, where are we now, and where are we going? Adv Urol. 2008;459630 [PMC free article] [PubMed]
16. Puri P. Endoscopic correction of vesicoureteral reflux. Curr Opin Urol. 2000;10:593–7. [PubMed]
17. Stenberg A, Hensle TW, Lackgren G. Vesicoureteral reflux: a new treatment algorithm. Curr Urol Rep. 2002;3:107–14. [PubMed]
18. Isaacs D, Fitzgerald D. Seven alternatives to evidence based medicine. BMJ. 1999;319:1618. [PMC free article] [PubMed]
19. Estrada CR, Jr, Passerotti CC, Graham DA, et al. Nomograms for predicting annual resolution rate of primary vesicoureteral reflux: results from 2,462 children. J Urol. 2009;182:1535–41. [PubMed]
20. Roussey-Kesler G, Gadjos V, Idres N, et al. Antibiotic prophylaxis for the prevention of recurrent urinary tract infection in children with low grade vesicoureteral reflux: results from a prospective randomized study J Urol 2008. 179674–9.9; discussion 679. [PubMed]
21. Pennesi M, Travan L, Peratoner L, et al. Is antibiotic prophylaxis in children with vesicoureteral reflux effective in preventing pyelonephritis and renal scars? A randomized, controlled trial. Pediatrics. 2008;121:e1489–94. [PubMed]
22. Montini G, Rigon L, Zucchetta P, et al. Prophylaxis after first febrile urinary tract infection in children? A multicenter, randomized, controlled, noninferiority trial. Pediatrics. 2008;122:1064–71. [PubMed]
23. Garin EH, Olavarria F, Garcia Nieto V, et al. Clinical significance of primary vesicoureteral reflux and urinary antibiotic prophylaxis after acute pyelonephritis: a multicenter, randomized, controlled study. Pediatrics. 2006;117:626–32. [PubMed]
24. Craig JC, Simpson JM, Williams GJ, et al. Antibiotic prophylaxis and recurrent urinary tract infection in children. N Engl J Med. 2009;361:1748–59. [PubMed]
25. Mathews R, Carpenter M, Chesney R, et al. Controversies in the management of vesicoureteral reflux: the rationale for the RIVUR study. J Pediatr Urol. 2009;5:336–41. [PMC free article] [PubMed]
26. Greenfield SP, Chesney RW, Carpenter M, et al. Vesicoureteral reflux: the RIVUR study and the way forward. J Urol. 2008;179:405–7. [PubMed]
27. Keren R, Carpenter MA, Hoberman A, et al. Rationale and design issues of the Randomized Intervention for Children With Vesicoureteral Reflux (RIVUR) study. Pediatrics. 2008;122:S240–50. [PMC free article] [PubMed]
28. Kushner FG, Hand M, Smith SC, Jr, et al. 2009 focused updates: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction (updating the 2004 guideline and 2007 focused update) and ACC/AHA/SCAI guidelines on percutaneous coronary intervention (updating the 2005 guideline and 2007 focused update) a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2009;54:2205–41. [PubMed]
29. Rushton HG, Majd M, Jantausch B, et al. Renal scarring following reflux and nonreflux pyelonephritis in children: evaluation with 99mtechnetium-dimercaptosuccinic acid scintigraphy. J Urol. 1992;147:1327–32. [PubMed]
30. Peters CA. Challenging the orthodoxy in vesicoureteral reflux: a perfect storm. J Urol. 2008;179:1666–7. [PubMed]
31. Sedberry-Ross S, Rice DC, Pohl HG, et al. Febrile urinary tract infections in children with an early negative voiding cystourethrogram after treatment of vesicoureteral reflux with dextranomer/hyaluronic acid J Urol 2008. 1804Suppl1605–9.9; discussion 1610. [PubMed]
32. Traxel E, DeFoor W, Reddy P, et al. Risk factors for urinary tract infection after dextranomer/hyaluronic acid endoscopic injection. J Urol. 2009;182(4Suppl):1708–12. [PubMed]
33. Chi A, Gupta A, Snodgrass W. Urinary tract infection following successful dextranomer/hyaluronic acid injection for vesicoureteral reflux. J Urol. 2008;179:1966–9. [PubMed]
34. Koff SA, Wagner TT, Jayanthi VR. The relationship among dysfunctional elimination syndromes, primary vesicoureteral reflux and urinary tract infections in children. J Urol. 1998;160(3Pt2):1019–22. [PubMed]
35. Whittam BM, Thomasch JR, Makari JH, et al. Febrile urinary tract infection after ureteroneocystostomy: a contemporary assessment at a single institution. J Urol. 2010;183:688–92. [PubMed]
36. Upadhyay J, Bolduc S, Bagli DJ, et al. Use of the dysfunctional voiding symptom score to predict resolution of vesicoureteral reflux in children with voiding dysfunction J Urol 2003. 1691842–6.6; discussion 1846; author reply 1846. [PubMed]
37. Swerkersson S, Jodal U, Sixt R, et al. Relationship among vesicoureteral reflux, urinary tract infection and renal damage in children J Urol 2007. 178647–51.51; discussion 650–1. [PubMed]
38. Jodal U, Smellie JM, Lax H, et al. Ten-year results of randomized treatment of children with severe vesicoureteral reflux. Final report of the International Reflux Study in Children. Pediatr Nephrol. 2006;21:785–92. [PubMed]
39. Olbing H, Smellie JM, Jodal U, et al. New renal scars in children with severe VUR: a 10-year study of randomized treatment. Pediatr Nephrol. 2003;18:1128–31. [PubMed]
40. Smellie JM, Tamminen-Mobius T, Olbing H, et al. Five-year study of medical or surgical treatment in children with severe reflux: radiological renal findings. The International Reflux Study in Children. Pediatr Nephrol. 1992;6:223–30. [PubMed]
41. Hodson EM, Wheeler DM, Vimalchandra D, et al. Interventions for primary vesicoureteric reflux. Cochrane Database Syst Rev. 2007:CD001532. [PubMed]
42. Duckett JW, Walker RD, Weiss R. Surgical results: International Reflux Study in Children--United States branch. J Urol. 1992;148(5Pt2):1674–5. [PubMed]
43. Weiss R, Duckett J, Spitzer A. Results of a randomized clinical trial of medical versus surgical management of infants and children with grades III and IV primary vesicoureteral reflux (United States). The International Reflux Study in Children. J Urol. 1992;148(5Pt2):1667–73. [PubMed]
44. Routh JC, Inman BA, Reinberg Y. Dextranomer/hyaluronic acid for pediatric vesicoureteral reflux: systematic review. Pediatrics. 2010;125:1010–9. [PubMed]
45. Chertin B, Kocherov S. Long-term results of endoscopic treatment of vesicoureteric reflux with different tissue-augmenting substances J Pediatr Urol Epub 2009 Nov 5. [PubMed]
46. Lee EK, Gatti JM, Demarco RT, Murphy JP. Long-term followup of dextranomer/hyaluronic acid injection for vesicoureteral reflux: late failure warrants continued followup J Urol 2009. 1811869–74.74; discussion 1874–5. [PubMed]
47. Hensle TW, Hyun G, Grogg AL, et al. Part 2: Examining pediatric vesicoureteral reflux: a real-world evaluation of treatment patterns and outcomes. Curr Med Res Opin. 2007;23:S7–13. [PubMed]
48. Conway PH, Cnaan A, Zaoutis T, et al. Recurrent urinary tract infections in children: risk factors and association with prophylactic antimicrobials. JAMA. 2007;298:179–86. [PubMed]
49. Allen UD, MacDonald N, Fuite L, et al. Risk factors for resistance to “first-line” antimicrobials among urinary tract isolates of Escherichia coli in children. CMAJ. 1999;160:1436–40. [PMC free article] [PubMed]
50. Nelson CP, Copp HL, Lai J, et al. Is availability of endoscopy changing initial management of vesicoureteral reflux? J Urol. 2009;182:1152–7. [PMC free article] [PubMed]
51. Al-Sayyad AJ, Pike JG, Leonard MP. Can prophylactic antibiotics safely be discontinued in children with vesicoureteral reflux? J Urol 2005. 1744Pt21587–9.9; discussion 1589. [PubMed]
52. Alconcher LF, Meneguzzi MB, Buschiazzo R, et al. Could prophylactic antibiotics be stopped in patients with history of vesicoureteral reflux? J Pediatr Urol. 2009;5:383–8. [PubMed]
53. Thompson RH, Chen JJ, Pugach J, et al. Cessation of prophylactic antibiotics for managing persistent vesicoureteral reflux. J Urol. 2001;166:1465–9. [PubMed]
54. National Institute for Health and Clinical Excellence UTI in children. http://www.nice.org.uk/nicemedia/pdf/CG54quickrefguide.pdf Accessed June 23,2010.
55. Craig JC, Irwig LM, Knight JF, et al. Does treatment of vesicoureteric reflux in childhood prevent end-stage renal disease attributable to reflux nephropathy? Pediatrics. 2000;105:1236–41. [PubMed]

Articles from Canadian Urological Association Journal are provided here courtesy of Canadian Urological Association