Cochrane review: Interventions for primary vesicoureteric reflux
Authors: Hodson EM , Wheeler DM , Vimalchandra D , Smith GH , Craig JC 
Published: March 2008

Background

Vesicoureteric reflux (VUR) results in urine passing, in a retrograde manner, up the ureter. Urinary tract infections (UTIs) have been considered the main cause of permanent renal parenchymal damage in children with reflux. Management of these children has been directed at preventing infection by antibiotic prophylaxis and/or surgical correction of reflux. Controversy remains as to the optimum strategies.

Objectives

To evaluate the benefits and harms of different treatment options for primary VUR.

Search strategy

Randomised controlled trials (RCTs) were identified from the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, reference lists of articles and abstracts from conference proceedings. Date of last search: June 2006

Selection criteria

Any treatment of VUR including surgery, antibiotic prophylaxis of any duration, non‐invasive techniques and any combination of therapies.

Data collection and analysis

Two authors independently searched the literature, determined study eligibility, assessed quality, extracted and entered data. For dichotomous outcomes, results were expressed as relative risk (RR) and 95% confidence intervals (CI). Data were pooled using the random effects model.

Main results

Eleven studies (1148 children) were identified. Seven compared correction of VUR (by surgery or endoscope) plus antibiotics for 1‐24 months with antibiotics alone, two compared antibiotics with no treatment and two compared different materials for endoscopic correction of VUR. Risk of UTI by 2, 5 and 10 years was not significantly different between surgical and medical groups (2 years RR 1.07, 95% CI 0.32 to 2.09; 5 years RR 0.99, 95% CI 0.79 to 1.26; 10 years RR 1.06, 95% CI 0.78 to 1.44). Combined treatment resulted in a 50% reduction in febrile UTI by 10 years (RR 0.54, 95% CI 0.55 to 0.92) but no concomitant reduction in risk of new or progressive renal damage by 10 years (RR 1.03, 95% CI 0.53 to 2.00). In two small studies no significant differences in risk for UTI (RR 0.75, 95% CI 0.15 to 3.84) or renal damage (RR 1.70, 95% CI 0.36 to 8.07) were found between antibiotic prophylaxis and no treatment.

Authors' conclusions

It is uncertain whether the 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.

Plain language summary

It is unclear whether the identification and treatment of children with vesicoureteric reflux has any clinically important benefit

Vesicoureteric reflux (VUR) is the backflow of urine from the bladder up the ureters to the kidney. People with VUR are thought to be more likely to get urinary tract infections (UTIs) involving the kidney tissue, which may cause permanent kidney damage. Current treatment options include surgery, surgery plus long‐term antibiotics, long‐term antibiotics alone and endoscopic (injection of a substance around the entry of the ureter into the bladder) correction using different materials. Surgery decreased the number of feverish UTIs, but did not change the number of children developing any UTI or kidney damage. In small studies, antibiotics did not change the number of children developing UTI compared with no treatment. More studies are needed.