Interventions for primary vesicoureteric reflux
Abstract
Background
Vesicoureteric reflux (VUR) results in urine passing, in a retrograde manner, up the ureter. Urinary tract infections (UTIs) have been considered to be the main cause of permanent renal parenchymal damage in children with reflux. Therefore management of these children has been directed at preventing infection by antibiotic prophylaxis and/or surgical correction of reflux. However controversy remains as to the optimum strategies for management of children with primary VUR.
Objectives
To evaluate the benefits and harms of the different treatment options for primary VUR.
Search methods
Published and unpublished randomised controlled trials (RCTs) were identified from the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, reference lists of articles and abstracts from conference proceedings.
Selection criteria
RCTs were included if they compared any treatments of VUR including surgery (open and closed techniques), antibiotic prophylaxis of any duration, non‐invasive techniques such as bladder training and any combination of therapies.
Data collection and analysis
Two reviewers independently searched the literature, determined trial eligibility, assessed quality, extracted and entered data. For dichotomous outcomes, results were expressed as relative risk (RR) and 95% confidence intervals (CI). Data were pooled using the random effects model.
Main results
Ten trials involving 964 evaluable children comparing long‐term antibiotics and surgical correction of VUR with antibiotics (seven trials), antibiotics with no treatment (one trial) and different materials for endoscopic correction of VUR (two trials) were identified. Risk of UTI by 1‐2 and 5 years was not significantly different between surgical and medical groups (by 2 years RR 1.07, 95% CI 0.55 to 2.09; by 5 years RR 0.99; 95% CI 0.79 to 1.26). Combined treatment resulted in a 60% reduction in febrile UTI by 5 years (RR 0.43, 95% CI 0.27 to 0.70) but no concomitant significant reduction in risk of new or progressive renal damage at 5 years (RR 1.05, 95% CI 0.85 to 1.29). In one small study no significant differences in risk for UTI or renal damage were found between antibiotic prophylaxis and no treatment.
Authors' conclusions
It is uncertain whether the identification and treatment of children with VUR confers clinically important benefit. The additional benefit of surgery over antibiotics alone is small at best. Assuming a UTI rate of 20% for children with VUR on antibiotics for five years, nine reimplantations would be required to prevent one febrile UTI, with no reduction in the number of children developing any UTI or renal damage.
PICOs
Plain language summary
It is unclear whether the identification and treatment of children with vesicoureteric reflux has any clinically important benefit
Vesicoureteric reflux (VUR) is the backflow of urine from the bladder up the ureters to the kidney. People with VUR are thought to be more likely to get urinary tract infections (UTIs) involving the kidney tissue, which may cause permanent kidney damage. Current treatment options include surgery, surgery plus long‐term antibiotics, long‐term antibiotics alone and endoscopic (injection of a substance around the entry of the ureter into the bladder) correction using different materials. Surgery decreased the number of feverish UTIs, but did not change the number of children developing any UTI or kidney damage. More studies are needed.
