Pediatric Vesicoureteral Reflux Follow-up

Febrile urinary tract infection (UTI) with signs of pyelonephritis in children with vesicoureteral reflux (VUR) requires admission and also treatment with parenteral antibiotics to prevent renal damage. This is particularly true in children who are dehydrated, unable to retain oral intake, or toxic. The need for inpatient admission should be based on the clinical assessment at the time of presentation. Many patients with febrile UTI can be managed as outpatients. Children who are severely dehydrated or septic, or those with social concerns regarding the reliability of caregivers at home to properly and completely care for the ill child, should be admitted.

Hospitalization after open antireflux surgery typically lasts 24-72 hours. Increasingly children may be discharged home the morning after surgery, and some centers are performing these procedures on an outpatient basis. Children are discharged once they tolerate a regular age-appropriate diet, their pain is managed with oral pain medication, and they are active at an age-appropriate level. Endoscopic antireflux surgery is generally performed as outpatient surgery.

Children on medical management of vesicoureteral reflux are regularly seen on an annual basis (see Treatment). Routine evaluation includes urinalysis and urine culture, appropriate imaging, and blood pressure measurement. Parents must understand the need for proper evaluation and urine culture if they suspect UTI. In some cases, parents are taught to perform urinalysis at home. Positive home urinalysis results should prompt formal testing at a physician's office.

• After surgical correction of vesicoureteral reflux, patients are seen in the clinic 2-6 weeks after discharge with renal ultrasonography or renal scintigraphy to exclude upper tract obstruction.
• Patients continue taking prophylactic antibiotics until a second return visit 3-6 months postoperatively, at which time voiding cystourethrography (VCUG) or nuclear cystography is performed.
• Some have abandoned the practice of a follow-up VCUG or radionuclide cystography (RNC) after open surgical treatment because success rates are high. Antibiotic therapy is usually stopped after normal postnatal ultrasonography results are obtained.
• If VCUG or RNC is performed postoperatively and reveals resolution of reflux, antibiotics are discontinued, and no further invasive studies are necessary unless the child develops further febrile UTIs.
• Some clinicians continue to observe children with vesicoureteral reflux periodically with blood pressure checks and renal ultrasonography.

See Medication.

Postsurgical obstruction after open antireflux surgery

• Most cases of postoperative upper tract obstruction are mild, produce no symptoms, and spontaneously resolve. These cases are due to edema at the ureteroneocystostomy site, blood clots, or mucous causing mechanical obstruction. Cases of severe obstruction often have a delayed presentation (1-2 wk or more) and may be associated with flank or abdominal pain, nausea, and vomiting.
• Ultrasonography reveals dilation on the affected side, although this can be difficult to assess in patients who had significant dilation preoperatively.
• High-grade obstruction is usually due to ischemia of the implanted ureteral segment with resulting fibrosis and stricture. This is a rare complication.
• Occasionally, patients may present with intermittent obstruction due to kinking of the reimplanted ureter with bladder filling.
• Treatment for high-grade obstruction is surgical revision of the obstructed system. Percutaneous nephrostomy for temporary drainage may be required if the patient is symptomatic or toxic.

Persistent vesicoureteral reflux after open antireflux surgery

• Modern series consistently report success rates greater than 95% for antireflux surgery.
• In cases in which reflux persists postoperatively, initial observation with continued antibiotic prophylaxis is indicated. Reoperation is generally reserved for patients with persisted febrile UTI despite prophylaxis.
• A very high percentage of patients in whom surgery has failed have voiding dysfunction, thus urodynamic evaluation should be considered in these patients, especially if reoperation is considered. Even so, a substantial majority of patients with reflux at the first postoperative study have complete resolution at the 1-year follow-up point.

Persistent vesicoureteral reflux after endoscopic antireflux surgery: Initial management is often repeat injection. Many investigators report routinely injecting up to 3 separate times. Patients who fail multiple injections should be reevaluated and treated for causes of secondary vesicoureteral reflux. Patients with persistent vesicoureteral reflux and indications for surgical correction should proceed to open surgery.

New contralateral vesicoureteral reflux after unilateral antireflux surgery: New onset of vesicoureteral reflux in a renal unit that had no vesicoureteral reflux on preoperative imaging occurs in 10-32% of patients after open correction and 7-14% of patients after endoscopic correction. In general, the new vesicoureteral reflux is thought to be of low grade and may be more likely to spontaneously resolve; however, data are lacking in this area.

Primary reflux

• Studies comparing medical management with surgical treatment of primary vesicoureteral reflux have demonstrated that both have excellent long-term outcomes if surveillance is conscientious and compliance is good.
• Rates of reflux nephropathy are similar in the 2 groups, although surgically treated patients have a lower prevalence of pyelonephritis.
• Recent studies of adults with childhood reflux and children presenting to a pediatric nephrology clinic have shown that the prevalence of reflux nephropathy in these groups is substantially lower than in historical series. Whether this phenomenon is a result of aggressive treatment of vesicoureteral reflux, changes over time in definitions of reflux nephropathy, or other factors is not known.

Secondary reflux

• Treatment of children with secondary reflux continues to pose challenges to pediatricians and urologists.
• A clear understanding of bladder function is essential.
• Other children have complex combinations of reflux, obstruction, and bladder and renal dysfunction that require a concerted multidisciplinary approach to achieve the maximum potential benefit of therapy.

Effective education of parents and effective communication with the primary care physician are essential if medical management is to be successful.

Poor compliance and untreated episodes of UTI are likely to lead to reflux nephropathy.