University of Michigan
Department of Pediatrics
Evidence-Based Pediatrics Web Site

Question

• In children with moderate to severe bilateral VUR, is surgical management better than medical management in preventing recurrent UTI and complications of chronic UTI (development of hypertension, ESRD)?

Clinical Bottom Lines

1. There is no difference in terms of change in GFR, progression of renal scarring, or recurrent UTI in patients with severe VUR treated with medical or surgical management.¹
2. Surgery does correct vesicoureteral reflux but does not significantly alter clinical outcomes in these patients.^2,3
3. The main factor determining clinical outcome seems to be extent of renal scarring or renal parenchymal damage at onset.¹

Summary of Key Evidence

1. Fifty-two children ages 1-12 with bilateral grade III-V VUR were randomized to medical vs. surgical management.¹
2. Patients were followed with imaging (IVP, VCUG, and DMSA) and renal functional assessment (GFR) at baseline and at 4 years, with GFR measurements at 10 years follow-up as well.
3. Main outcomes reported were mean percentage change in GFR at 4 years.  Secondary outcomes included somatic growth, blood pressure, recurrent UTI, renal growth, and renal scarring.
4. Mean GFR at enrollment was 72.4 mL/min and 71.7 mL/min for the medical and surgical groups respectively.  All patients enrolled had some evidence of renal scarring at enrollment; approximately 70% had more than mild scarring.
5. Mean percentage change in GFR was -2.4% in the medical group and 4.7% in the surgical group with a difference of 7.1% [95% CI (-6.4 to 20.6%)].
6. Relative risk for recurrent UTI was 1.69 [95% CI 0.74-3.86.]. RR for development of ESRD was 0.88 [95% CI 0.14-5.73]. Both results were not significant.
7. The authors state that in order for a 7% difference to be statistically significant, 90 children in each group would have needed to be enrolled to achieve a 90% power. Thus, this study was underpowered.
8. This study selected only patients with severe bilateral reflux, and in this group of patients, surgery was not shown to be more effective than medical management.

Additional Comments

• Larger studies including the Birmingham Study and the International Reflux Study report similar findings of no difference between medically and surgically managed patients.^2,3
• Appropriate length of medical treatment for patients with severe VUR is not clear.  Studies do report that the more severe the reflux, the slower it is to resolve.  The rate of disappearance of grade IV reflux is approximately 8% per year.^2,4
• These studies raise the question that other factors, independent of the presence or absence of VUR, contribute to the development of long-term complications including ESRD.

Citation

1. Smellie JM. Barratt TM. Chantler C.  Medical versus surgical treatment in children with severe bilateral vesicoureteric reflux and bilateral nephropathy: a randomised trial.  Lancet 2001; 357: 1329-33.
2. Weiss R. Duckett J. Spitzer A.  Results of a randomized clinical trial of medical versus surgical management of infants and children with grades III and IV primary vesicoureteral reflux (United States).  Journal of Urology 1992; 148: 1667-73, 1674-75.  
3. Smellie JM. Tamminen-Mobius T. Obling H. Claesson I. Wikstad I. Jodal U. Seppanen U.  Five year study of medical or surgical treatment in children with severe reflux: radiologic renal findings. The International Reflux Study in Children.  Pediatric Nephrology 1992;6: 223-230. 
4. American Academy of Pediatrics.  The diagnosis, treatment, and evaluation of the initial urinary tract infection in febrile infants and young children.  Pediatrics 1999;103: 843-852.
5. See also the role of ultrasound and VCUG in the diagnosis of VUR.
    

CAT Author: Annissa F. Jabarin, MD

CAT Appraisers: Jonathan Fliegel, MD

Date appraised: November 5, 2001