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Primary Vesicoureteral Reflux: Review of Current Concepts
1590
PEDIATRIC UROLOGY
levels (mean 2.0 2 0.91 SD) than those parents who avoided upsetting details (mean 3.1 t 0.47 SD). We conclude that distress associated with the MCUG can be reduced by therapeutic preparation of the child and family prior to investigation.
Editorial Comment: Previously, the authors demonstrated a significant level of distress in children undergoing a voiding cystourethrogram. Using the same methods of assessment, the authors studied the effect of patient preparation on child behavior. One week following this study these children demonstrated fewer behavioral changes, such as sleeplessness, clinginess and withdrawal. Assessment of the effect of multiple cystograms on children, as is typical in the medical followup for reflux, should be encouraged. Jack S. Elder, M.D.
Primary Vesicoureteral Reflux: Review of Current Concepts E. H. GARIN, A. Cmpos ANDY.HOMSY, Nephrology Division, Department of Pediatrics and Pediatric Urology Division, University of South Florida, Tampa, Florida Ped. Nephrol., 12: 249-256, 1998 The well-known association between vesicoureteral reflux and urinary tract infection is the basis for pathophysiological and therapeutic implications which have dominated the literature on the subject for the last 2 decades. We critically review the following issues: (1)does urinary tract infection cause reflux? (2) does reflux predispose to infection? (3)does reflux predispose to pyelonephritis? (4) does reflux predispose to a renal parenchymal scar? (5) does long-term urinary antibiotic prophylaxis prevent renal damage in patients with reflux? We conclude that none of the reviewed issues have been rigorously proven or validated and that the role of vesicoureteral reflux in urinary tract infections needs to be redefined through welldesigned, multicenter, prospective, randomized, controlled studies using state of the art. renal imaging techniques.
Editorial Comment: This review is a critical summary of the current understanding of the interrelationship among urinary tract infection, reflux and renal isiu.u, as well as current approaches to therapy. I disagree with some of the conclusions. For example, approximately 60% of children with and 60% without reflux and a febrile urinary tract infection have a positive dimercapto-succinic acid renal scan, consistent with acute pyelonephritis. The authors concluded that reflux does not predispose to acute pyelonephritis. A more appropriate way of reviewing the statistics would be to compare the incidence of acute pyelonephritis in children with reflux in the general population to those who do not have reflux. Because only 1%of children have reflux, it seems intuitively obvious that reflux predisposes to acute pyelonephritis. Furthermore, following successful antireflux surgery the incidence of acute pyelonephritis decreases significantly. The fact that acute pyelonephritis develops in many children without reflux has been known for many years, and simply demonstrates that reflux is a risk factor that predisposes to pyelonephritis. Jack S. Elder, M.D. Asymptomatic Vesicoureteral Reflux Detected by Neonatal Ultrasonographic Screening
J.-D. TSAI, F.-Y. HUANG AND T.-C. TSAI, Department of Pediatrics, Mackay Memorial Hospital, Taipei, Taiwan Ped. Nephrol., 1 2 206-209,1998 Renal ultrasonography was performed in 2,384 healthy and asymptomatic neonates. The definition and grading of hydronephrosis was according to the system of the Society for Fetal Urology. Voiding cystourethrography was performed in the cases with moderate to severe hydronephrosis or persistent mild hydronephrosis. In cases with vesicoureteral reflux (VUR), a dimercaptosuccinic acid (DMSA) renal scan was arranged immediately to evaluate the renal parenchyma. VUR was diagnosed in 30 infants with a prevalence of 1.26%; 7 had bilateral W R . The malelfemale ratio was 4:l and the righaeft ratio was 1.85:1. Comparing with the abnormal ultrasonographic findings, VUR appeared ipsilaterally in 23 ureters and contralaterally in 14 ureters. Using ultrasonography for diagnosing WR, the sensitivity, specificity, positive predictive value, and negative predictive value were 62.2%,36.1%, 11.0%,and 88.2%, respectively. DMSA renal scan was performed in 31 refluxing kidneys, and congenital renal scaning was found in 9 (29.0%)kidneys. Six neonates underwent reimplantation surgery. We conclude that although ultrasonography is not a reliable tool for diagnosing VUR, it can detect many cases of W R during the newborn stage using our screening program, which thus makes early treatment from the neonatal period possible. Whether our screening program can improve the outcome of W R will require further follow-up.
Editorial Comment: The authors performed screening renal ultrasonography in 2,384 healthy neonates. A voiding cystourethrogram was done in newborns with hydronephrosis (8.1%) or those with persistent mild renal pelvic dilatation (9.6%). Reflux was diagnosed in 30 newborns (1.3%).Of the patients approximately 80% were male and 75% had at least grade I11 reflux. Of the patients with upper tract changes 18%had reflux. This study supports the evaluation of neo-
PEDIATRIC UROLOGY
levels (mean 2.0 2 0.91 SD) than those parents who avoided upsetting details (mean 3.1 t 0.47 SD). We conclude that distress associated with the MCUG can be reduced by therapeutic preparation of the child and family prior to investigation.
Editorial Comment: Previously, the authors demonstrated a significant level of distress in children undergoing a voiding cystourethrogram. Using the same methods of assessment, the authors studied the effect of patient preparation on child behavior. One week following this study these children demonstrated fewer behavioral changes, such as sleeplessness, clinginess and withdrawal. Assessment of the effect of multiple cystograms on children, as is typical in the medical followup for reflux, should be encouraged. Jack S. Elder, M.D.
Primary Vesicoureteral Reflux: Review of Current Concepts E. H. GARIN, A. Cmpos ANDY.HOMSY, Nephrology Division, Department of Pediatrics and Pediatric Urology Division, University of South Florida, Tampa, Florida Ped. Nephrol., 12: 249-256, 1998 The well-known association between vesicoureteral reflux and urinary tract infection is the basis for pathophysiological and therapeutic implications which have dominated the literature on the subject for the last 2 decades. We critically review the following issues: (1)does urinary tract infection cause reflux? (2) does reflux predispose to infection? (3)does reflux predispose to pyelonephritis? (4) does reflux predispose to a renal parenchymal scar? (5) does long-term urinary antibiotic prophylaxis prevent renal damage in patients with reflux? We conclude that none of the reviewed issues have been rigorously proven or validated and that the role of vesicoureteral reflux in urinary tract infections needs to be redefined through welldesigned, multicenter, prospective, randomized, controlled studies using state of the art. renal imaging techniques.
Editorial Comment: This review is a critical summary of the current understanding of the interrelationship among urinary tract infection, reflux and renal isiu.u, as well as current approaches to therapy. I disagree with some of the conclusions. For example, approximately 60% of children with and 60% without reflux and a febrile urinary tract infection have a positive dimercapto-succinic acid renal scan, consistent with acute pyelonephritis. The authors concluded that reflux does not predispose to acute pyelonephritis. A more appropriate way of reviewing the statistics would be to compare the incidence of acute pyelonephritis in children with reflux in the general population to those who do not have reflux. Because only 1%of children have reflux, it seems intuitively obvious that reflux predisposes to acute pyelonephritis. Furthermore, following successful antireflux surgery the incidence of acute pyelonephritis decreases significantly. The fact that acute pyelonephritis develops in many children without reflux has been known for many years, and simply demonstrates that reflux is a risk factor that predisposes to pyelonephritis. Jack S. Elder, M.D. Asymptomatic Vesicoureteral Reflux Detected by Neonatal Ultrasonographic Screening
J.-D. TSAI, F.-Y. HUANG AND T.-C. TSAI, Department of Pediatrics, Mackay Memorial Hospital, Taipei, Taiwan Ped. Nephrol., 1 2 206-209,1998 Renal ultrasonography was performed in 2,384 healthy and asymptomatic neonates. The definition and grading of hydronephrosis was according to the system of the Society for Fetal Urology. Voiding cystourethrography was performed in the cases with moderate to severe hydronephrosis or persistent mild hydronephrosis. In cases with vesicoureteral reflux (VUR), a dimercaptosuccinic acid (DMSA) renal scan was arranged immediately to evaluate the renal parenchyma. VUR was diagnosed in 30 infants with a prevalence of 1.26%; 7 had bilateral W R . The malelfemale ratio was 4:l and the righaeft ratio was 1.85:1. Comparing with the abnormal ultrasonographic findings, VUR appeared ipsilaterally in 23 ureters and contralaterally in 14 ureters. Using ultrasonography for diagnosing WR, the sensitivity, specificity, positive predictive value, and negative predictive value were 62.2%,36.1%, 11.0%,and 88.2%, respectively. DMSA renal scan was performed in 31 refluxing kidneys, and congenital renal scaning was found in 9 (29.0%)kidneys. Six neonates underwent reimplantation surgery. We conclude that although ultrasonography is not a reliable tool for diagnosing VUR, it can detect many cases of W R during the newborn stage using our screening program, which thus makes early treatment from the neonatal period possible. Whether our screening program can improve the outcome of W R will require further follow-up.
Editorial Comment: The authors performed screening renal ultrasonography in 2,384 healthy neonates. A voiding cystourethrogram was done in newborns with hydronephrosis (8.1%) or those with persistent mild renal pelvic dilatation (9.6%). Reflux was diagnosed in 30 newborns (1.3%).Of the patients approximately 80% were male and 75% had at least grade I11 reflux. Of the patients with upper tract changes 18%had reflux. This study supports the evaluation of neo-