What is the treatment for Grade 5 vesicoureteral reflux?

Treatment for Grade 5 Vesicoureteral Reflux

Surgical correction is strongly recommended for patients with persistent grade 5 vesicoureteral reflux, with ureteral reimplantation being the preferred surgical approach over endoscopic correction due to superior outcomes for this high-grade reflux. 1

Initial Management Approach

The treatment strategy for grade 5 VUR depends on several key factors:

For Children Under 1 Year:

• Initial treatment with continuous antibiotic prophylaxis (CAP) regardless of reflux grade 1
• Typically trimethoprim-sulfamethoxazole (avoid in infants <6 weeks), amoxicillin, or nitrofurantoin (avoid before 4 months) at 1/4 to 1/2 of therapeutic dose 1
• Immediate parenteral antibiotics for any breakthrough febrile UTIs 1

For Children Over 1 Year:

• With abnormal kidneys: Surgical repair is recommended 1, 2
• With lower urinary tract dysfunction (LUTD): Initial treatment for LUTD with concurrent CAP, with intervention if breakthrough infections occur 1, 2
• Without LUTD: Direct surgical intervention is recommended 1

Surgical Options

1. Ureteral Reimplantation (Open Surgery)

   • Gold standard for grade 5 VUR 1
   • Higher success rates than endoscopic treatment for high-grade reflux
   • Success rates >95% for open surgical correction

2. Endoscopic Injection of Bulking Agents

   • Lower success rate for grade 5 VUR (51% after first injection) 1
   • May require multiple procedures (success increases to 85% with multiple injections)
   • Uses dextranomer/hyaluronic acid or polyacrylate-polyalcohol copolymer hydrogel
   • Less invasive but less effective for high-grade reflux

Risk Factors Requiring More Aggressive Management

• Bilateral high-grade reflux
• Abnormal renal parenchyma/scarring
• Recurrent febrile UTIs despite prophylaxis
• Decreased renal function
• Male gender (less likely to resolve spontaneously in grade 5)

Special Considerations

• Bladder and Bowel Dysfunction (BBD): Must be identified and treated concurrently, as it doubles the risk of recurrent UTIs and can impact surgical success 1, 2
• Antimicrobial Resistance: Long-term CAP increases risk of resistant organisms, particularly with cephalosporins 3
• Circumcision: May be considered in male infants as it reduces infection risk 1

Follow-up Protocol

• Regular renal ultrasound to monitor upper tract dilation
• Voiding cystourethrogram (VCUG) after surgical correction to confirm resolution
• Monitoring for UTIs, particularly febrile episodes
• Assessment of renal function and blood pressure

Pitfalls to Avoid

1. Delaying intervention: Grade 5 VUR has only a 51% success rate with endoscopic treatment and is unlikely to resolve spontaneously 1
2. Failing to address BBD: Untreated BBD significantly reduces success rates of both medical and surgical management 1, 2
3. Underestimating breakthrough infections: Febrile breakthrough UTIs require immediate parenteral antibiotics and consideration of surgical intervention 1
4. Inappropriate antibiotic selection: Co-trimoxazole remains the preferred prophylactic agent, while cephalosporins should be avoided due to increased risk of extended-spectrum beta-lactamase-producing organisms 3

The European Association of Urology guidelines clearly state that surgical correction should be considered in patients with persistent high-grade reflux (grades IV/V), with reimplantation being superior to endoscopic correction for these cases 1.