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Endoscopic Management Of Vesicoureteral Reflux In Women Presenting With Pyelonephritis

April 01, 2017

UroToday- Vesicoureteral reflux has been always regarded as a disease of childhood. It has always been deemed not to be an issue in the adult population. Adults who present with acute pyelonephritis and never evaluated with a VCUG. However, if one is concerned that urinary tract infections, especially febrile ones, were present throughout childhood and there was no evaluation and the adult now presents with repeated episodes of acute pyelonephritis, one cannot be sure if vesicoureteral reflux actually plays a role.

This study by Okeke, et al, retrospectively reviewed the records of 13 women who presented with clinical pyelonephritis between 2001 and 2005. All of these patients had either a history of vesicoureteral reflux in childhood or family history of reflux. Some had previously undergone surgery for reflux. All patients underwent voiding cystourethrogram studies and DMSA renal scans as part of their evaluation.

The group found that 9 of these 13 patients had vesicoureteral reflux. Five of them had been operated on for vesicoureteral reflux as children. Two of these patients had a strong family history of reflux and another 2 patients had resolution of reflux during childhood. Six of the 9 patients with reflux exhibited renal scarring on DMSA scans. Endoscopic correction of the reflux was done in all 9 patients and was successful in 8, proven by VCUG studies 3 months postoperatively. One patient required a second procedure, which was successful. Only 1 patient continued to have an acute episode of pyelonephritis, however, that patient's VCUG study showed resolution of reflux.

The group concluded that there is a subset of patients that present with acute pyelonephritis and whom vesicoureteral reflux can be a contributing factor. These patients may benefit from endoscopic treatment. Since we all know that pyelonephritis is multifactorial, relieving one of these factors may actually help some patients. It is difficult to predict who would actually benefit from the resolution of vesicoureteral reflux.

However, with proper informed consent in the adult population, this seems to be promising. I will conclude by stating that I have had a similar experience here at The Children's Hospital of Philadelphia. I have treated adult women with histories of pyelonephritis, especially during pregnancy that had a history of vesicoureteral reflux as a child that was uncorrected or a history of febrile urinary tract infections that were not worked-up during their childhood years that benefited from endoscopic surgery. It virtually eliminated pyelonephritis in this patient population, especially during pregnancy when it can be detrimental to both the mother and baby.

Okeke Z, Fromer D, Katz MH, Reiley EA, Hensle TW
The Journal of Urology 176 (5): 2219-2221, November 2006.

Reviewed by UroToday Medical Editor Pasquale Casale, MD

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