Highlights of the Webinar “Management of High Grade VUR in Asymptomatic Children”, May 2020

These are my notes from the Webinar. The panelists were Dr. Koyle, Kirsch, and Caldamone. The link to the video is at the bottom.

 

A study from Australia showed that circumcision is better than reflux surgery at preventing recurrent UTI’s.

Case 1: Asymptomatic high-grade reflux in a newborn boy (reflux found due to hydronephrosis) with congenital renal dysplasia (one kidney with 20% function)

  • Dr. Koyle would recommend circumcision and prophylactic antibiotics initially, and then do a follow up renal ultrasound at 1 year. He would not repeat the VCUG. He would stop antibiotics in one year (stress test).
  • Dr. Kirsch would involve nephrology for long term follow up asymptomatic high-grade reflux with dysplasia.
  • The 3 doctors were ok discontinuing prophylaxis after 1-2 years and observing if the family was reliable.
  • DMSA can be done at any time — as opposed to Mag 3 where you have to wait until 6 weeks of age.

Case 2: 8-year-old girl with a prior history of VUR lost to follow up (poor compliance), asymptomatic, bilateral grade 3 VUR plus spinning top urethra, DMSA no scarring.

  • Dr. Kirsch would continue to do nothing or consider Deflux.
  • The panelist would not do open surgery for her at this point.
  • Koyle: educate about the “peaks of UTIs in girls: potty training, puberty, sexual activity, menopause”.
  • Kirsch: in 30-40% of girls that have BBD and Reflux, treating the reflux helps with the BBD, suggesting reflux causes some BBD. Dr. Caldamone was skeptical about these findings since the recurrent UTI’s themselves can cause bladder irritation and BBD symptoms.

Case 3: 12-year-old boy, presented at 10 years with one episode of hematuria. No BBD symptoms, no UTI’s. VCUG bilateral VUR, grade 5 on left with duplication, and grade 3 on the right. DMSA showing non-functioning left kidney.

  • Caldamone/Koyle would avoid any catheterization or instrumentation if the patient has a history consistent with urethrorragia — terminal hematuria and bloody spotting of the underwear between episodes of voiding– to avoid creating a stricture.
  • Kirsch would remove the left kidney and Deflux the right kidney.
  • Koyle would remove the kidney for proteinuria, UTI’s, or hypertension.
  • Caldamone would observe or also do left nephrectomy plus VUR surgery on the right.

Case 4: Newborn boy with congenital hydronephrosis, right UTD p3 with dilated ureter, left normal. VUR grade 5 right, grade 3 on left. DMSA right kidney 37% with scarring.

  • All would recommend both circumcision and prophylaxis.
  • The case and comments were similar to case 1.

Kirsch on predictors of VUR resolution

He discussed a scoring system to predict VUR resolution called the VUR index:

  • Timing of reflux: Early-mid (3 points), late (2 points), voiding only (1 point)
  • Anomalies (duplex, diverticulum: Yes (1 point)
  • VUR grade: 4-5 VUR (1 point)
  • Gender: Girl (1 point).
  • Chance of resolution:
    • 1 point: 92%
    • 2 points: 70%
    • 3 points: 27%
    • 4 points: 10%
    • 5-6 points: 8%

Recommended reading by the moderators: VUR is it important to find?

 

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