Managing Vesicoureteral Reflux in the Pediatric Patient: a Spectrum of Treatment Options for a Spectrum of Disease

Abstract

Vesicoureteral reflux (VUR), or the reverse flow of urine from the bladder into the ureter or renal collecting system, is characterized by a wide spectrum of severity. Consequently, a spectrum of treatment options exists that can be broadly divided into non-operative and surgical management. Non-operative management is based on the natural history of reflux which suggests that the vast majority of VUR, and in particular low grades of reflux, will resolve spontaneously. Furthermore, most patients with lower grades of VUR are at relatively low risk for recurrent pyelonephritis. The focus of non-operative management is to prevent urinary tract infections that, when combined with VUR, place a child’s kidney at risk for renal damage and potential loss of renal function. This is typically achieved by optimizing bladder and bowel function through a combination of dietary, behavioral, or pharmacologic therapies and in some cases may include the use of antibiotic prophylaxis. Surgical management seeks to mechanically correct VUR, either by endoscopic injection of the intravesical ureteral tunnel with bulking agents (Deflux) or with open or minimally invasive surgical ureteral reimplantation. Deflux provides a less invasive but comparatively less successful alternative to surgical reimplantation, and therefore, surgical reimplantation is more frequently utilized in children with persistent high-grade VUR, known renal damage, and associated bladder and bowel dysfunction. These approaches are not mutually exclusive, and the management of VUR is highly individualized, taking into consideration a litany of factors including a child’s age, sex, severity of reflux, response to previous therapy options, the presence and severity of renal damage, and concomitant bladder and bowel dysfunction. These considerations must also be balanced with patient/parent preference and the potential consequences of choosing a particular treatment strategy.