EAU guidelines on vesicoureteral reflux in children.
BACKGROUND
Primary vesicoureteral reflux (VUR) is a common congenital urinary tract abnormality in children. There is considerable controversy regarding its management. Preservation of kidney function is the main goal of treatment, which necessitates identification of patients requiring early intervention.


OBJECTIVE
To present a management approach for VUR based on early risk assessment.


METHODS
A literature search was performed and the data reviewed. From selected papers, data were extracted and analyzed with a focus on risk stratification. The authors recognize that there are limited high-level data on which to base unequivocal recommendations, necessitating a revisiting of this topic in the years to come.


RESULTS
There is no consensus on the optimal management of VUR or on its diagnostic procedures, treatment options, or most effective timing of treatment. By defining risk factors (family history, gender, laterality, age at presentation, presenting symptoms, VUR grade, duplication, and other voiding dysfunctions), early stratification should allow identification of patients at high potential risk of renal scarring and urinary tract infections (UTIs). Imaging is the basis for diagnosis and further management. Standard imaging tests comprise renal and bladder ultrasonography, voiding cystourethrography, and nuclear renal scanning. There is a well-documented link with lower urinary tract dysfunction (LUTD); patients with LUTD and febrile UTI are likely to present with VUR. Diagnosis can be confirmed through a video urodynamic study combined with a urodynamic investigation. Early screening of the siblings and offspring of reflux patients seems indicated. Conservative therapy includes watchful waiting, intermittent or continuous antibiotic prophylaxis, and bladder rehabilitation in patients with LUTD. The goal of the conservative approach is prevention of febrile UTI, since VUR will not damage the kidney when it is free of infection. Interventional therapies include injection of bulking agents and ureteral reimplantation. Reimplantation can be performed using a number of different surgical approaches, with a recent focus on minimally invasive techniques.


CONCLUSIONS
While it is important to avoid overtreatment, finding a balance between cases with clinically insignificant VUR and cases that require immediate intervention should be the guiding principle in the management of children presenting with VUR.
Department of Urology, Hacettepe University, Ankara, Turkey. tekgul-k@tr.net
Serdar
S
Tekgül
Hubertus
H
Riedmiller
Piet
P
Hoebeke
Radim
R
Kočvara
Rien J M
RJ
Nijman
Christian
C
Radmayr
Raimund
R
Stein
Hasan Serkan
HS
Dogan
D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D002648:Child; D002675:Child, Preschool; D003950:Diagnostic Techniques, Urological / Q000592:standards; D042241:Early Diagnosis; D005260:Female; D006801:Humans; D007223:Infant; D007668:Kidney / Q000503:physiopathology; D010535:Laparoscopy / Q000592:standards; D008297:Male; D010372:Pediatrics / Q000592:standards*; D011237:Predictive Value of Tests; D016896:Treatment Outcome; D013520:Urologic Surgical Procedures / Q000592:standards; D014572:Urology / Q000592:standards*; D014718:Vesico-Ureteral Reflux / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy*; D057832:Watchful Waiting / Q000592:standards
D000900:Anti-Bacterial Agents