Pediatric Urinary Tract Infections and Vesicoureteral Refl ux: What Have We Learned?

It has been nearly 50 years since Victor Politano and Wyland Leadbetter developed the first reliable operation for the surgical correction of vesicoureteral refl ux (VUR). It dispelled the notion of bladder outlet obstruction as the primary cause of refl ux. One might argue, however, since the operation was so reproducible that we learned too quickly how to correct VUR before truly understanding its pathophysiology and potential risk in children. There have been many controversies that have arisen lately regarding the management of refl ux. These controversies include: (1) The role of imaging in evaluating children with urinary tract infections (UTIs). More specifi cally, does every child need a voiding cystourethrogram (VCUG) and where does the DMSA scan fi t into our evaluation? (2) There is a growing concern for the use of long-term prophylactic antibiotics and we lack controlled studies that verify their usefulness. (3) Where does the endoscopic correction of reflux fi t into our armamentarium of managing children with refl ux? Is it an alternative for antibiotic prophylaxis or is it an alternative for open surgical reimplantation? (4) How do we truly establish the risk of refl ux in a given child? We have traditionally assigned risk to the grade of refl ux, however, are there other variables that may better defi ne the true risk of renal damage in a child who has refl ux and UTIs? This paper explores each of these controversial areas to stimulate us to think more deeply about this common problem that we think we know so much about Keywords: Urinary tract infection, vesicoureteral reflux, childrenAfrican Journal of Urology Vol. 13 (4) 2007: pp. 242-25