A perspective on vesicoureteral reflux.

Prevention of UTI appears to be the most important way to avoid the serious complications of vesicoureteral reflux, which then requires early recognition, ideally prior to bacterial invasion. With early evaluation of children noted to have dilated collecting systems in utero and the screening of siblings and offspring of those with reflux, this prevention becomes possible. This screening should be performed in the first weeks to months after birth, before the first UTI. The choice of management appears to be less important than control of infection, because the results of both medical and surgical management are equal; however, because mild-to-moderate (grades I-III) reflux is likely to resolve, it seems appropriate to pursue an aggressive nonsurgical course in these patients, at least until some minimally invasive, safe interventional treatment becomes available. If reflux remains severe (grades IV and V) beyond 24 to 48 months of age, surgical intervention appears appropriate because resolution is unlikely, assuming, of course, that an experienced surgeon performs the procedure. As was evident from the European branch of the IRS, renal scarring occurred most frequently in the few patients who had ureteral obstruction after failed surgical correction. In those who continued to have mild reflux beyond 5 to 7 years of age, a trial of medication is justifiable. If infection occurs during that time and reflux persists, correction should be considered for those with clinical or scan-documented pyelonephritis. Patients who have reflux plus bacteriuria present a special problem because it is unclear whether their risks are increased. Finally, we must forewarn all our female patients with UTI in childhood that they are at risk for bacilluria during pregnancy and may require prophylaxis regardless of the state of their reflux at that time.