Management of Vesicoureteral Reflux: What Have We Learned Over the Last 20 Years?

Abstract

Vesicoureteral reflux (VUR) is associated with increased risks of urinary tract infection, renal scarring and reflux nephropathy. We review advancements over the last two decades in our understanding and management of VUR. Over time, the condition may resolve spontaneously but it can persist for many years and bladder/bowel dysfunction is often involved. Some factors that increase the likelihood of persistence (e.g., high grade) also increase the risk of renal scarring. Voiding cystourethrography (VCUG) is generally considered the definitive method for diagnosing VUR, and helpful in determining the need for treatment. However, this procedure causes distress and radiation exposure. Therefore, strategies to reduce clinicians' reliance upon VCUG (e.g., after a VUR treatment procedure) have been developed. There are several options for managing patients with VUR. Observation is suitable only for patients at low risk of renal injury. Antibiotic prophylaxis can reduce the incidence of UTIs, but drawbacks such as antibiotic resistance and incomplete adherence mean that this option is not viable for long-term use. Long-term studies of endoscopic injection have helped us understand factors influencing use and the effectiveness of this procedure. Ureteral reimplantation is still performed commonly, and robot-assisted laparoscopic methods are gaining popularity. Over the last 20 years, there has been a shift toward more conservative management of VUR with an individualized, risk-based approach. For continued treatment improvement, better identification of children at risk of renal scarring, robust evidence regarding the available interventions, and an improved VUR grading system are needed.

Clinical practice in vesicoureteral reflux with respect to EAU guidelines: A multicenter study

“…Hence, performing VCUG routinely in long‐term follow‐up after either ureteroneocystostomy or endoscopic treatment is not recommended any more. This invasive examination is reserved for cases of symptomatic UTIs taking into account the individual patient's health status, recurrent UTI risk and parent/personal preference 22 . Because of the >99% success rates of uncomplicated ureteral reimplantation, it is recommended to omit postoperative VCUG 21 .…”

Vesikoureteraler Reflux beim Kind – eine Übersicht

“…Je late-Abb. 2 8 Miktionszystourethrographie (MCUG) einer 1-jährigen Patientin mit vesikoureteralem Reflux (VUR) Grad II-III beidseits. a retrograde Füllung der Blase, b während der Füllung bereits sichtbarer Reflux bds, c am Ende der Untersuchung VURGrad II-III bds.…”

“…Das Follow-up erfolgt hauptsächlich anhand der Klinik (Infektfreiheit) sowie mit Ultraschall in regelmässigen Abständen (z. B. alle 6-12 Monate; [2]).…”

“…physiotherapeutischer Unterstützung, eine allfällige anticholinerge Therapie zur Entspannung der Detrusormuskulatur sowie bei rez. Harnwegsinfekten eine temporäre Antibiotikaprophylaxe [2,15].…”

“…Die Prävalenz symptomatischer Kinder liegt bei 1-2 % [1]. Bei 30 % aller Kinder mit febrilen Harnwegsinfekten findet sich ein VUR [2]. Im Neugeborenenalter sind Jungen häufiger betroffen als Mädchen und haben prinzipiell einen höhergradigen VUR [3,4].…”