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The Changing Landscape of VUR a Decade after the 2011 AAP Urinary Tract Infection Guidelines: Results from a Single Center
Sarah H. Williamson, MD, Omar Abuzeid, BS, Carol A. Davis-Dao, PhD, Kai-Wen Chuang, MD, Heidi A. Stephany, MD, Elias J. Wehbi, MD, Kathy H. Huen, MD, Timothy C. Boswell, MD, Antoine E. Khoury, MD.
Children's Hospital of Orange County; University of California, Irvine, Orange, CA, USA.

BACKGROUND: The indications for voiding cystourethrogram (VCUG) were changed with the 2011 American Academy of Pediatrics guidelines, which recommended delaying VCUG until after the second febrile urinary tract infection (UTI). We hypothesized that prevalence of high grade VUR and surgical intervention have increased following publication of the guidelines.
METHODS: Patients with primary VUR were prospectively collected at a single center. The modern cohort was born between 2012-2020 and the historical cohort from 2007-2010. Children with secondary VUR, ureterocele, duplication anomalies, multicystic dysplastic kidney, ectopic ureter were excluded. The two populations were compared based on demographic, VUR characteristics, and the outcomes of UTI development and surgical intervention. UTI development defined as pyuria and bacteriuria on urinalysis and greater than 50,000 CFU/mL of a single organism. Chi-square and Wilcoxon tests were used for analysis. RESULTS: In the modern cohort, 256 patients met inclusion criteria and 73 patients in the historical cohort. Median age at diagnosis did not differ between the two groups (p = 0.16). No differences were found in circumcision status, race/ethnicity, or median follow-up time between the two groups (median 3.2 years in both, p = 0.85). However, the historical cohort had more female patients (68%, 50/73) compared to modern cohort (50%, 128/256, p = 0.005). The rate of high grade VUR increased from 15% (12/73) in historical cohort to 36% (92/256) in modern cohort (p = 0.002). More patients in the contemporary cohort (20%, 52/256) developed UTI during follow-up compared to historical cohort (6.9%, 5/73) but this was not significant (p = 0.20). In the modern cohort, more patients required surgical intervention (19%, 49/256) compared to historical patients (6.9%, 5/73, p= 0.02). CONCLUSIONS: We found a greater than two-fold increase in high grade VUR in the modern cohort and a significantly higher number of patients required surgical management compared to our historical cohort. Our results indicate that modern VUR patients have more severe VUR compared to patients seen prior to 2011. Modern VUR management should account for patients presenting with higher grade VUR and higher risk of UTI.


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