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High grade vesicoureteral reflux: analysis of observational therapy
G A McLorie1, P H McKenna, B M Jumper
1Hospital for Sick Children, Toronto, Ontario, Canada.
Insights
High-grade vesicoureteral reflux (VUR) rarely resolves spontaneously. Observational therapy for primary VUR showed persistent reflux in most patients, with new renal scars developing in 8%. Surgical correction is recommended after 4 years of observation.
Area of Science:
- Pediatric Urology
- Nephrology
Background:
- High-grade vesicoureteral reflux (VUR) in children poses risks of renal scarring and infection.
- Historically, management strategies have varied, with a focus on either observation or early surgical intervention.
Purpose of the Study:
- To evaluate the natural history of high-grade primary vesicoureteral reflux (VUR) managed with observational therapy.
- To determine the rate of spontaneous resolution and the incidence of renal scarring in patients treated with prophylactic antibiotics.
Main Methods:
- A retrospective analysis of 300 pediatric patients with high-grade VUR (grades III-V) treated between 1981 and 1987.
- Patients received either observational therapy with prophylactic antibiotics or surgical correction for specific indications.
- Life-table methods were used to analyze the duration of persistent reflux.
Main Results:
- Only a minority of patients with grade V VUR experienced spontaneous resolution; most required surgery.
- In the observational group, 83% of patients with grade IV VUR and 83% with grade III VUR had persistent reflux at 2 years.
- New renal scars developed in 8% of patients during the observational period.
Conclusions:
- High-grade VUR resolves spontaneously in a small proportion of children over extended periods.
- Observational therapy alone for high-grade VUR is associated with a significant risk of persistent reflux and renal scarring.
- Surgical correction should be strongly considered for high-grade VUR after a 4-year observation period or upon development of specific indications.
Abstract:
Between 1981 and 1987, 300 patients with high grade (III, IV and V international classification) vesicoureteral reflux were treated at a single pediatric hospital. Only patients with primary vesicoureteral reflux were included in the study. The guiding principle during this period was that all patients with high grade vesicoureteral reflux would be observed on prophylactic antibiotics (observational therapy) and surgical correction would be reserved for specific indications. Of the 300 patients 132 received observational therapy alone and 168 required surgical correction for specific indications after varying periods of observation. In both groups the duration of persistent reflux was analyzed using a life-table method. In patients with grade V reflux we observed resolution in 3 patients whereas 23 required surgical correction. Of those patients in the observation group with grade IV reflux 83% had persistent reflux at 2 years and 70% still had reflux at 5 years. For those with grade III reflux the persistence rate was 83% and 50%, respectively. Neither age, sex nor side of reflux had a correlation with the rate of resolution. When tested grade of reflux correlated loosely (p = 0.07). During the period of observational therapy new renal scars developed in 23 patients (8%). We conclude that high grade vesicoureteral reflux can resolve in a minority of patients over a protracted interval. On the basis of this analysis, we advocate consideration of surgical correction in these patients after a 4-year period of observational therapy and for specific indications.