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Renal scarring — Clinical Guidelines

Overview

Vesicoureteral reflux (VUR) is a congenital condition characterized by the retrograde flow of urine from the bladder into the ureter and renal pelvis, potentially leading to recurrent urinary tract infections (UTIs) and renal scarring 1 4 20.

Diagnosis

Key Diagnostic Criteria: Retrograde flow confirmed by voiding cystourethrography (VCUG) 11 25.

Recommended Tests:

- Voiding cystourethrography (VCUG) for grading (grades I-V) 11 25. - Renal ultrasound to assess for hydronephrosis or renal scarring 1 13.

Grading System: VUR is typically graded from I to V based on the degree of reflux seen on VCUG 11.

Management

First-Line Treatments:

- Antibiotic prophylaxis to prevent UTIs 6 26. - Endoscopic injection of bulking agents (e.g., dextranomer/hyaluronic acid copolymer [Deflux]) 5 17 22.

Adjunctive Treatments:

- Surgical interventions such as ureteral reimplantation for severe or refractory cases 3 13 33. - Urotherapy to improve bladder function and voiding habits 6 26.

Special Populations

Pregnancy: Women with a history of VUR are at increased risk for pregnancy-related complications, including UTIs 1.

Pediatrics: Management focuses on preventing renal damage through early detection and appropriate intervention 8 20.

Comorbidities: Presence of renal scarring or recurrent UTIs necessitates more aggressive management 1 13.

Key Recommendations

Regular Monitoring with VCUG: Perform VCUG to assess and grade VUR, especially in pediatric patients, to guide management decisions (Evidence: Moderate 11 25).

Endoscopic Injection for Grades II-IV: Consider endoscopic injection of bulking agents as a first-line treatment for VUR grades II-IV to reduce reflux and prevent renal damage (Evidence: Moderate 5 17).

Antibiotic Prophylaxis for High-Risk Patients: Use antibiotic prophylaxis in patients at high risk of recurrent UTIs to prevent renal scarring (Evidence: Moderate 6 26).

Surgical Intervention for Refractory Cases: Opt for surgical reimplantation in cases where endoscopic treatments fail or are not suitable (Evidence: Moderate 3 13).

Follow-Up Protocols: Implement consistent follow-up protocols post-treatment to monitor for recurrence and renal health (Evidence: Expert opinion 28).

References

1 Selvi I, Dönmez Mİ, Baydilli N, Quirroz Madarriaga Y, Lammers RJM, Bindi E et al.. Factors associated with pregnancy related complications in women with a history of vesicoureteral reflux: A systematic review by the EAU-YAU Paediatric Urology Working Group. Actas urologicas espanolas 2025. link 2 Escolino M, Chiodi A, Esposito G, Di Mento C, Florio L, Porcaro M et al.. Validation of A 3D-printed simulator for training in endoscopic injection of bulking agent for vesicoureteral reflux: a pilot study. Surgical endoscopy 2024. link 3 Gnech M, 't Hoen L, Zachou A, Bogaert G, Castagnetti M, O'Kelly F et al.. Update and Summary of the European Association of Urology/European Society of Paediatric Urology Paediatric Guidelines on Vesicoureteral Reflux in Children. European urology 2024. link 4 Bortnick EM, Nelson CP. Vesicoureteral Reflux: Current Care Trends and Future Possibilities. The Urologic clinics of North America 2023. link 5 Kutasy B, Coyle D. History of endoscopic treatment of vesicoureteral reflux. Pediatric surgery international 2023. link 6 Golpinar M, Ekici M. Global research productivity and publication trends in vesicoureteral reflux: a bibliometric analysis. Minerva pediatrics 2023. link 7 Selvi I, Canbaz FA, Dönmez Mİ, Özkuvancı Ü, Çetin B, Kart M et al.. Does pre-fellowship experience alter success rates of endoscopic treatment of vesicoureteral reflux during pediatric urology fellowship?. Journal of pediatric urology 2022. link 8 Arlen AM, Kirsch AJ. Armamentarium to treat primary vesicoureteral reflux in children. Seminars in pediatric surgery 2021. link 9 Tokat E, Gurocak S, Ozkan S, Dogan HS, Citamak B, Satar N et al.. Clinical practice in vesicoureteral reflux with respect to EAU guidelines: A multicenter study. International journal of clinical practice 2021. link 10 Oetzmann von Sochaczewski C, Deigendesch N, Lindner A, Baumgart J, Schröder A, Heimann A et al.. Comparing Aachen Minipigs and Pietrain Piglets as Models of Experimental Pediatric Urology to Human Reference Data. European surgical research. Europaische chirurgische Forschung. Recherches chirurgicales europeennes 2020. link 11 Johnin K, Kobayashi K, Tsuru T, Yoshida T, Kageyama S, Kawauchi A. Pediatric voiding cystourethrography: An essential examination for urologists but a terrible experience for children. International journal of urology : official journal of the Japanese Urological Association 2019. link 12 Gnech M, Lovatt CA, McGrath M, Rickard M, Sanger S, Lorenzo AJ et al.. Quality of reporting and fragility index for randomized controlled trials in the vesicoureteral reflux literature: where do we stand?. Journal of pediatric urology 2019. link 13 Çitamak B, Bozaci AC, Altan M, Haberal HB, Kahraman O, Ceylan T et al.. Surgical outcome of patients with vesicoureteral reflux from a single institution in reference to the ESPU guidelines: a retrospective analysis. 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Current options in the management of primary vesicoureteral reflux in children. Pediatric clinics of North America 2012. link 20 Tekgül S, Riedmiller H, Hoebeke P, Kočvara R, Nijman RJ, Radmayr C et al.. EAU guidelines on vesicoureteral reflux in children. European urology 2012. link 21 Badawi A, Tome MA, Atteya A, Sami N, Morsy IA. Retrospective analysis of non-ablative scar treatment in dark skin types using the sub-millisecond Nd:YAG 1,064 nm laser. Lasers in surgery and medicine 2011. link 22 Kim SO, Shin BS, Hwang IS, Hwang EC, Oh KJ, Jung SI et al.. Clinical efficacy and safety in children with vesicoureteral reflux of a single injection of two different bulking agents--polydimethylsiloxane (Macroplastique) or dextranomer/hyaluronic acid copolymer (Deflux): a short-term prospective comparative study. Urologia internationalis 2011. link 23 Hong CH, Kim JH, Jung HJ, Im YJ, Han SW. Single-surgeon experience with transvesicoscopic ureteral reimplantation in children with vesicoureteral reflux. Urology 2011. link 24 Bennett SD, Foot LM, Abel EJ, Snow BW, Cartwright PC, Devries CR et al.. Is there a learning curve for subureteric injection of dextranomer/hyaluronic acid in the treatment of vesicoureteral reflux?. Journal of pediatric urology 2010. link 25 Ellison JS, Maxfield CM, Wiener JS. Voiding cystography practices and preferences of North American pediatric urologists. The Journal of urology 2009. link 26 Elder JS. Therapy for vesicoureteral reflux: antibiotic prophylaxis, urotherapy, open surgery, endoscopic injection, or observation?. Current urology reports 2008. link 27 Gargollo PC, Diamond DA. Therapy insight: What nephrologists need to know about primary vesicoureteral reflux. Nature clinical practice. Nephrology 2007. link 28 Benway B, Slaughenhoupt B. Robert Lich, Jr., M.D.: innovator in pediatric and adult urology. 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Renal scarring