Clinical care of vesicoureteral reflux: preventing adoption of a procedure-driven algorithm.

Objectives: Although minimally invasive procedures have created a groundswell, supportive of early intervention as on expedient alternative to surveillance, we present a patient-driven model of care that weighs risk and benefit for each individual.

Methods: A practice review was performed for the period 2000-2006. The records of all patients diagnosed by, or referred to, our group (three full-time Pediatric Urologists with a regional service population of 1.7 million) were included in on analysis of vesicoureteral incidence, initial management, and surgical approach.

Results: During the review period, the incidence of newly diagnosed VUR increased at a rate of 4% per year, with 66% of these accrued from evaluation of prenatal hydronephrosis and asymptomatic siblings of known reflux patients. The number of children with VUR and a significant component of DES also increased over time. During this period of higher case volume, surgical intervention failed to increase significantly but did show a dramatic procedural shift toward minimally invasive techniques for all providers and probable delayed intervention in a substantive number of cases until endoscopic treatment was freely accessible between 2002-2004.

Conclusion: Our patient-driven model respects current literature and clinical experience, while acknowledging that our understanding is still currently in evolution. As our knowledge grows, from well-designed prospective study, we adopt new techniques and retire archaic practices. At this point in time, however, we find evidence lacking to support adoption of a procedure-driven algorithm in the care of VUR.