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  • Review Article
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Diagnosis and management of vesicoureteral reflux in children

Nature Reviews Urology volume 6, pages 481–489 (2009)Cite this article

Abstract

Critical evaluation of previously accepted dogma regarding the evaluation and treatment of vesicoureteral reflux (VUR) has raised significant questions regarding all aspects of VUR management. Whereas the standard of care previously consisted of antibiotic prophylaxis for any child with VUR, it is now unclear which children, if any, truly benefit from antibiotic prophylaxis. Operative intervention for VUR constitutes overtreatment in many children, yet there are limited data available to indicate which children benefit from VUR correction through decreased rates of adverse long-term clinical sequelae. Studies with longer follow-up demonstrate decreased efficacy of endoscopic therapy that was previously hoped to approach the success of ureteroneocystostomy. Prospective studies might identify risk factors for pyelonephritis and renal scarring without antibiotic prophylaxis. Careful retrospective reviews of adults with a history of reflux might allow childhood risk factors for adverse sequelae to be characterized. Through analysis of multiple characteristics, better clinical management of VUR on an individualized basis will become the new standard of care.

Key Points

  • Many children with vesicoureteral reflux (VUR) do not benefit from either diagnosis or treatment of their condition

  • Prospective studies have not demonstrated utility of antibiotic prophylaxis in preventing urinary tract infections in many children with VUR

  • Prospective studies generally showed no difference in renal function or growth, progression or development of new scars, or urinary tract infections in those treated by operative intervention versus prophylactic antibiotics

  • Increasing grades of reflux and renal scars identify a higher risk group for subsequent renal damage and long-term clinical sequelae

  • Better definition of children likely to benefit from intervention remains the greatest challenge to the advancement of VUR management

  • Management decisions are complex and require an individualized approach, taking into account numerous variables

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Figure 1: Diagram of the bladder submucosal tunnel.
Figure 2: International Reflux Grading System.
Figure 3: Voiding cystourethrogram, demonstrating right-sided reflux with a periureteral diverticulum (arrows).
Figure 4: Dimercaptosuccinic acid scintigraphy with single photon emission computed tomography imaging demonstrating a cortical defect in the upper pole of the left kidney.
Figure 5: Endoscopic injection for vesicoureteral reflux.
Figure 6: Common ureteral re-implantation techniques for correction of vesicoureteral reflux.
Figure 7: User interface of a neural network for predicting the chance and timing of spontaneous resolution of vesicoureteral reflux based on a 2-year resolution model.

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Acknowledgements

Désirée Lie, University of California, Irvine, CA, is the author of and is solely responsible for the content of the learning objectives, questions and answers of the MedscapeCME-accredited continuing medical education activity associated with this article.

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    Christopher S. Cooper

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Cooper, C. Diagnosis and management of vesicoureteral reflux in children. Nat Rev Urol 6, 481–489 (2009). https://doi.org/10.1038/nrurol.2009.150

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