UroToday - Dr. Carlos Estrada et al. from Boston Children's examined one of our most difficult scenarios for addressing hydronephrosis in the postnatal period. They evaluated the use of VCUG studies in cases of persistent Grade II hydronephrosis from the antenatal to postnatal period. The group maintains a longitudinal database. They identified patients with postnatally persistent Grade II hydronephrosis. They divided the cohort into patients who received VCUG's and those who did not receive one. They also looked at the rates of vesicoureteral reflux and the development of febrile UTI's. Interestingly the group found that there was a 9-fold increase risk in febrile UTI in patients who did not undergo VCUG screening for Grade II postnatal hydronephrosis. The group felt that postnatal VCUG's significantly reduced the risk of febrile UTI by identifying patients with reflux which would establish those who might benefit from treatment with prophylactic antibiotics.

There were 2 editorial comments on this paper. The first by Paul A. Merguerian discussed the fact that the circumcision status is unknown and a potential cofounder in this study. He brought up a valid point as well that if only 4% of those not screened had significant reflux, you would do 100 VCUG's with 96 of them being potentially unnecessary.

The next editorial comment was by George Steinhardt. He felt that children should not be screened based on the fact that only 11% of the unscreened patients with reflux had a febrile UTI. He also stated that since 1.6% of screened patients with reflux had a UTI despite prophylaxis, there would be just 40 infants among the entire 1,514 who had been spared a febrile UTI.

In my opinion it would be most interesting to be able to sort out these 40 patients ahead of time and hopefully proteomic might lead us in that direction.

Estrada CR, Peters CA, Retik AB, Nguyen HT
J Urol. 2009 Feb;181(2):801-6; discussion 806-7.
doi:10.1016/j.juro.2008.10.057

UroToday Medical Editor Pasquale Casale, MD

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