Approach Considerations
In the child with vesicoureteral reflux (VUR) who is experiencing chronic pyelonephritis, the goals of management are as follows:
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Prevent recurring febrile urinary tract infections (UTIs)
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Prevent kidney injury
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Minimize the morbidity of treatment and follow-up
Preventive strategies include the administration of prophylactic antibiotics, endoscopic injection of dextranomer hyaluronic acid, and antireflux surgery. [4] Selecting the treatment option for different grades of VUR depends on the clinical presentation and kidney function.
According to a study by Su et al, risk factors for the development of breakthrough UTI in children with VUR who receive continuous antibiotic prophylaxis include younger age at the initial diagnosis of UTI (≤ 12 mo), bilateral VUR, and bladder and bowel dysfunction. [25]
If symptomatic breakthrough UTI occurs during preventive therapy, a change in therapy is recommended. The clinical scenario (ie, VUR grade, degree of renal scarring, and evidence of bowel/bladder dysfuntion), as well as parental preferences, will guide the choice of alternative treatment. In the absence of new renal cortical abnormalities, a change in the antibiotic used for prophylaxis may be effective. Therapy with curative intent, including open surgery, offers protection against febrile UTI but is associated with morbidity. Endoscopic injection therapy may be less successful than open surgery in resolution of VUR. [4]
Medical Care
Continuous antibiotic prophylaxis (CAP) is often the initial treatment. Agents typically selected include amoxicillin, trimethoprim/sulfamethoxazole (Bactrim), trimethoprim alone, or nitrofurantoin. CAP should continue until puberty or until reflux resolves.
Surgical Care
Endoscopic Injections
Endoscopic injection have advantages over open surgery, including less postoperative pain and fewer bladder spasms and infections, and the absence of surgical scarring. Endoscopic injection can be performed in a shorter operation time, in an outpatient setting, and with minimal use of postoperative analgesics and is preferred as the first-line treatment for children with vesicoureteral reflux (VUR). [26]
The American Urological Association (AUA) Vesicoureteral Reflux Guideline Update Committee analyzed data from 17,972 patients, and reported that the overall success rate of a single endoscopic treatment was 83.0%, compared to 98% success rates for open surgery. [4] When an injection treatment fails, open ureteral reimplantation may be needed to treat persistent VUR. [26]
Open Ureteral Reimplantation
Surgery entails the reimplantation of the ureters, with the creation of an adequate submucosal tunnel and detrusor support. Open reimplantation surgery may be a primary treatment or may be performed as second-line therapy after endoscopic injection failure. Studies have reported no adverse effect on success rates, operation time, or complications when open reimplantation follows endospic injection treatment. [26]
Laparoscopic Ureteral Reimplantation
Robot-assisted laparoscopic extravesical ureteral reimplantation has been proposed as a minimally invasive alternative to open ureteral reimplantation for correcting primary VUR in children. However, the current literature contains conflicting data regarding the safety and efficacy of this approach. In a multi-institutional review, a success rate of 87.9% was reported in a series of 260 patients who underwent robot-assisted laparoscopic extravesical ureteral reimplantation for primary VUR. [27]
Prevention
Progressive kidney injury can be reduced by dietary protein restriction, while aggressive blood pressure control aids in slowing progression of kidney disease. Angiotensin-converting enzyme (ACE) inhibitors are particularly beneficial in treating hypertension.
Careful follow-up and monitoring of kidney function is beneficial. Vigorously treat a UTI or bacteriuria in a patient who is pregnant, to prevent acute kidney injury, preeclampsia, and abortion. [28]
Renal ultrasonography is recommended for siblings of patients with VUR. [29] If an abnormality is found, then perform a voiding cystourethrogram (VCUG).
