Management of vesicoureteral reflux
- Tej K Mattoo, MD, DCH, FRCP
Tej K Mattoo, MD, DCH, FRCP
- Section Editor — Pediatric Nephrology
- Professor of Pediatrics
- Wayne State University School of Medicine
- Saul P Greenfield, MD
Saul P Greenfield, MD
- Clinical Professor of Urology, State University of New York at Buffalo School of Medicine & Biomedical Sciences
- Director of Pediatric Urology, Children’s Hospital of Buffalo
- Section Editors
- Laurence S Baskin, MD, FAAP
Laurence S Baskin, MD, FAAP
- Section Editor — Pediatric Urology
- Frank Hinman, Jr., MD, Distinguished Professorship in Pediatric Urology
- Chief Pediatric Urology
- Professor of Urology and Pediatrics
- UCSF Benioff Children’s Hospital
- F Bruder Stapleton, MD
F Bruder Stapleton, MD
- Editor-in-Chief — Pediatrics
- Section Editor — Pediatric Nephrology
- Professor and Chair, Department of Pediatrics
- University of Washington School of Medicine
Vesicoureteral reflux (VUR) is the retrograde passage of urine from the bladder into the upper urinary tract. Management of VUR has been based upon the premise that VUR predisposes patients to acute pyelonephritis by transporting bacteria from the bladder to the kidney. Pyelonephritis itself is a morbid event that requires acute medical care and possible hospitalization in young infants. In addition, the resulting infection may lead to loss of renal parenchyma (renal scarring). However, there are inconclusive data comparing the effectiveness of an interventional versus an observational approach in improving long-term renal outcome As a result, there is controversy regarding the optimal management of patients with VUR.
The management of VUR will be reviewed here. The manifestations and diagnosis of VUR is discussed elsewhere in the program. (See "Clinical presentation, diagnosis, and course of primary vesicoureteral reflux".)
The use of therapeutic interventions in the management of vesicoureteral reflux (VUR) is based upon the following :
●Identification of children with VUR (see "Clinical presentation, diagnosis, and course of primary vesicoureteral reflux")
●Prevention of recurrent urinary tract infections (UTI)
- Peters CA, Skoog SJ, Arant BS Jr, et al. Summary of the AUA Guideline on Management of Primary Vesicoureteral Reflux in Children. J Urol 2010; 184:1134.
- Weiss R, Duckett J, Spitzer A. Results of a randomized clinical trial of medical versus surgical management of infants and children with grades III and IV primary vesicoureteral reflux (United States). The International Reflux Study in Children. J Urol 1992; 148:1667.
- Prospective trial of operative versus non-operative treatment of severe vesicoureteric reflux in children: five years' observation. Birmingham Reflux Study Group. Br Med J (Clin Res Ed) 1987; 295:237.
- Practice parameter: the diagnosis, treatment, and evaluation of the initial urinary tract infection in febrile infants and young children. American Academy of Pediatrics. Committee on Quality Improvement. Subcommittee on Urinary Tract Infection. Pediatrics 1999; 103:843.
- Cheng CH, Tsai MH, Huang YC, et al. Antibiotic resistance patterns of community-acquired urinary tract infections in children with vesicoureteral reflux receiving prophylactic antibiotic therapy. Pediatrics 2008; 122:1212.
- Cooper CS, Chung BI, Kirsch AJ, et al. The outcome of stopping prophylactic antibiotics in older children with vesicoureteral reflux. J Urol 2000; 163:269.
- Thompson RH, Chen JJ, Pugach J, et al. Cessation of prophylactic antibiotics for managing persistent vesicoureteral reflux. J Urol 2001; 166:1465.
- Al-Sayyad AJ, Pike JG, Leonard MP. Can prophylactic antibiotics safely be discontinued in children with vesicoureteral reflux? J Urol 2005; 174:1587.
- Uhari M, Nuutinen M, Turtinen J. Adverse reactions in children during long-term antimicrobial therapy. Pediatr Infect Dis J 1996; 15:404.
- Kennelly MJ, Bloom DA, Ritchey ML, Panzl AC. Outcome analysis of bilateral Cohen cross-trigonal ureteroneocystostomy. Urology 1995; 46:393.
- Ellsworth PI, Merguerian PA. Detrusorrhaphy for the repair of vesicoureteral reflux: comparison with the Leadbetter-Politano ureteroneocystostomy. J Pediatr Surg 1995; 30:600.
- McLorie GA, Jayanthi VR, Kinahan TJ, et al. A modified extravesical technique for megaureter repair. Br J Urol 1994; 74:715.
- Barrieras D, Lapointe S, Reddy PP, et al. Are postoperative studies justified after extravescial ureteral reimplantation? J Urol 2000; 164:1064.
- Hubert KC, Kokorowski PJ, Huang L, et al. Clinical outcomes and long-term resolution in patients with persistent vesicoureteral reflux after open ureteral reimplantation. J Urol 2012; 188:1474.
- Gargollo PC, Diamond DA. Therapy insight: What nephrologists need to know about primary vesicoureteral reflux. Nat Clin Pract Nephrol 2007; 3:551.
- Marchini GS, Hong YK, Minnillo BJ, et al. Robotic assisted laparoscopic ureteral reimplantation in children: case matched comparative study with open surgical approach. J Urol 2011; 185:1870.
- Smith RP, Oliver JL, Peters CA. Pediatric robotic extravesical ureteral reimplantation: comparison with open surgery. J Urol 2011; 185:1876.
- Grimsby GM, Dwyer ME, Jacobs MA, et al. Multi-institutional review of outcomes of robot-assisted laparoscopic extravesical ureteral reimplantation. J Urol 2015; 193:1791.
- O'Donnell B, Puri P. Treatment of vesicoureteric reflux by endoscopic injection of Teflon. 1984. J Urol 2002; 167:1808.
- Capozza N, Caione P. Dextranomer/hyaluronic acid copolymer implantation for vesico-ureteral reflux: a randomized comparison with antibiotic prophylaxis. J Pediatr 2002; 140:230.
- Läckgren G, Wåhlin N, Sköldenberg E, Stenberg A. Long-term followup of children treated with dextranomer/hyaluronic acid copolymer for vesicoureteral reflux. J Urol 2001; 166:1887.
- Puri P, Chertin B, Velayudham M, et al. Treatment of vesicoureteral reflux by endoscopic injection of dextranomer/hyaluronic Acid copolymer: preliminary results. J Urol 2003; 170:1541.
- Capozza N, Lais A, Nappo S, Caione P. The role of endoscopic treatment of vesicoureteral reflux: a 17-year experience. J Urol 2004; 172:1626.
- Yu RN, Roth DR. Treatment of vesicoureteral reflux using endoscopic injection of nonanimal stabilized hyaluronic acid/dextranomer gel: initial experience in pediatric patients by a single surgeon. Pediatrics 2006; 118:698.
- Elder JS, Diaz M, Caldamone AA, et al. Endoscopic therapy for vesicoureteral reflux: a meta-analysis. I. Reflux resolution and urinary tract infection. J Urol 2006; 175:716.
- Chertin B, Colhoun E, Velayudham M, Puri P. Endoscopic treatment of vesicoureteral reflux: 11 to 17 years of followup. J Urol 2002; 167:1443.
- Routh JC, Inman BA, Reinberg Y. Dextranomer/hyaluronic acid for pediatric vesicoureteral reflux: systematic review. Pediatrics 2010; 125:1010.
- 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.
- Brandström P, Esbjörner E, Herthelius M, et al. The Swedish reflux trial in children: I. Study design and study population characteristics. J Urol 2010; 184:274.
- Holmdahl G, Brandström P, Läckgren G, et al. The Swedish reflux trial in children: II. Vesicoureteral reflux outcome. J Urol 2010; 184:280.
- Elmore JM, Scherz HC, Kirsch AJ. Dextranomer/hyaluronic acid for vesicoureteral reflux: success rates after initial treatment failure. J Urol 2006; 175:712.
- Menezes MN, Puri P. The role of endoscopic treatment in the management of grade v primary vesicoureteral reflux. Eur Urol 2007; 52:1505.
- Chi A, Gupta A, Snodgrass W. Urinary tract infection following successful dextranomer/hyaluronic acid injection for vesicoureteral reflux. J Urol 2008; 179:1966.
- Hunziker M, Mohanan N, D'Asta F, Puri P. Incidence of febrile urinary tract infections in children after successful endoscopic treatment of vesicoureteral reflux: a long-term follow-up. J Pediatr 2012; 160:1015.
- Elmore JM, Kirsch AJ, Lyles RH, et al. New contralateral vesicoureteral reflux following dextranomer/hyaluronic Acid implantation: incidence and identification of a high risk group. J Urol 2006; 175:1097.
- Vandersteen DR, Routh JC, Kirsch AJ, et al. Postoperative ureteral obstruction after subureteral injection of dextranomer/hyaluronic Acid copolymer. J Urol 2006; 176:1593.
- Cerwinka WH, Qian J, Easley KA, et al. Appearance of dextranomer/hyaluronic Acid copolymer implants on computerized tomography after endoscopic treatment of vesicoureteral reflux in children. J Urol 2009; 181:1324.
- Cerwinka WH, Grattan-Smith JD, Scherz HC, Kirsch AJ. Appearance of Deflux implants with magnetic resonance imaging after endoscopic treatment of vesicoureteral reflux in children. J Pediatr Urol 2009; 5:114.
- Gargollo PC, Paltiel HJ, Rosoklija I, Diamond DA. Mound calcification after endoscopic treatment of vesicoureteral reflux with autologous chondrocytes--a normal variant of mound appearance? J Urol 2009; 181:2702.
- Shaikh N, Hoberman A, Keren R, et al. Recurrent Urinary Tract Infections in Children With Bladder and Bowel Dysfunction. Pediatrics 2016; 137.
- Homayoon K, Chen JJ, Cummings JM, Steinhardt GF. Voiding dysfunction: outcome in infants with congenital vesicoureteral reflux. Urology 2005; 66:1091.
- Sillén U, Brandström P, Jodal U, et al. The Swedish reflux trial in children: v. Bladder dysfunction. J Urol 2010; 184:298.
- Hong YK, Altobelli E, Borer JG, et al. Urodynamic abnormalities in toilet trained children with primary vesicoureteral reflux. J Urol 2011; 185:1863.
- Carpenter MA, Hoberman A, Mattoo TK, et al. The RIVUR trial: profile and baseline clinical associations of children with vesicoureteral reflux. Pediatrics 2013; 132:e34.
- Koff SA, Wagner TT, Jayanthi VR. The relationship among dysfunctional elimination syndromes, primary vesicoureteral reflux and urinary tract infections in children. J Urol 1998; 160:1019.
- Upadhyay J, Bolduc S, Bagli DJ, et al. Use of the dysfunctional voiding symptom score to predict resolution of vesicoureteral reflux in children with voiding dysfunction. J Urol 2003; 169:1842.
- Fast AM, Nees SN, Van Batavia JP, et al. Outcomes of targeted treatment for vesicoureteral reflux in children with nonneurogenic lower urinary tract dysfunction. J Urol 2013; 190:1028.
- Nagler EV, Williams G, Hodson EM, Craig JC. Interventions for primary vesicoureteric reflux. Cochrane Database Syst Rev 2011; :CD001532.
- Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management, Roberts KB. Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics 2011; 128:595.
- RIVUR Trial Investigators, Hoberman A, Greenfield SP, et al. Antimicrobial prophylaxis for children with vesicoureteral reflux. N Engl J Med 2014; 370:2367.
- Brandström P, Esbjörner E, Herthelius M, et al. The Swedish reflux trial in children: III. Urinary tract infection pattern. J Urol 2010; 184:286.
- Mattoo TK, Chesney RW, Greenfield SP, et al. Renal Scarring in the Randomized Intervention for Children with Vesicoureteral Reflux (RIVUR) Trial. Clin J Am Soc Nephrol 2016; 11:54.
- Wang HH, Gbadegesin RA, Foreman JW, et al. Efficacy of antibiotic prophylaxis in children with vesicoureteral reflux: systematic review and meta-analysis. J Urol 2015; 193:963.
- Jodal U, Smellie JM, Lax H, Hoyer PF. Ten-year results of randomized treatment of children with severe vesicoureteral reflux. Final report of the International Reflux Study in Children. Pediatr Nephrol 2006; 21:785.
- Smellie JM, Barratt TM, Chantler C, et al. Medical versus surgical treatment in children with severe bilateral vesicoureteric reflux and bilateral nephropathy: a randomised trial. Lancet 2001; 357:1329.
- Greenfield SP, Carpenter MA, Chesney RW, et al. The RIVUR voiding cystourethrogram pilot study: experience with radiologic reading concordance. J Urol 2012; 188:1608.
- Mattingly RF, Borkowf HI. Clinical implications of ureteral reflux in pregnancy. Clin Obstet Gynecol 1978; 21:863.
- Mansfield JT, Snow BW, Cartwright PC, Wadsworth K. Complications of pregnancy in women after childhood reimplantation for vesicoureteral reflux: an update with 25 years of followup. J Urol 1995; 154:787.
- Yeoh JS, Greenfield SP, Adal AY, Williot P. The incidence of urinary tract infection after open anti-reflux surgery for primary vesicoureteral reflux: early and long-term follow up. J Pediatr Urol 2013; 9:503.
- Lowe LH, Patel MN, Gatti JM, Alon US. Utility of follow-up renal sonography in children with vesicoureteral reflux and normal initial sonogram. Pediatrics 2004; 113:548.
- THERAPEUTIC INTERVENTIONS
- Medical treatment
- - Complications
- Surgical treatment
- - Surgical reimplantation
- Open surgical reimplantation
- Robotic assisted laparoscopic reimplantation
- - Endoscopic correction
- Bladder and bowel dysfunction
- CHOICE OF THERAPY
- Antibiotic prophylaxis versus surveillance/placebo trials
- Medical versus surgical therapy
- OUR APPROACH
- Grades III to V
- Grade I and II
- Surveillance and medical therapy
- - Discontinuation of medical therapy
- Surgical therapy
- Long-term follow-up
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS