PEDIATRIC UROLOGY

Antibiotics and surgery for vesicoureteric reflux: a meta-analysis of randomised controlled trials
Wheeler D, Vimalachandra D, Hodson EM, Roy LP, Smith G, Craig JC
Centre for Kidney Research and Cochrane Renal Group, NHMRC Centre of Clinical Research Excellence in Renal Medicine, The Children’s Hospital at Westmead, Sydney, NSW, Australia
Arch Dis Child. 2003; 88: 688-94

• Aims: To evaluate the benefits and harms of treatments for vesicoureteric reflux in children.
• Methods: Meta-analyses of randomised controlled trials using a random effects model. Main outcome measures were incidence of urinary tract infection (UTI), new or progressive renal damage, renal growth, hypertension, and glomerular filtration rate.
• Results: Eight trials involving 859 evaluable children comparing long term antibiotics with surgical correction of reflux (VUR) and antibiotics (seven trials) and antibiotics compared with no treatment (one trial) were identified. Risk of UTI by 1-2 and 5 years was not significantly different between surgical and medical groups (relative risk (RR) by 2 years 1.07; 95% confidence interval (CI) 0.55 to 2.09, RR by 5 years 0.99; 95% CI 0.79 to 1.26). Combined treatment resulted in a 60% reduction in febrile UTI by 5 years (RR 0.43; 95% CI 0.27 to 0.70) but no concomitant significant reduction in risk of new or progressive renal damage at 5 years (RR 1.05; 95% CI 0.85 to 1.29). In one small study no significant differences in risk for UTI or renal damage were found between antibiotic prophylaxis and no treatment.
• Conclusion: It is uncertain whether the identification and treatment of children with VUR confers clinically important benefit. The additional benefit of surgery over antibiotics alone is small at best. Assuming a UTI rate of 20% for children with VUR on antibiotics for five years, nine reimplantations would be required to prevent one febrile UTI, with no reduction in the number of children developing any UTI or renal damage.
  
• Editorial Comment
  This paper reviews randomized controlled trials of children with vesicoureteral reflux. Only eight trials were felt to be adequate for analysis. Nonetheless, the conclusion that the authors reach is that there are few differences in the results of antibiotic treatment vs. surgical treatment. Indeed, the only difference demonstrated was a 60% reduction is febrile UTI at 5 years. The authors calculate that 9 to 17 children would require antireflux surgery to prevent one UTI during the five-year follow-up. If indeed there is limited benefit, the authors intimate that even voiding cistourethrograms (VCUG) may not be needed. All children could be treated with antibiotics. Furthermore, the only study that reviews the results of no antibiotic treatment for patients with reflux showed no significant differences between groups. If this data holds up, it is conceivable that no VCUG would be needed in these children and no antibiotics would be necessary except for treatment of acute UTI.
  On the other hand, the paper also documents the weaknesses in those trials. The studies all have significant problems. Even accounting for the weaknesses of the studies of medical vs. surgical management, it is likely that longer follow-up would show an even larger difference in febrile UTIs. Similarly, longer follow-up might well show benefits of antibiotic use in children with reflux, as the single study reported had only 29 children and 14 months of follow-up. It seems that the main point of this manuscript is that more studies are needed to obtain scientific data that enable optimal decision-making.

Dr. Barry A. Kogan
Chief and Professor of Urology and Pediatrics
Albany Medical College
Albany, New York, USA