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PEDIATRIC
UROLOGY
doi: 10.1590/S1677-553820100002000030
Improvement
in vesicoureteral reflux grade on serial imaging predicts resolution
Cannon GM Jr, Arahna AA, Graham DA, Passerotti CC, Silva A, Retik AB,
Nguyen HT
Children’s Hospital Boston, Harvard Medical School, Boston, Massachusetts,
USA
J Urol. 2010; 183: 709-13
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Purpose:
When children are initially diagnosed with vesicoureteral reflux most
undergo a period of antibiotic prophylaxis followed by serial imaging.
Although improvement in reflux grade through time presumably predicts
eventual resolution, the significance of changing grade through time
is unknown. We examined whether improvement in reflux on serial imaging
predicts resolution.
Materials and Methods: We retrospectively reviewed 1,761 children
diagnosed with vesicoureteral reflux, of which 965 had a minimum of
2 years of follow-up. We examined initial reflux grade and grade on
serial imaging up to 5 years after the original diagnosis. For each
child it was determined whether reflux was resolved, eventually resolved
or never resolved. Groups were further stratified by clinical characteristics.
Results: Multivariate analysis revealed that male gender (HR 1.33,
p = 0.05), age younger than 1 year at diagnosis (HR 1.35, p = 0.004),
lower grade at presentation (grade I HR 2.2, grade II HR 1.96, grade
III HR 1.33; p <0.001) and unilateral reflux (HR 1.39, p = 0.001)
were all independent predictors of reflux resolution. Multivariate
analysis also showed that reflux improvement on imaging 1 year after
diagnosis (HR 3.14, p <0.0001) and improvement from the previous
year at any point during follow-up (HR 1.8, p = 0.009) were independent
predictors of reflux resolution.
Conclusions: Consistent with previous findings, male gender, lower
reflux grade at presentation, age less than 1 year at presentation
and unilateral reflux were all predictive of reflux resolution. Our
analysis also demonstrated that improvement in reflux grade on imaging
study 1 year after diagnosis was predictive of resolution, and that
reflux improvement from the previous year at any point during follow-up
was an independent predictor of resolution. This information will
prove valuable in clinical counseling and therapeutic decision making.
- Editorial
Comment
The authors utilized their database of over 1,700 children with vesicoureteral
reflux to determine whether improvement in reflux grade on serial
imaging would predict resolution of reflux. They were able to identify
965 patients who had 2-5 years of follow-up for the study and then
performed a multivariate analysis to identify predictors of resolution.
Nuclear cystograms were performed routinely for follow-up studies
in these children, therefore they considered Grade I reflux on a nuclear
cystogram to be equivalent to a grade 1 on VCUG study. A nuclear cystogram
with Grade II reflux was equivalent to a VCUG with Grade II and III
on VCUG and Grade III reflux on nuclear cystogram was equivalent to
Grade IV and V reflux on VCUG. Their results demonstrated that male
gender, age less than one year at diagnosis, lower grade of reflux
at presentation and unilateral reflux were all predictors of spontaneous
resolution, which is consistent with previous studies. In addition,
they were able to demonstrate that reflux improvement on imaging one
year after diagnosis, as well as improvement in reflux grade from
the previous year at any point during follow-up, were both independent
predictors of resolution.
This study has important clinical implications when counseling with
parents over the decision to continue waiting for spontaneous resolution
versus pursuing surgical correction of reflux. Though many of us have
assumed that improvement in the grade of reflux is a positive indicator
of a greater likelihood for spontaneous resolution, we now have data
to back up our assumptions.
M.
Chad Wallis
Division of Pediatric Urology
University of Utah
Salt Lake City, Utah, USA
E-mail: chad.wallis@hsc.utah.edu
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