[Vesicoureteral reflux in children - there is still much controversy].

Correspondence to: Rejane de Paula Bernardes. Nefrokids Clinic Curitiba. Rua Brasilio Itibere, no 3933. Curitiba, PR, Brasil. CEP: 80240-060. E-mail: [email protected] Over 4 decades ago, Hodson & Edwards1 described the association between chronic pyelonephritis and vesicoureteral reflux (VUR). Soon after, the term “reflux nephropathy” started to be used. Since then, urinary tract infection (UTI) and VUR are considered as risk factors for the development of renal scars which cause hypertension in 10% to 20% of patients and chronic kidney disease (CKD) if the lesions are bilateral. Based on these concepts, urological studies have been recommended at the time of the first acute pyelonephritis in recurrent UTI in children of any age. In the last decade, NICE2 (National Institute for Health and Clinical Excellence) and the AAP3 (American Academy of Pediatrics) published their guidelines, with stringent protocols in relation to investigation, prioritizing young children. There have been several Publications4-8 in order to demonstrate that the injudicious application of these protocols can induce a failure in prevention, since a significant number of children would be without a VUR and scarring diagnosis that can occur after the first UTI in 5%-15% of cases. If investigation and antibiotic prophylaxis are still controversial nowadays, even more are the indications of conservative, surgical or endoscopic treatment for VUR. In the absence of international consensus, today we try to stratify risk factors according to family history, gender, age, laterality, UTI recurrence, VUR grade, scars and association with lower urinary tract dysfunction (LUTD). In this sense, it is interesting to notice the current trend to separate two groups of patients: a) Boys with more hydronephrosis, UTI and higher grade VUR in the neonatal period, often with congenital kidney lesion by dysplasia (10%) and which may also include acquired scarring lesions, are best suited to surgical treatment.9 b) Girls with higher recurrence of febrile UTI and renal scarring acquired after the neonatal period and related to LUTD. Forty to sixty percent of children with VUR have LUTD and prevalence of renal scarring reaches 30%.10 LUTD presents symptoms of urine urgency or postponement, daytime and/or nighttime incontinence, changes in urine flow, post-void residual volume, urethra deformations (spindle-shaped) and recurrent UTI; there may be chronic and severe constipation (eliminations syndrome). The American Urological Association (AUA) in their guidelines,11 emphasizes the need to investigate these symptoms early on in the first UTI episode, and thus, the focus should be the treatment of LUTD, stating "A happy bladder is an empty bladder and an empty rectum." Infants also have VUR-related LUTD. In a recently-published paper12 (Swedish Reflux Trial), including 203 infants with III-IV grade VUR, 34% had LUTD with a negative effect on VUR resolution and renal scarring in two years of follow up. Noninvasive bladder function assessment in infants is possible and has been applied in this study through the 4-hour voiding observation test,13 enabling an early selection of these patients. Conservative treatment is based on the fact that spontaneous VUR resolution occurs mainly in young patients with