Critical appraisal of the top-down approach for vesicoureteral reflux

Area of Science:

• Pediatric Nephrology
• Diagnostic Imaging in Urology
• Renal Medicine

Background:

• Vesicoureteral reflux (VUR) is associated with recurrent urinary tract infections (UTIs), renal scarring, hypertension, and kidney disease.
• Current diagnostic imaging strategies for VUR in children aim to minimize morbidity, radiation, and cost, but none are universally accepted.
• The top-down approach (TDA) seeks to reduce voiding cystourethrograms (VCUGs) by using dimercapto-succinic acid (DMSA) scans to identify renal inflammation in febrile UTIs.

Purpose of the Study:

• To critically evaluate the limitations of the top-down approach (TDA) for diagnosing vesicoureteral reflux (VUR) in children.
• To discuss the drawbacks of TDA, including its segregation of patients, omission of UTI morbidity, and potential misattribution of DMSA lesions.
• To advocate for a patient-centered approach as a superior alternative for managing VUR.

Main Methods:

• Review of existing literature on diagnostic strategies for VUR in children.
• Analysis of the top-down approach (TDA), including its methodology and outcomes.
• Comparison of TDA with alternative approaches, emphasizing patient-centered care.

Main Results:

• The TDA can identify clinically significant VUR with high sensitivity.
• Limitations of TDA include overlooking UTI morbidity, misinterpreting DMSA lesions as congenital dysplasia, radiation exposure, cost, and variable interpretation.
• The TDA's reliance on DMSA scans in the acute setting is limited by availability and yield.

Conclusions:

• The top-down approach (TDA) for diagnosing vesicoureteral reflux (VUR) has significant limitations.
• A patient-centered approach is proposed as a more comprehensive and valuable strategy for VUR management.
• Addressing the drawbacks of TDA is crucial for optimizing pediatric VUR diagnosis and care.