Primary VUR - To Treat or not to Treat?

• 17 Mar 2020 10:07:08 AM
• |Pediatic Urology

Dear All,

I am providing the Latest Cochrane Systematic Review (2019) on ‘Interventions in Primary VUR’. Some of the important points brought out in this review are:

Low-dose antibiotic prophylaxis compared to no treatment/placebo may make little or no difference to the risk of repeat symptomatic UTI.

Surgery plus antibiotic treatment may reduce the risk of repeat febrile UTI by 57% but there was little or no difference in the risk of new kidney defects detected.

Studies showed little or no difference in the risk of febrile UTI with endoscopic injection compared to antibiotics. Studies showed that there was no difference between the materials.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6380991/pdf/CD001532.pdf

If medical therapy or surgical interventions have no real merit in the management of Primary VUR, then what options do we have for the treatment of Pr VUR? We have been repeatedly informed that some form of intervention may be required for Dilating VUR’s. Are we wrong in this assumption? Jatin Bhandari* and Steven G Docimo (2017) proposed that evaluation for VUR is not necessary or helpful except in the small subset of children whose UTIs have proven refractory to management of their other risk factors. (PDF of article provided, not for circulation).

The more I try to understand, the more confused I become. Can our esteemed colleagues help me understand where we stand and what we should do as regards Pr VUR?

With warm Regards,

Venu

Comments(5)

• 

  Dr. Anil Takvani

  17 Mar 2020 06:39:56 PM

  "Primary VUR - To Treat or not to Treat?"

  Post initiated by Prof. Venugopal Sir.

  My first response is 'Yes' and I will give sufficient cases and literature support to give human face to this never ending argument.

  1.There are high risk group case of recurrent FUTI, where we have to look for VUR as that can be significant risk factor for febrile UTI, recurrence and subsequent renal damage and its sequelae.

  2. Recurrent febrile UTI is a very morbid condition as patient requires repeated admission and /or injectable antibiotics. Child if school going, off from school, working parents looses income along with medical bills. So even treating VUR reduces recurrent FUTI is a great service to VUR patients and we urologist can not work as physicians we are meant for fixing the problems.

  3. If you prevent FUTi, you are definitely reducing chances of new pyelonephritis and new scar formation. It gives growing kidney chance for best possible rest, recovery and growth. Which also reflects in to over all gain in general health of VUR children when recurrent FUTIs are prevented effectively with the help of AB prophylaxis , addressing bowel and bladder habits and/or correcting reflux surgically.

  These are just opening points in favor of diagnosis ant treatment of VUR. I will continue posting appropriate cases and write ups on this thread.  Thanks

• 

  Dr. Anil Takvani

  18 Mar 2020 07:39:50 AM

  Many and probably most of things in management of UTI and VUR on pediatric group of patients is controversial. 

  May be because of severe heterogeneity related to disease and because that we don't have complete account of natural history. 

  Additionally there are half cooked evidances on either side making things worst. 

  What absolutely non controversial in management of UTI and VUR is risk categorization.

  Patient of febrile UTI if not evaluated or treated adequately can have recurrent FUTI. Any delay in treatment more than 2 to 3 days increases chances of liquification of infected renal paranchyma and scar formations and its sequelae. Secondly failure  in avoiding recurrence of FUTI by ignoring underlying high grade reflux and /or bowel and bladder issues we are inviting very much increase chances of scarring. 

  By detecting VUR in such cases 

  1. We are increasing awareness of parents and treating pediatricians of possibilities of delay and /or recurrence so patients can be offer prophylaxis,  addressed bowel and bladder habits and proper follow up related to weight,  height,  BP and breakthrough infections.  In long term this measures help in maintaining health of kidneys and body of the patients. 

  I am posting images of male patient with recurrent febrile episodes in past couple of years,  UTI was ignored everytime.  He was having febrile UTIs ((pyelonephritis) which were missed, treated empirically, inadequetly and now you can see peripheral, scattered and polar absent uptakes with loss of contour of kidney representative of scars. 

  
  

  

• 

  Ravindra Sabnis

  19 Mar 2020 07:29:05 PM

  I keep listening / reading to this evidence based on many trials - that chemo prophylaxis Vs no antibiotics - is same. I keep wondering, as our own experience is different. There are many examples that children who have recurrent UTI & when AB prophylaxis is started they do so well, no UTI at all & in case, it is stopped, UTI recurs. 

  what is experience of others. This is real dilemma of evidence based Vs experience based medicine. 

• 

  Venugopal P

  20 Mar 2020 10:41:02 AM

  Dear All,

  Ravi has hit the nail on the head and rightly so.

  What I have written at the initiation of this discussion is based on Cochrane study which is one of the areas where Evidenced Based reports are published. Anil has countered it with his experience. As Ravi has mentioned, what do we follow. As pointed out by him, long term CAP has helped many of our patients and in many subsequently this regime has been stopped with no ill effects. But if you read the Cochrane report, as mentioned by Ravi, there seem to be no difference in outcomes whether antimicrobials are given or not.

  The question that will have to be answered is whether we are giving much importance to the so called EBM. The answer appears yes and sadly so. As regards VUR and CAP is concerned, it is nice to remember that many of our patients do not return immediately when URI returns. Hence it is better to institute CAP and not wait for the patients/parents to understand the return of UTI and return.

  We should form our own yardstick and not entirely harp on what is being shoved down our throats as gospel truth.

  I post materials like a devil’s advocate attempting to invite comments from our members as what should be our way for such scenarios.

  With warm regards,

  Venu

• 

  Dr. Isteaq Shameem

  23 Mar 2020 10:40:38 PM

  Dr Isteaq Shameem

  Indeed a very opinions differed condition. Very interesting to read Prof. Sabnis comment. As rightly pointed experience based approach can be more appropriate than evidence based.Respecting others opinion I like to share my little experience where AB prophylaxis helps in stopping fUTI and growth of children continues with no school absence. Yes, still dilemma persists when to operate. 

  Warm regards to Venugopal sir, Dr Anil and others. Hope we all stay safe and healthy in this pandemic