UROLOGICAL SURVEY
Pediatric urology
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
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
Publication Dates
-
Publication in this collection
31 May 2010 -
Date of issue
Apr 2010
