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Indian Pediatr 2018;55: 1039-1040 |
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Current Perspectives in Management of
Vesicoureteral Reflux
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Shandip Kumar Sinha 1
and Amit Agarwal2
From the Departments of 1Pediatric Surgery
and Pediatric Urology, and 2Pediatric Nephrology; Madhukar
Rainbow Children Hospital, Delhi, India.
Email: [email protected]
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V esicoureteral reflux (VUR) is a major contributor
to renal morbidity in children and its management is controversial. The
two major goals of management of VUR have been prevention of urinary
tract infection (UTI) and renal damage. The treatment options for VUR
include watchful waiting, continuous antibiotic prophylaxis (CAP), and
endoscopic (injection of tissue bulking substances) and surgical (open,
laparoscopic, robotic) strategies. Each of these has certain advantage
and disadvantages. Continuous antibiotic prophylaxis (CAP) has been
efficacious in reducing the risk of UTI in children with VUR and
evidence for the same is based on sufficiently powered studies [1].
However, CAP may be hampered by poor compliance; the Randomized
Intervention for Children with Vesicoureteral Reflux (RIVUR) trial
showed that one-third of the participating children needed to be
withdrawn from the study because of non-compliance [1]. Whether CAP can
reduce the risk of renal damage is another area of concern, as in a
recent meta-analysis, it was not associated with decrease in new renal
scarring [2]. In this context, the endoscopic management of VUR seems to
be an attractive option, more so in our set-up, where compliance and
long-term follow up can be problematic.
It is with great interest that we read the article by
Rao, et al. [3] published in the current issue of Indian
Pediatrics, on the long-term outcomes of more than 500 children and
767 renal units, in which endoscopic management of VUR has been done. As
was evident from this study, endoscopic management offers a one-time
solution for majority of children with VUR, with a resolution rate of
90% of children. However, we need to remember that resolution of VUR is
never the end-point in its management, as the primary aim of treatment
remains prevention of UTI and renal damage.
The incidence of febrile UTI after endoscopic
treatment had been reported to be in 0.75% of children in a
meta-analysis [4]. Rao, et al. [3] have shown 96% success in
symptomatic relief (preventing UTI), establishing endoscopic therapy as
a reliable treatment option for preventing UTI.
The other major treatment goal, i.e., ability
of endoscopic therapy to protect against renal damage is still unclear
with only few studies evaluating this outcome. In the present study by
Rao, et al. [3], a fresh scar was seen in 1% of cases at mean
follow-up of 27 months after endoscopic treatment; although,
approximately 50% of cases had scars before injection. Similar results
in terms of development of new scars have been documented earlier by
Chertin, et al. [5]. However, they raised concern regarding renal
function deterioration on follow-up. Rao, et al. [3] have not
commented on the deterioration in renal functions; albeit, they have
reported that there was no improvement in renal units who had poor
function before endoscopic treatment and few of them had to undergo
nephrectomy. It will be interesting to know what happens to those renal
units on long-term follow-up, in which VUR had been corrected and no
fresh scars are formed.
The open surgical treatment of VUR has had a long
history, but now with increased knowledge about natural history of VUR,
it is now being used more selectively. In a meta-analysis, Wheeler,
et al. [6] analyzed that surgery has only a minimal benefit over
antibiotics alone. Although compliance can be an issue with CAP, open
surgery is associated with abdominal incision, hospital stay, temporary
urinary catheter, possible damage to trigone, and possibility of bladder
dysfunction. In an interesting article published recently, it was seen
that after careful explanation, although CAP was parental preference of
all children with VUR, approximately 30% of parents also considered open
surgery as a mode of treatment [7].
Since the approval of endoscopic treatment of VUR by
dextranomer/ hyaluronic acid co-polymer in 2001 by FDA, concerns
regarding its long-term success rates and long term complications like
delayed ureteral obstructions have emerged [8-10]. Swedish reflux trial
reported a recurrence rates of 20% after two years of endoscopic
treatment [8]. Lee, et al. [9] reported overall recurrence of
46%. Rao, et al. [3], in this study, reported only six late
recurrences after many years. This suggests that regular follow-up is
required to evaluate the long-term durability of endoscopic treatment,
even though postoperative VCUG had shown success of procedure.
It is interesting to note that the popularity of
endoscopic injection has decreased in last few years, although the
number of open surgical interventions have remained same [11]. The
decrease in the popularity of endoscopic treatment can be attributed to
evolving concept of benign nature of lower grade efflux, which neither
require too much investigations or treatment. For higher grade reflux,
open surgical interventions have been used, based on a belief that
endoscopic treatment is not dependable for higher grade reflux. In this
context, the current study is relevant as it suggests that even for
higher grades of reflux, endoscopic treatment by an experienced person
can provide good results. The other reasons for decreasing popularity of
endoscopic treatment, as suggested by Rao, et al. [3], are cost
and availability of tissue bulking substance – dextranomer/ hyaluronic
acid co-polymer.
To conclude, although many guidelines are available
for management of VUR, it is still a clinical art in which the clinician
has to incorporate many variables like age, grade of reflux, history of
previous febrile UTI, existing renal scarring, other urogenital
malformations, compliance to treatment, patient’s preferences,
availability of resources, and available scientific evidence for each
mode of treatment, in order to decide the appropriate management
strategy with ultimate aim of prevention of recurrent UTI and renal
damage.
Funding: None; Competing interests: None
stated.
References
1. RIVUR Trial Investigators, Hoberman A, Greenfield
SP, Mattoo TK, Keren R, Mathews R, et al. Antimicrobial
prophylaxis for children with vesicoureteral reflux. N Engl J Med.
2014;370:2367-76.
2. Wang HH, Gbadegesin RA, Foreman JW, Nagaraj SK,
Wigfall DR, Wiener JS, et al. Efficacy of antibiotic pro-phylaxis
in children with vesicoureteral reflux: systematic review and
metaanalysis. J Urol. 2015;193:963-9.
3. Rao KLN, Menon P, Samujh R, Mahajan JK, Bawa M,
Malik MA, et al. Endoscopic management of vesicoureteral reflux
and long-term follow-up. Indian Pediatr. 2018;55:1046-9.
4. Elder JS, Diaz M, Caldamone AA, Cendron M,
Greenfield S, Hurwitz R, et al. Endoscopic therapy for
vesicoureteral reflux: a meta-analysis. I. Reflux resolution and urinary
tract infection. J Urol. 2006;175:716-22
5. Chertin B, Natsheh A, Fridmans A, Shenfeld OZ,
Farkas A. Renal scarring and urinary tract infection after successful
endoscopic correction of vesicoureteral reflux. J Urol 2009;182(4Suppl):
1703-6.
6. Wheeler D, Vimalachandra D, Hodson EM, Roy LP,
Smith G, Craig JC. Antibiotics and surgery for vesicoureteric reflux: a
meta-analysis of randomised controlled trials. Arch Dis Child.
2003;88:688-94.
7. Tran GN, Bodapati AV, Routh JC, Saigal CS, Copp
HL. Parental Preference Assessment for Vesicoureteral Reflux Management
in Children. J Urol. 2017;197:957-62.
8. Holmdahl G, Brandstrom P, Lackgren G, Sillen U,
Stokland E, Jodal U, et al. The Swedish reflux trial in children:
II. Vesicoureteralreflux outcome. J Urol. 2010;184:280-5.
9. 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;181:1869-74.
10. Okawada M, Murakami H, Tanaka N, Ogasawara Y,
Lane GJ, Okazaki T, et al. Incidence of ureterovesical
obstruction and Cohen antireflux surgery after Deflux® treatment for
vesicoureteric reflux. J Pediatr Surg. 2018;53:310-2.
11. Herbst KW, Corbett ST, Lendvay TS, Caldamone AA.
Recent trends in the surgical management of primary vesicoureteral
reflux in the era of dextranomer/hyaluronic acid. J Urol. 2014;191 (5
Suppl):1628-33.
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