Abstract
Vesicoureteral reflux (VUR) is the most common underlying etiology responsible for febrile urinary tract infections (UTIs) or pyelonephritis in children. Along with the morbidity of pyelonephritis, long-term sequelae of recurrent renal infections include renal scarring, proteinuria, and hypertension. Treatment is directed toward the prevention of recurrent infection through use of continuous antibiotic prophylaxis during a period of observation for spontaneous resolution or by surgical correction. In children, bowel and bladder dysfunction (BBD) plays a significant role in the occurrence of UTI and the rate of VUR resolution. Effective treatment of BBD leads to higher rates of spontaneous resolution and decreased risk of UTI.
Highlights
The prevalence of febrile urinary tract infection (UTI) in infants and children ranges from 3 to 7% and varies by age, race, sex, and circumcision status[1,2,3]
UTI in the setting of Vesicoureteral reflux (VUR) is often associated with pyelonephritis, as reflux results in direct communication of infected urine between the bladder and kidney, permitting cystitis to rapidly progress to acute pyelonephritis
The diagnosis and management of VUR have been met with controversy between recent UTI guidelines published by the American Academy of Pediatrics (AAP) and the American Urological Association (AUA) reflux guidelines
Summary
The prevalence of febrile urinary tract infection (UTI) in infants and children ranges from 3 to 7% and varies by age, race, sex, and circumcision status[1,2,3]. Indications for surgical correction include breakthrough UTI while on CAP, poor adherence to CAP resulting in infection, persistence of VUR after a period of observation, low likelihood of spontaneous resolution in a high-risk patient, or parent’s preference given the benefits and risks of each treatment modality. Our group has demonstrated modifications in technique that resulted in a consistent 90% radiographic and 93% clinical success in children with primary grades I-IV VUR Complex cases, such as duplex ureters or injection following failed open surgery, tend to have an approximately 10% lower success. Breakthrough UTI after anti-reflux surgery Persistent reflux or recurrent UTI are possible after open or endoscopic surgical VUR correction, representing radiographic or clinical failure, respectively The risk for these varies based on procedure type, as outlined above. Arlen et al reported the success after robot-assisted ureteral reimplant in 11 previously treated children (10 endoscopic injection and one open reimplant) with complete resolution in all reimplanted ureters; one developed new onset contralateral VUR39
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