Two pathways to manage vesicoureteral reflux with 90% difference in the rate of surgery

The traditional way of managing vesicoureteral reflux (VUR) consisted of:

  1. Yearly voiding cystourethrograms (VCUG’s) until resolution or age 5-6 years.
  2. Antibiotic prophylaxis while VUR is present.
  3. Surgery for persistent VUR after age 5-6 or for urinary infections while taking preventative antibiotics.

This old-fashioned approach led to 200-300 VUR surgeries a year in Seattle and Toronto’s Children’s Hospitals (according to doctors from these hospitals).

A more modern approach focuses primarily on bladder and bowel function, leaving VUR surgery for patients with recurrent febrile UTI’s with no evidence of bladder and bowel dysfunction (BBD). Also:

  • No routine VCUGs.
  • No surgeries for lack of spontaneous resolution at age 5-6 years.
  • Minimal follow-up

This new approach resulted in a decrease in VUR surgeries in both Seattle and Toronto from 200-300/year to 20-30/year: a 90% reduction!

What follows now is my evolving approach to the management of children diagnosed with VUR which is similar to what is been done in Seattle and Toronto. I will focus on specific index patients:

  • Healthy children diagnosed with VUR, either after a UTI or because of prenatal hydronephrosis.
  • Do not have a neurogenic bladder, posterior urethral valves or any other cause of secondary VUR. 

 

Circumcised boys with no prior UTI’s: Observation

I recommend observation when VUR is found in circumcised boys with no prior history of UTIs. For higher degrees of VUR/kidney scars,  I have them follow up in 1 year with a renal ultrasound to “make sure the kidneys are growing ok” and because that is what the AUA guidelines on VUR recommend. However, I don’t find the ultrasounds to be that clinically useful other than to have an excuse for the visit.

Circumcised boys with prior febrile UTI: Surgery

I lean towards surgery on circumcised boys who present with febrile UTI’s. UTI’s are rare in this group and thus I consider them as a sign of significant anatomic problems that could benefit from surgery.  

Uncircumcised boys with or without prior febrile UTI

I would offer circumcision as an option, especially if under 3 months of age (which would allow doing the circumcision in the office). If they elect to not have a circumcision, then I would treat the same as girls.

Girls with no prior history of UTI

For grades 1-3 VUR, I would consider antibiotic prophylaxis for the first year of life with follow up on as needed basis and no more imaging.

For grades 4-5 VUR, I would consider/recommend antibiotic prophylaxis until after fully potty trained with follow up on as needed basis and no more imaging.

Girls with a prior history of febrile UTI

Basically the same as above but I would recommend and not just consider antibiotic prophylaxis. That been said, I think is reasonable for families to choose against antibiotic prophylaxis given the marginal 12% overall benefit  (more for higher degrees, less for lower degrees).

For girls older than 3 years diagnosed with VUR after febrile UTI’s, I recommend antibiotic prophylaxis and intensive management of BBD by a specialized nurse practitioner for at least 6 months. Once their BBD has been under control for a few months, I would stop the antibiotics and observe.

 

Conclusion

The modern approach decreases VUR surgeries by 90% without putting the patient at significantly higher risk of renal damage, hypertension or renal scarring. I don’t expect most pediatric urologists to agree 100% with this approach as VUR is probably the most controversial topic in our field.

What is your approach?

 

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