Vesicoureteral reflux (VUR) has long been considered a risk factor for pyelonephritis in children. Over the past 15 years, a number of randomized controlled trials have demonstrated that there is minimal risk of kidney damage from VUR, and treatment does not alter that risk. In a recently published article, Jeremy B. Wiygul, MD, a pediatric urologist at NewYork-Presbyterian and Weill Cornell Medicine, explains the history of VUR as a pathologic condition, the miscalculation of management implications from earlier studies, and how recent research findings negate the need for long-established diagnostic and treatment practices. Below, Dr. Wiygul discusses the key points to consider about VUR diagnostics and treatment.
Research Background
A decade ago, the highly anticipated Randomized Intervention for Children with Vesicoureteral Reflux (RiVUR) study about VUR was set to resolve how we as pediatric urologists approach VUR, its diagnosis, and management. The RiVUR study compared continued antibiotic prophylaxis (CAP) to placebo in preventing new UTIs over a two-year period in children from two to 71 months old. The research also evaluated renal scarring, treatment failure, and antimicrobial resistance. Results showed patients receiving CAP had a statistically significant advantage than those receiving placebo in the prevention of new UTIs.
RiVUR confirmed the findings of several similar randomized controlled trials that indicated VUR grade three or higher is associated with an increasing risk of recurrent UTIs in young kids. By treating VUR with CAP or, in certain cases surgery, to resolve the reflux, you could reduce recurrence of these infections, but not prevent them entirely. All of these studies confirmed that the risk for kidney damage is small and that interventions do nothing to change that risk. All of this research led me to start investigating how VUR should be diagnosed and treated moving forward.
Since the RiVUR study, two additional studies confirmed the same findings. This means there are nine randomized control trials, eight of which have looked at the impact of treatment on kidney scarring, and all of them have concluded that there is none. Therefore, if VUR carries a very low risk of health problems developing in the future and requires diagnostics and treatment regimens that have their own side effects, pediatric urologists may be able to look at VUR treatment differently.
Changes to Patient Care
Based on the extensive research findings, I believe that VUR diagnosis and treatment in young children should only be utilized in extreme circumstances when there is severe preexisting kidney disease due to a bladder that is impaired. For those cases, when it comes to testing urine, a catheterized urine specimen is the standard-of-care for a child who are not toilet trained, but we need a more reliable way to obtain urine specimens from young kids that minimizes the chance of false positives as close as possible to zero.
Recognizing this need, I developed a new catheter, which is FDA approved, that aims to prevent contamination during urine specimen collection by protecting the eyelets at the tip of the catheter as it is inserted. A sliding mechanism covers the eyelets during the insertion. Once the catheter is in place, the mechanism is retracted to expose the eyelets while withdrawing the urine. The initial results of using this catheter are extremely encouraging, but we need to further study the device in larger numbers of patients.
If we can prove, via this catheter, that most UTIs are in fact false positives, the worry regarding the presence of VUR falls away; put another way, if children are not getting UTIs, the presence of VUR doesn’t matter, even in the eyes of the most aggressive pediatric urologist.
Future Implications
While the RiVUR trial informed my approach to caring, diagnosing, and treating VUR based on evidence, I was further persuaded by a patient who had been on prophylaxis for recurrent UTI for years. She had been found to not have VUR previously, but since she continued to develop UTIs, I felt that we needed to repeat the test for VUR, which is called a voiding cystourethrogram. Due to the other testing we were going to perform at the same time, I performed the test myself, which requires a catheter. The intense discomfort the patient experienced when using a catheter made me realize it should be used cautiously and only in critical circumstances. I encourage pediatric urologists to review the evidence from the research so VUR can be diagnosed cautiously and thoughtfully, and new standards of care can be considered.
