How do the various treatment options compare?

The American Urological Association guidelines recommend the following treatment options

They are based on a child’s age, grade of VUR, and other factors. The chart below details the advantages and disadvantages of these options, derived from a number of sources.1, 7

Antibiotic prophylaxis treatment

Advantages Noninvasive
Easy decision for parents vs surgical options
Recovery NA
Disadvantages Does not treat VUR
Does not prevent renal scarring
Potential noncompliance
Time consuming
Low resolution rates compared to other therapies
Risk of antibiotic resistance
Induces antibiotic resistance

Endoscopic treatment

Advantages Outpatient procedure (~15 min) 6
Resolution rate for VUR up to 93% of patients3
Minimally invasive6
Low surgical complications7
Open surgery still an option
Little Pain7
Return to normal activity the next day7
Recovery 2 hours
Disadvantages Cost compared to antibiotics
Performed under general anesthesia
Lower efficacy than open surgery
VCUG follow-up recommended (but not mandatory)
Risk of infection and bleeding associated with procedure
Adverse events have been reported with Deflux®

Open ureteral reimplantation surgery

Advantages Most effective treatment option for higher VUR grades (IV-V)
High resolution rates (~98%)
Recovery 1-3 days
Disadvantages Inpatient procedure
Cost
Performed under general anesthesia
Potential surgery complications
Postoperative pain/recovery longer than expected in recent study4
Parents perceived overall more bleeding and spasms than anticipated4
Requires pain medication

*The following adverse events have been reported with Deflux (occurring <1%): ureteral obstruction (some cases requiring temporary placement of a ureteric stent), dysuria, hematuria, urgency, frequency, hydronephrosis, pyelonephritis, urinary tract infection, foreign body reaction, calcification and pyrexia.

References:

  1. Park JM and Retik AB. Surgery for vesicoureteral reflux. In: Gearhart JP, Rink RC, Mouriquand PD, eds. Pediatric Urology. 2nd ed. Philadelphia, PA: Saunders Elselvier; 2010:330-336.
  2. Ogan K, Pohl HG, Carlson D, Belman AB, Rushton HG. Parental preferences in the management of vesicoureteral reflux. J Urol. 2001;166(1):240-243.
  3. Kalisvaart JF. Intermediate to long-term follow-up indicates low risk of recurrence after double hit endoscopic treatment for primary vesicoureteral reflux. J Ped Urol. 2012;8(4):359-365.
  4. Bayne A, Herbst K, Corbett S, Nelson E. Parental perception of bladder spasms and hematuria after surgery for reflux: a prospective multicenter study. J Urol. 2019;201(4S):e949.
  5. Mattoo TK, Chesney RW, Carpenter MA, et al. The RIVUR study: A factual interpretation of our data. Pediatr Nephrol. 2015;30(5):707-712.
  6. Cerwinka WH, Scherz HC, Kirsch AJ. Endoscopic treatment of vesicoureteral reflux with dextranomer/hyaluronic acid in children. Advances in Urology. 2008; 1-7.
  7. Sung J, Skoog S. Surgical management of vesicoureteral reflux in children. Pediatr Nephrol. 2012;27:551-561.