An Analysis of Social and Economic Factors Associated with Followup of Patients With Vesicoureteral Reflux

Rationale and design issues of the Randomized Intervention for Children With Vesicoureteral Reflux (RIVUR) study

OBJECTIVE

Our goal is to determine if antimicrobial prophylaxis with trimethoprim/sulfamethoxazole prevents recurrent urinary tract infections and renal scarring in children who are found to have vesicoureteral reflux after a first or second urinary tract infection.

DESIGN, PARTICIPANTS, AND METHODS

The Randomized Intervention for Children With Vesicoureteral Reflux (RIVUR) study is a double-blind, randomized, placebo-controlled trial. Six hundred children aged 2 to 72 months will be recruited from both primary and subspecialty care settings at clinical trial centers throughout North America. Children who are found to have grades I to IV vesicoureteral reflux after the index febrile or symptomatic urinary tract infection will be randomly assigned to receive daily doses of either trimethoprim/sulfamethoxazole or placebo for 2 years. Scheduled follow-up contacts include in-person study visits every 6 months and telephone interviews every 2 months. Biospecimens (urine and blood) and genetic specimens (blood) will be collected for future studies of the genetic and biochemical determinants of vesicoureteral reflux, recurrent urinary tract infection, renal insufficiency, and renal scarring.

RESULTS

The primary outcome is recurrence of urinary tract infection. Secondary outcomes include time to recurrent urinary tract infection, renal scarring (assessed by dimercaptosuccinic acid scan), treatment failure, renal function, resource utilization, and development of antimicrobial resistance in stool flora.

CONCLUSIONS

The RIVUR study will provide useful information to clinicians about the risks and benefits of prophylactic antibiotics for children who are diagnosed with vesicoureteral reflux after a first or second urinary tract infection. The data and specimens collected over the course of the study will allow researchers to better understand the pathophysiology of recurrent urinary tract infection and its sequelae.

Part 1: Vesicoureteral reflux treatment: the past, present, and future

The purpose of this manuscript is to provide clinicians with highlights of key findings pertaining to our current understanding and treatment of the condition of vesicoureteral reflux (VUR). This includes a review of the disease, patient characteristics, current treatment options, challenges for managed care and patients, and opportunities for improvements in care. This is not intended as a comprehensive review of VUR. This manuscript does, however, serve to introduce three additional manuscripts contained within this supplement. The first article in this series is designed to provide the clinician with real-world data pertaining to treatment patterns and outcomes in patients with VUR (Examining pediatric vesicoureteral reflux: a real-world evaluation of treatment patterns and outcomes: Hensle TW, Hyun G, Grogg AL, Eaddy M). The second article considers the efficacy of prophylactic antibiotics in reducing the likelihood of urinary tract infections (UTIs) when compared with endoscopic injection with dextranomer/hyaluronic acid (Endoscopic injection versus antibiotic prophylaxis in the reduction of urinary tract infection in patients with vesicoureteral reflux: Elder JS, Shah MB, Batiste LR, et al.). The third article explores the role medication noncompliance plays in contributing to antibiotic resistance, the consequences associated with resistance (longer lasting illness and costs), and the difficulties with resistance specific to UTI pathogens in children (Considerations regarding the medical management of VUR: what have we really learned?: Koyle MA, Caldamone A). This supplement is intended to provide the clinician with valuable information regarding the treatment patterns, the role of compliance, and the efficacy of treatments for pediatric patients with VUR.

Vesicoureteral reflux – current treatment options

Vesicoureteral reflux has long been recognised as a major child and public health problem. Widespread recognition and screening of at-risk populations has the potential to significantly reduce long-term morbidity in both children and adults. Advances in pharmacotherapy, materials science and surgery, have caused many experts to reassess established dictums of treatment. Concern regarding the overuse of antibiotics and surgery has led to efforts to tailor therapy more narrowly for those who are at the highest risk from recurrent urinary tract infection and pyelonephritis. Children after a certain age, without underlying voiding dysfunction, might not require treatment at all. Newer surgical and anaesthetic techniques have the potential of transforming surgical correction from a painful experience to an ambulatory procedure, with a rapid return to daily activities. Both the promise and pitfalls of these newest advances will be discussed in this review.

Endoscopic Treatment of Vesicoureteral Reflux with Autologous Chondrocytes: Postoperative Sonographic Features

PURPOSE

To analyze sonographic imaging features of renal collecting systems, ureters, and bladder in 32 children after endoscopic treatment of vesicoureteral reflux with autologous chondrocytes and to determine whether any features are associated with persistent reflux.

MATERIALS AND METHODS

Sonograms obtained at mean intervals of 1.4 and 12 months after treatment were compared with cystograms obtained at mean intervals of 2.7 and 12 months. Sonograms were analyzed for chondrocyte mound contour and volume, changes in mound volume over time, and presence of hydroureteronephrosis. Mean differences in mound volume were detected with paired t tests in 14 patients with early and late sonograms available for review.

RESULTS

Early cystograms and sonograms were available for 25 of 32 patients (45 of 56 treated ureters). Reflux occurred in 16 of 45 ureters. In 16 ureters, chondrocyte mounds were absent in six, unilobed in seven, and multilobed in three. In 29 treated ureters without reflux, mounds were unilobed in 28 and multilobed in one. Three patients had mild hydronephrosis and one had distal hydroureter; these conditions resolved. Late cystograms and sonograms were available in 18 of 22 patients (30 of 38 treated ureters). Reflux occurred in seven of 30 ureters. In seven ureters, mounds were unilobed in five and multilobed in two. In 23 treated ureters without reflux, mounds were unilobed in 21 and multilobed in two. One patient had mild hydronephrosis that resolved. In 14 patients with early and late sonograms available for review, mean mound volume in late group (0.37 cm3 +/- 0.25 [standard deviation]) was significantly smaller than that in early group (0.56 cm3 +/- 0.39; P =.004, paired t test).

CONCLUSION

Absence of chondrocyte mound or presence of multilobed mound contour was associated with persistent reflux. Mean mound volume decreased over time. Treatment-induced hydroureteronephrosis was uncommon and self-limited.

Prospective comparison and 1-year follow-up of a single endoscopic subureteral polydimethylsiloxane versus dextranomer/hyaluronic acid copolymer injection for treatment of vesicoureteral reflux in children

OBJECTIVES

To compare, in a prospective study, the efficacy of a single injection of polydimethylsiloxane (Macroplastique) or dextranomer/hyaluronic acid copolymer (Deflux), a new biodegradable substance, and to assess the short-term and 1-year clinical effects concerning reflux resolution and the safety of these two bulking agents. Subureteral injection of bulking agents has recently demonstrated good success rates for endoscopic treatment of vesicoureteral reflux. Macroplastique has been one of the most popular bulking agents during the past years. Nevertheless, considering the synthetic property, new biodegradable substances have become more relevant.

METHODS

From January 2000 to June 2001, 16 boys and 56 girls (total of 114 ureters) with a mean age of 34.5 months were treated endoscopically for vesicoureteral reflux. A single subureteral Macroplastique or Deflux injection was performed in 34 children (58 ureters) and 38 children (56 ureters), respectively. Both groups were comparable in terms of baseline parameters. Vesicoureteral reflux was grade II in 52, grade III in 57, and grade IV in 5 ureterorenal units. The procedure was performed on an outpatient basis, with the children under general anesthesia. In addition to the routine parameters, the follow-up evaluation consisted of renal ultrasonography and voiding cystourethrography at 3 and 12 months postoperatively.

RESULTS

Endoscopic treatment was performed without any complications in all cases. At the 3-month follow-up visit, reflux was corrected in 50 (86.2%) of 58 refluxing ureters in the Macroplastique group and in 40 (71.4%) of 56 refluxing ureters in the Deflux group. At 1 year of follow-up, reflux correction was maintained in 80.9% of ureters in the Macroplastique group and in 67.6% of ureters in the Deflux group. No postoperative complications were observed in either group.

CONCLUSIONS

A single subureteral injection of either polydimethylsiloxane (Macroplastique) or dextranomer/hyaluronic acid copolymer (Deflux) is an effective treatment modality for children with vesicoureteral reflux. The procedure was well tolerated, safe, and associated with low morbidity. Deflux, a new biocompatible, biodegradable substance, seems to be an alternative modality to other bulking agents for treating vesicoureteral reflux in children, with acceptable short-term and 1-year results.

Long-term followup of 158 young adults surgically treated for vesicoureteral reflux in childhood: the ongoing risk of urinary tract infections

PURPOSE

We recorded urinary tract infections in the long term after surgical reflux correction.

MATERIALS AND METHODS

A total of 158 of 189 patients (160 females and 29 males) who were followed in 1985, an average of 10.8 years after reflux surgery were contacted again in 1995. At that time median patient age was 26 years (range 15.7 to 38.8) and the average period of observation was 20.3 years (range 13.4 to 26).

RESULTS

In 82% of the patients febrile and in 18% afebrile symptomatic urinary tract infections had developed preoperatively. In the first 10-year period after operation 46% of patients continued to have symptomatic urinary tract infections compared with 52% in the second 10-year interval. In the 2 periods the incidence of febrile urinary tract infection was about 17%. In the whole postoperative observation period symptomatic urinary tract infections developed in 66% of all patients, including 74% of female patients. Symptomatic urinary tract infections were observed during 8 of 46 pregnancies (17%).

CONCLUSIONS

After successful surgical reflux correction susceptibility to urinary tract infection continues for a number of years in many girls and women. However, postoperatively urinary tract infections are primarily afebrile.

Management of vesicoureteral reflux in children

Although much has been learned about the diagnosis and management of vesicoureteral reflux, several important areas of investigation remain. Because not all children with reflux are equally susceptible to renal scarring and the development of reflux nephropathy, controversy surrounds the need to evaluate all children with urinary tract infection or to continue prophylaxis in known refluxing children after a certain age. In addition to age, other factors such as sex, grade of reflux, and the presence of voiding dysfunction can all play a role. The grade of reflux as seen on the contrast voiding cystourethrogram is the best predictor of reflux resolution in large numbers of patients, but grade alone cannot predict spontaneous cessation in any one individual. Attempts at refining more quantitative imaging modalities have so far proved unsuccessful. Open ureteral reimplantation remains the standard for surgical care if surgery is necessary. Both cystoscopic and laparoscopic techniques, however, may ultimately prove to be reliable, minimally invasive approaches to definitive correction. Finally, there are data to support continued diagnosis and treatment of reflux in at-risk populations. The incidence of reflux-related morbidity in children has significantly diminished over the last three decades. A major challenge is to better identify at-risk subpopulations of children with reflux, so that not every child will require intensive, long-term medical treatment or surgery.