PEDIATRIC UROLOGY

Natural history of neonatal reflux associated with prenatal hydronephrosis: long-term results of a prospective study
Upadhyay J, Mclorie GA, Bolduc S, Bägli DJ, Khoury AE, Farhat W
From the Division of Urology, Hospital for Sick Children, University of Toronto, Ontario, Canada
J Urol. 2003; 169:1837-41

• Purpose: We have previously reported on patients with neonatal vesicoureteral reflux followed conservatively. The current study is a long-term follow-up of our prospective expectant management protocol for the overall cohort.
• Materials and Methods: Between 1993 and 1998, 31 of 260 patients with prenatal hydronephrosis had vesicoureteral reflux and were followed prospectively. Outcome analysis was done on 25 patients, excluding 6 who underwent surgery, with the end point of complete resolution or improvement of reflux using our previously reported Kaplan-Meier survival curve, urinary tract infection, dysfunctional voiding, and changes in renal function or growth, somatic growth and hypertension.
• Results: Of the 25 cases reflux was grades I to V in 7%, 20%, 34%, 16% and 23%, respectively. Reflux resolved in 13 patients (52%) and improved in 6 (24%). Grades I to V disease resolved in 100%, 77%, 53%, 28% and 40% of refluxing units, respectively. The improvement rate for grades III to V reflux was 13%, 14% and 30%, respectively. Breakthrough urinary tract infection occurred in 4 patients with grades IV and V reflux, and dysfunctional voiding developed in 5. Follow-up renal scans showed 19% and 17% decreased differential function in 2 units without new scars. There was no difference in renal length in patients with resolved versus persistent reflux or low versus high grade reflux. All patients had normal somatic growth at the 4-year follow-up and none had hypertension.
• Conclusions: Expectant management was effective in the majority of cases and associated with a low urinary tract infection rate. Neonatal vesicoureteral reflux resolved or improved in 76% of our patients by age 4 years without somatic growth retardation or hypertension. High grade reflux resolved or improved in 59% of the units and showed normal renal growth with expectant management.
  
• Editorial Comment
  This is an interesting review of the mid-term follow-up (median of 44 months) of children diagnosed with vesicoureteral reflux as neonates. The reflux resolved spontaneously in 52%. Four patients had UTIs and dysfunctional voiding developed in 5. Two patients developed decreased renal function. The authors conclude that expectant management was effective in the majority of cases.
  This paper is an interesting contribution, but the interpretation of the data seems skewed and the conclusions are arguable. In the first instance, 6 patients underwent surgery and are excluded. In general, studies are better reported in an “intent-to-treat” format. Excluding the 6 patients needing surgery changes the results. Furthermore, not all patients underwent follow-up DMSA scans, hence there may have been more than 2 cases of renal injury. Finally, despite 4 years of antimicrobial therapy, 48% of patients did not have resolution of their reflux. My personal opinion is that this study could also be used to argue more forcefully for more surgical therapy.

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