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Paediatric Surgery
The Diagnosis and Medical Management of Vesicoureteral Ref
Built from Puri — Pediatric Surgery and Pediatric Urology
What’s inside
8 sections · 81 slides
Overview
- What this talk covers
What reflux is
The valve, and why it fails
- Vesicoureteral reflux in plain terms
- Two kinds of reflux
- Why reflux matters
- The scale of the problem
How we detect and grade reflux
Every test is a trade-off
- The grading scale (International Reflux Study)
- The five grades of vesicoureteral reflux
- Grading is subjective — a real weakness
- The mainstay test: contrast VCUG
- VCUG: strengths vs costs
- A more objective grade: ureteral diameter ratio (UDR)
- Intrarenal reflux (IRR)
- Intrarenal reflux on a voiding cystourethrogram
- Hunting “occult” reflux: PIC cystography
- Finding occult reflux with PIC cystography
- Lower-radiation alternatives to VCUG
- The dream of no catheter — noninvasive cystography
- Why ultrasound alone is not enough
- The “top-down” approach and DMSA
- DMSA reveals a scar the ultrasound misses
- How well does acute DMSA detect dilating reflux?
- Urine and blood markers
Who should even be tested?
Three ways children present — and the debate over each
- Three groups that might have reflux
- How reflux causes kidney infection
- After a UTI: how much reflux, how much risk
- The AAP guidelines (2011)
- AAP action statement: DMSA not recommended first
- AAP: VCUG only if the ultrasound is abnormal
- Why the AAP guidance drew fire
- The NICE guidelines (UK, 2007)
- NICE imaging, simplified by age
- NICE recommendations by age and infection type
- NICE recommendations, continued
- NICE recommendations, further age bands
- The problem with leaning on ultrasound
- Infants with prenatal hydronephrosis
- Reflux after prenatal hydronephrosis
- Screening symptom-free siblings
- What the AUA panel could recommend
Managing reflux medically
Prophylaxis, resolution, and the bladder-bowel link
- The classic principles
- Early evidence that prophylaxis was safe
- Long-term resolution rate by starting grade
- Predicting who will resolve
- Bowel and bladder dysfunction (BBD)
- Overlap of bladder-bowel dysfunction and reflux
- Treating BBD: biofeedback
The prophylaxis controversy
Conflicting trials — and why they conflict
- Should prophylaxis be stopped — or started at all?
- Why the older literature is untrustworthy
- Geography and circumcision skew the results
- Studies that discontinued prophylaxis
- Trials of NOT starting prophylaxis (1)
- Trials of NOT starting prophylaxis (2)
- Two trials that clearly favored prophylaxis
The RIVUR trial
The study designed to settle it
- RIVUR: built to fix the old flaws
- Who was in RIVUR
- The headline result: prophylaxis halved infections
- RIVUR: fewer infections on prophylaxis than placebo
- The benefit held in the youngest — and across subgroups
- RIVUR: prophylaxis benefit in children under two
- What RIVUR did not settle: scarring
- What RIVUR means
Where this leaves us
- Success story or overtreatment?
- Three things to take away
- Future directions
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- Pediatric Surgery and Pediatric Urology