New developments mark paradigm shift in Tx of VUR

March 1, 2005

Primary endoscopic treatment of VUR certainly offers a high level of success with minimal morbidity.

Endoscopic treatment of reflux has generated a great deal of interest. The U.S. introduction of dextranomer/hyaluronic acid (Deflux), a dextran polymer, has finally given us a truly effective substance to create support for the intramural ureter. Its use in treating VUR was first developed by Prem Puri, MD, and Barry O'Donnell, MD, in 1983. A meta-analysis led by Jack Elder, MD, indicates that broadly experienced urologists have been able to achieve a 75% success rate. Success is better with lower grades of reflux, as expected.

Andrew Kirsch, MD, presented his results using a modification to endoscopic treatment known as hydrodistention. In his technique, the orifice of the ureter is opened via saline irrigation through the cystoscope to enable placement of the dextranomer/hyaluronic acid further inside the ureteric orifice with accordingly better support for the submucosal course. With increasing experience, his results have steadily improved. Now, with one or two injections, it is reasonable to expect an 80% to 90% success rate in patients with lower grades of reflux.

The criteria used in the 2000 paper, from our group at the Children's Hospital of Philadelphia, formed the principle we follow today: Consider cessation of antibiotics in older children who can verbalize early symptoms of ascending infection, have low-grade reflux generally below grade III, have no voiding dysfunction, and normal to near-normal kidneys with a minor history of urinary infection. Our experience-and that of other groups-is that better than 90% of such children will do well. Cessation of antibiotics should be discussed with parents.

Taken together, this research provides us with two important take-home points about the evolving management of VUR:

First, cessation of antibiotics is an option that can be suggested to families if patients fulfill the criteria given above. This approach can be taken with the understanding that if a febrile UTI develops, then endoscopic correction of the reflux could be carried out.