PEDIATRIC UROLOGY

Treatment of vesico-ureteric reflux: a new algorithm based on parental preference
Capozza N, Lais A, Matarazzo E, Nappo S, Patricolo M, Caione P
Division of Paediatric Urology, “Bambino Gesu” Children’s Hospital, IRCCS, Rome, Italy
BJU Int. 2003; 92: 285-8

• Objective: To assess parental preference (acknowledged in treatment guidelines as important when choosing therapy) about treatments for vesico-ureteric reflux (VUR, commonly associated with urinary tract infection and which can cause long-term renal damage if left untreated), as at present there is no definitive treatment for VUR of moderate severity (grade III).
• Subjects and Methods: The parents of 100 children with grade III reflux (38 boys and 62 girls, mean age 4 years, range 1-15) were provided with detailed information about the three treatment options available for treating VUR (antibiotic prophylaxis, open surgery and endoscopic treatment), including the mode of action, cure rate and possible complications, and the practical advantages and disadvantages. They were then presented with a questionnaire asking them to choose their preferred treatment.
• Results: Most parents preferred endoscopic treatment (80%), rather than antibiotic prophylaxis (5%) or open surgery (2%); 13% could not decide among the three options and endoscopic treatment was recommended.
• Conclusion: Given the strong preference for endoscopic treatment we propose a new algorithm for treating VUR; endoscopic treatment would be considered as the first option for persistent VUR, except in severe cases where open surgery would still be recommended.
  
• Editorial Comment
  The authors examine parental preferences in choices of treatment for vesicoureteral reflux. Using 100 families of children with Grade III/V reflux as a test group, the authors presented information on 3 treatment options (antimicrobial therapy, open surgery and endoscopic injection). 80% chose endoscopic therapy vs. only 2% for open surgery and 5% for antimicrobial therapy!
  The parental choices in this case are striking. On the other hand, the choices are based primarily on the counseling. In particular, the account of open surgery described a hospitalization of 7-10 days and a follow-up voiding cistourethrogram (VCUG). In our hospital, the majority of patients go home the next day after antireflux surgery and VCUG are only done if patients have persistent hydronephrosis or UTI. This difference in practice may make an enormous difference in parental choice. Nonetheless, it is important to recognize the emotional appeal of endoscopic therapy.

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