Article

Interventions for primary vesicoureteric reflux

Renal Division, Department of Internal Medicine, University Hospital Ghent, Ghent, Belgium.
Cochrane database of systematic reviews (Online) (Impact Factor: 6.03). 06/2011; DOI: 10.1002/14651858.CD001532.pub4
Source: PubMed

ABSTRACT

: Vesicoureteric reflux (VUR) results in urine passing retrograde up the ureter. Urinary tract infections (UTI) associated with VUR have been considered a cause of permanent renal parenchymal damage in children with VUR. Management of these children has been directed at preventing UTI by antibiotic prophylaxis and/or surgical correction of VUR. The optimum strategy is not clear.
Objectives : To evaluate the benefits and harms of different treatment options for primary VUR.
Search methods : In August 2010 we searched CENTRAL, MEDLINE and EMBASE and screened reference lists of papers and abstracts from conference proceedings.
Selection criteria : RCTs in any language comparing any treatment of VUR including surgical or endoscopic correction, antibiotic prophylaxis, non-invasive non-pharmacological techniques and any combination of therapies.
Data collection and analysis : Two authors independently searched the literature, determined study eligibility, assessed quality, extracted and entered data. We expressed dichotomous outcomes as risk ratios (RR) and their 95% confidence intervals (CI) and continuous data as mean differences (MD) and their 95% CI's Data were pooled using the random effects model.
Main results : Twenty RCTs (2324 children) were included. Long-term low-dose antibiotic prophylaxis compared to no treatment/placebo did not significantly reduce repeat symptomatic UTI (846 children: RR 0.68, 95% CI 0.39 to 1.17) or febrile UTI (946 children: RR 0.77, 95% CI 0.47 to 1.24) at two years. There was considerable heterogeneity in the analyses and only one study was adequately blinded. At one to three years, antibiotic prophylaxis reduced the risk of new or progressive renal damage on DMSA scan (446 children: RR 0.35, 95% CI 0.15 to 0.80). Side effects were infrequent when reported, but antibiotics increased the likelihood of bacterial drug resistance threefold (132 UTIs: RR 2.94, 95% CI 1.39 to 6.25).
When long-term antibiotic prophylaxis was compared with surgical or endoscopic correction of VUR plus antibiotics for one to 24 months (10 studies, 1141 children), the risk of symptomatic UTI was not significantly different at any time point. Combined surgical and antibiotic treatment caused a 57% reduction in febrile UTI by five years (2 studies, 449 children: RR 0.43, 95% CI 0.27 to 0.70) but did not decrease the risk of new or progressive renal damage at any time point. Postoperative obstruction was seen in 0% and 7% of children in two surgical studies and 0% in one endoscopic study.
Authors' conclusions : Compared with no treatment, use of long-term, low-dose antibiotics did not significantly reduce the number of repeat symptomatic and febrile UTIs in children with VUR. Considerable heterogeneity in the analyses and inclusion of only one adequately blinded study, made drawing firm conclusions challenging. Antibiotic prophylaxis significantly reduced the risk of developing new or progressive renal damage, but assuming an 8% baseline risk, 33 children would need long-term antibiotic prophylaxis to prevent one more child developing kidney damage over the course of two to three years.
The added benefit of surgical or endoscopic correction of VUR over antibiotic treatment alone remains unclear. Eight children would require combined surgical and antibiotic treatment to prevent one additional child developing febrile UTI by five years, but it would not cause fewer children developing renal damage.

Download full-text

Full-text

Available from: Elisabeth M Hodson, Aug 18, 2014
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Urinary tract infection, one of the commonest bacterial diseases in children, carries a substantial risk of serious complications. Amongst them, renal scarring and recurrent infections seem to be the most important. In this review, we analyze the pathogenesis of urinary tract infection in order to identify those children who run the highest risk of unfavorable outcome. During infection, multiple bacterial and host factors interact with each other. Bacteria possess specific characteristics involved in the process of adhesion, invasion, survival and host damage during infection. Host factors also substantially participate in the pathogenesis of the disease. According to current knowledge, the specific host response appears to be the main factor predisposing for complications. However, prompt and adequate treatment of acute urinary tract infection remains the most important measure to prevent scarring. Dysfunctional holding and elimination of urine, on the other hand, mainly seem to influence the development of recurrent infection. Despite intensive research for many years, urinary tract infections are still a challenge for patients and health care professionals.
    Full-text · Article · Feb 2007 · Current Pediatric Reviews
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: In addition to conventional open surgery and endoscopic techniques, laparoscopic correction of vesicoureteric reflux, sometimes even robot-assisted, is becoming an alternative surgical treatment modality for this condition in a number of centres around the world. At least for a subgroup of patients laparoscopists are trying to develop new techniques in an effort to combine the best of both worlds: the minimal invasiveness of the STING and the same lasting effectiveness as in open surgery. The efficacy and potential advantages or disadvantages of these techniques are still under investigation. The different laparoscopic techniques and available data are presented.
    Full-text · Article · Sep 2007 · European Journal of Pediatrics
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Long term controlled studies in children with vesicoureteral reflux (VUR) largely conducted in developed societies, challenge the validity of established management principles.The backflow of urine into the upper tracts is not a disease by itself, but part of a clinical spectrum which is heterogeneous and has low risk and high risk categories. Management, medical, endoscopic or surgical have to take into consideration the risk to the child not only from the reflux but also from renal dysplasia and voiding dysfunction which are important risk factors for end stage renal disease (ESRD) and perpetuation of VUR respectively. Social factors, parental choices and access to medical treatment are also important in choosing therapy.
    Preview · Article · Nov 2008 · The Indian Journal of Pediatrics
Show more