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An Immature Murine Model of Reversible Unilateral Ureteral Obstruction
Published on: April 4, 2025
Interventions for primary vesicoureteric reflux
D M Wheeler1, D Vimalachandra, E M Hodson
1Department of Clinical Epidemiology, Children's Hospital at Westmead, Locked Bag 4001, Westmead, NSW, Australia, 2145.
Insights
The optimal management strategy for primary vesicoureteric reflux (VUR) in children remains uncertain. While combined treatments may reduce febrile urinary tract infections (UTIs), they do not significantly lower the risk of renal damage.
Area of Science:
- Pediatric Nephrology
- Urology
- Evidence-Based Medicine
Background:
- Vesicoureteric reflux (VUR) is a condition where urine flows backward from the bladder to the ureters.
- Urinary tract infections (UTIs) in children with VUR can lead to permanent kidney damage.
- Current management strategies, including antibiotic prophylaxis and surgical correction, aim to prevent UTIs but lack definitive optimal approaches.
Purpose of the Study:
- To evaluate the benefits and harms associated with various treatment options for primary VUR in children.
- To synthesize evidence from randomized controlled trials (RCTs) to inform clinical decision-making.
Main Methods:
- A systematic literature search was conducted across multiple databases (Cochrane Register, MEDLINE, EMBASE) and conference proceedings.
- Included RCTs compared different VUR treatments: surgery (open/closed), antibiotic prophylaxis, non-invasive methods, and combination therapies.
- Data were extracted, quality assessed, and dichotomous outcomes analyzed using relative risk (RR) and random effects models.
Main Results:
- Ten RCTs involving 964 children were analyzed.
- No significant difference in UTI risk was observed between surgical and medical management at 1-2 and 5 years.
- Combined treatment reduced febrile UTIs by 60% at 5 years but did not significantly decrease renal damage risk. Antibiotic prophylaxis alone showed no significant benefit over no treatment.
Conclusions:
- The clinical benefit of identifying and treating children with VUR is uncertain.
- The added benefit of surgery over antibiotics alone appears minimal.
- Nine surgical reimplantations would be needed to prevent one febrile UTI in children with VUR on antibiotics for five years, without reducing overall UTI or renal damage.
Background:
Vesicoureteric reflux (VUR) results in urine passing, in a retrograde manner, up the ureter. Urinary tract infections (UTIs) have been considered to be the main cause of permanent renal parenchymal damage in children with reflux. Therefore management of these children has been directed at preventing infection by antibiotic prophylaxis and/or surgical correction of reflux. However controversy remains as to the optimum strategies for management of children with primary VUR.
Objectives:
To evaluate the benefits and harms of the different treatment options for primary VUR.
Search Strategy:
Published and unpublished randomised controlled trials (RCTs) were identified from the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, reference lists of articles and abstracts from conference proceedings.
Selection Criteria:
RCTs were included if they compared any treatments of VUR including surgery (open and closed techniques), antibiotic prophylaxis of any duration, non-invasive techniques such as bladder training and any combination of therapies.
Data Collection And Analysis:
Two reviewers independently searched the literature, determined trial eligibility, assessed quality, extracted and entered data. For dichotomous outcomes, results were expressed as relative risk (RR) and 95% confidence intervals (CI). Data were pooled using the random effects model.
Main Results:
Ten trials involving 964 evaluable children comparing long-term antibiotics and surgical correction of VUR with antibiotics (seven trials), antibiotics with no treatment (one trial) and different materials for endoscopic correction of VUR (two trials) were identified. Risk of UTI by 1-2 and 5 years was not significantly different between surgical and medical groups (by 2 years RR 1.07, 95% CI 0.55 to 2.09; by 5 years RR 0.99; 95% CI 0.79 to 1.26). Combined treatment resulted in a 60% reduction in febrile UTI by 5 years (RR 0.43, 95% CI 0.27 to 0.70) but no concomitant significant reduction in risk of new or progressive renal damage at 5 years (RR 1.05, 95% CI 0.85 to 1.29). In one small study no significant differences in risk for UTI or renal damage were found between antibiotic prophylaxis and no treatment.
Reviewers' Conclusions:
It is uncertain whether the identification and treatment of children with VUR confers clinically important benefit. The additional benefit of surgery over antibiotics alone is small at best. Assuming a UTI rate of 20% for children with VUR on antibiotics for five years, nine reimplantations would be required to prevent one febrile UTI, with no reduction in the number of children developing any UTI or renal damage.
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