VESICO URETERIC REFLUX, VUR: What The Trials Are Telling Us

VESICO URETERIC REFLUX, VUR: What The Trials Are Telling Us

Clarence Lei Chang Moh

Normah Medical Specialist Centre, Kuching

Introduction and Objectives:

About 40% of children with febrile UTI have been found to have vesico ureteric reflux. The international reflux study in children, first established in 1981, reported on 250 children for 10 years.  The conclusion is that antibiotic prophylaxis is as good as ureteric re-implantation.  Prophylactic antibiotics are associated with problems of compliance, side effects and the induction of antibiotic resistance.  The objective is to review the current evidence.

Materials and Methods:

The recent relevant publications in the English literature are reviewed, especially with regards to the use of antibiotic prophylaxis for vesico ureteric reflux.

Results:

Many RCTs, randomized controlled trials, do not show efficacy in preventing UTI and renal scarring.  Among the trials are:  The Swedish Reflux Trial In Children, published in J Urol 2010 and the RIVUR (Randomized Intervention For Children With Vesico Ureteral Reflux) published in the New England Journal of Medicine in 2014. The RIVUR study represents a collaboration of 15 clinical trial centres throughout North America, recruiting 607 children, followed up for 2 years, with the end points being febrile UTI, VCUG and DMSA scans. There has also been an increased use of injection of the ureteric orifice, namely, STING (sub-trigonal injection) or HIT (hydrodistension technique) as these are simple endoscopic therapy. Results published (e.g. by Puri in Urol 2007 and by Elder JS et al in J Urol 2006) indicated good success rate, 53% resolution after first injection, even for Grade 5 vesico ureteric reflux. However, Deflux is rather costly. There may therefore be a return to ureteric re-implantation for patients with recurrent febrile UTI  not responsive to antibiotic prophylaxis.  There has also been a change in the imaging techniques with more reliance on high quality and focussed ultrasound of the urinary tract.  Ultrasound should include:  bipolar length, anterior  posterior diameter of the pelvis, parenchymal thickness,  scars, ureteric dilation, bladder volume pre and post micturition and bladder wall thickness.  MCUG can be avoided in most patients especially those with mild hydronephrosis.  However, it should be done in males with bilateral hydronephrosis and a abnormal bladder and in patients with severe bilateral hydroureter.  Neonates and young children should not be exposed to radiation, especially that of CT. MRU is occasionally indicated if more detailed anatomy study is required.   Circumcision reduces the risk of recurrent UTI for patients with high grade VUR.  Antibiotic prophylaxis in neuropathic bladders, in patients on clean intermittent catheterisation  confer little benefit. 

Conclusion:

A detailed ultrasound of the urinary tract is usually sufficient as the investigation of the child with UTI.  Radio isotope scan, if available, can be useful looking for scars and excretion.  Most cases do not require antibiotic prophylaxis but rather a vigorous and immediate 5 days’ course of antibiotics, if they develop a febrile UTI.  Antibiotic prophylaxis would be indicated for patients with a history of recurrent febrile UTI, usually in patients with higher grade reflux. When prophylactic antibiotic fails, ureteric   re-implantation may be considered. 

Keywords:

Vesico ureteric reflux, MCUG, antibiotic prophylaxis, Deflux, ureteric re-implantation.

Presented at 25th Malaysian Urological Conference KL 25 Nov 2016