- Email: [email protected]
Swedish infant VUR trial
Accepted Manuscript Swedish Infant VUR Trial Craig A. Peters, MD, FAAP, FACS, Professor and Chief PII:
S1477-5131(17)30095-5
DOI:
10.1016/j.jpurol.2017.03.002
Reference:
JPUROL 2473
To appear in:
Journal of Pediatric Urology
Received Date: 1 March 2017 Accepted Date: 1 March 2017
Please cite this article as: Peters CA, Swedish Infant VUR Trial, Journal of Pediatric Urology (2017), doi: 10.1016/j.jpurol.2017.03.002. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Craig A. Peters, MD, FAAP, FACS. Professor and Chief, Pediatric Urology Children’s Medical Center University of Texas Southwestern Dallas, TX [email protected]
RI PT
Swedish Infant VUR Trial
M AN U
SC
High-grade vesicoureteral reflux in the infant has long challenged the pediatric urologist. Resolution rates are low, there seems to be a higher risk of infection threatening kidneys that may already be compromised, and surgical repair is not for the timid. The authors continue a long tradition of detailed clinical studies in pediatric infection and reflux; the study was partially concomitant with the larger Swedish reflux trial published in 2011. The over-arching goal of this study was to determine whether early correction of reflux might provide better clinical outcomes in this population. It is important to recognize however that in order to define a clinically useful parameter that will alter practice, it must reflect a high degree of differentiation of outcomes. Put another way, statistical significance does not always reflect clinical significance.
EP
TE D
What have the authors shown? The simple conclusion is that endoscopic therapy offers a greater chance of reflux resolution at one year of follow-up than antibiotic prophylaxis alone. Unfortunately, this is a trivial result since we know that grade 4 and 5 reflux are highly unlikely to have resolved that quickly. The more relevant comparison, which the authors explored, is a change in urinary infection and bladder dynamics. It would certainly be appealing if a simple endoscopic procedure would reliably reduce the risk of potentially damaging infections. Unfortunately the authors did not find a significant reduction in UTI or renal scarring either in those treated with endoscopic therapy or those who had resolution of the reflux.
AC C
The authors also asked the fascinating question of whether early resolution of reflux could improve bladder dynamics. It has long been debated as to the effect of voiding dysfunction on reflux and of reflux on voiding function. This is presumably, albeit simplistically, thought to be due to the recurrent bladder refilling of refluxed urine with each voiding episode. Unfortunately, no significant difference could be identified, although suggestions of the relationship were observed and should provide insight for further study. Finally, circling back to the authors’ concept of using endoscopic therapy to reduce highgrade reflux early in life; this is difficult to support clinically. The success rate was low and the recurrence rate was not insignificant. The treated group was exposed to a significant number of anesthetic episodes with their attendant costs and risks, including
ACCEPTED MANUSCRIPT
RI PT
the undefined risk of neurodevelopmental impairment. No benefit was seen in terms of UTI’s, scarring, or voiding dysfunction. While this may be a minimally invasive approach, it seems to be minimally beneficial. This study asks important questions, however I cannot see it justifying a change in my practice. The child with high-grade reflux and significant baseline impairment of renal function can be managed with definitive antireflux surgery with good long-term results, or temporary diversion to allow growth and reassessment. Note: I was the thesis opponent for the associated Swedish Reflux Trial authored by Dr. Per Brandström.
AC C
EP
TE D
M AN U
SC
Disclosure: This editorial was supported by the promise of several dozen cold New England oysters.
S1477-5131(17)30095-5
DOI:
10.1016/j.jpurol.2017.03.002
Reference:
JPUROL 2473
To appear in:
Journal of Pediatric Urology
Received Date: 1 March 2017 Accepted Date: 1 March 2017
Please cite this article as: Peters CA, Swedish Infant VUR Trial, Journal of Pediatric Urology (2017), doi: 10.1016/j.jpurol.2017.03.002. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Craig A. Peters, MD, FAAP, FACS. Professor and Chief, Pediatric Urology Children’s Medical Center University of Texas Southwestern Dallas, TX [email protected]
RI PT
Swedish Infant VUR Trial
M AN U
SC
High-grade vesicoureteral reflux in the infant has long challenged the pediatric urologist. Resolution rates are low, there seems to be a higher risk of infection threatening kidneys that may already be compromised, and surgical repair is not for the timid. The authors continue a long tradition of detailed clinical studies in pediatric infection and reflux; the study was partially concomitant with the larger Swedish reflux trial published in 2011. The over-arching goal of this study was to determine whether early correction of reflux might provide better clinical outcomes in this population. It is important to recognize however that in order to define a clinically useful parameter that will alter practice, it must reflect a high degree of differentiation of outcomes. Put another way, statistical significance does not always reflect clinical significance.
EP
TE D
What have the authors shown? The simple conclusion is that endoscopic therapy offers a greater chance of reflux resolution at one year of follow-up than antibiotic prophylaxis alone. Unfortunately, this is a trivial result since we know that grade 4 and 5 reflux are highly unlikely to have resolved that quickly. The more relevant comparison, which the authors explored, is a change in urinary infection and bladder dynamics. It would certainly be appealing if a simple endoscopic procedure would reliably reduce the risk of potentially damaging infections. Unfortunately the authors did not find a significant reduction in UTI or renal scarring either in those treated with endoscopic therapy or those who had resolution of the reflux.
AC C
The authors also asked the fascinating question of whether early resolution of reflux could improve bladder dynamics. It has long been debated as to the effect of voiding dysfunction on reflux and of reflux on voiding function. This is presumably, albeit simplistically, thought to be due to the recurrent bladder refilling of refluxed urine with each voiding episode. Unfortunately, no significant difference could be identified, although suggestions of the relationship were observed and should provide insight for further study. Finally, circling back to the authors’ concept of using endoscopic therapy to reduce highgrade reflux early in life; this is difficult to support clinically. The success rate was low and the recurrence rate was not insignificant. The treated group was exposed to a significant number of anesthetic episodes with their attendant costs and risks, including
ACCEPTED MANUSCRIPT
RI PT
the undefined risk of neurodevelopmental impairment. No benefit was seen in terms of UTI’s, scarring, or voiding dysfunction. While this may be a minimally invasive approach, it seems to be minimally beneficial. This study asks important questions, however I cannot see it justifying a change in my practice. The child with high-grade reflux and significant baseline impairment of renal function can be managed with definitive antireflux surgery with good long-term results, or temporary diversion to allow growth and reassessment. Note: I was the thesis opponent for the associated Swedish Reflux Trial authored by Dr. Per Brandström.
AC C
EP
TE D
M AN U
SC
Disclosure: This editorial was supported by the promise of several dozen cold New England oysters.