206 / Urology

surgery increased primarily due to increased use of endoscopy. This findingsuggests that despite the lack of evidence of benefit, endoscopy is increas-ingly viewed as first line therapy for reflux.

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Endoscopic correction of vesicoureteral reflux (VUR) was first described in

the 1980s. Polytetrafluoroethylene (Teflon) was initially used as the bulking

agent. It was hard to inject, and concerns regarding particle inflammatory

response and migration limited its adoption in the United States. Dextrano-

mer/hyaluronic acid copolymer implants (Deflux) for endoscopic antireflux

surgery were developed in Scandanavia in the early 1990s and were approved

for use in the United States in 2001. Has the availability of endoscopic treat-

ment changed the management of VUR? This analysis of a single payor’s claims

database shows that antireflux surgery is now performed earlier in children

diagnosed with reflux predominantly because of an increased use of endo-

scopic surgery. Has this shift occurred because our efforts to prevent pyelone-

phritis are failing, or is it simply because it is easier to perform an outpatient

procedure than to counsel families on all of the treatment modalities, including

observation with monitoring and modification of elimination pattern, antibiotic

prophylaxis, and surgical correction? The availability of endoscopic surgery

should not change the initial management of VUR. The initial management

strategy should. If endoscopic correction is offered to all children with reflux,

there is little doubt that a large number are receiving an unnecessary surgery

because pyelonephritis can be successfully prevented with behavioral modifica-

tion and judicious use of prophylactic antibiotics that, in the past, were

routinely used in all patients but are probably required in fewer patients. If

surgery is reserved for those children with pyelonephritis in spite of a good

prevention program, then the success of surgery will be greater, and the

management of reflux will be much more cost-effective.

D. E. Coplen, MD

Nomograms for Predicting Annual Resolution Rate of PrimaryVesicoureteral Reflux: Results From 2,462 ChildrenEstrada CR Jr, Passerotti CC, Graham DA, et al (Children’s Hosp Boston, MA)

J Urol 182:1535-1541, 2009

Purpose.—We determined the resolution rate of vesicoureteral refluxand the factors that influence it to formulate nomograms to predict theprobability of annual resolution for individual cases of reflux.

Materials and Methods.—We studied 2,462 children with primaryvesicoureteral reflux diagnosed between 1998 and 2006. Cox proportionalhazards regression was used to model time to resolution as a function ofstatistically significant demographic and clinical variables. The resultingmodel was used to construct nomograms predicting the annual cumulativeprobability of reflux resolution.

Chapter 15–Vesicoureteral Reflux / 207

Results.—Multivariate analysis showed that all cases of unilateral refluxresolved earlier than female bilateral reflux (HR 1.42, p < 0.001). Addi-tionally age less than 1 year at presentation (HR 1.31, p < 0.001), lowerreflux grade (2.96, p < 0.001 for grade I; 2.28, p < 0.001 for grade II;1.63, p < 0.001 for grade III), reflux diagnosed on postnatal evaluationfor prenatal hydronephrosis or sibling screening (1.24, p¼ 0.002) andsingle ureter (1.55, p < 0.001) were associated with significantly earlierresolution of reflux. Specific predicted cumulative probabilities of refluxresolution at annual intervals from diagnosis (1 to 5 years) were calculatedfor every possible combination of the significant variables.

Conclusions.—Our analyses demonstrate that resolution of vesicoure-teral reflux is dependent on age at presentation, gender, grade, laterality,mode of clinical presentation and ureteral anatomy. We constructed nomo-gram tables containing estimates of annual reflux resolution rate as a func-tion of these variables. This information is valuable for clinical counselingand management decisions.

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Historically, vesicoureteral reflux was managed medically (prophylaxis) and

surgically. Consequently, an understanding of the resolution rate was very

important because it allowed physicians and parents to have an idea of the

length of time their child would require prophylaxis. The authors report a very

large series from a single institution. The resolution rate is influenced by the

historical surgical and medical management practice pattern at that institution.

The resolution rate is also affected by omission of data on dysfunctional voiding

(decreases resolution rate) and auditing surgical patients as failure to resolve

(does not really evaluate the natural history).

Currently, a plurality of patients with low-grade reflux are managed without

prophylaxis. If they remain infection free, then it is not really important whether

reflux resolution occurs over 18 months or 8 years. A more important analysis

(not yet available in the literature) defines those patients at risk for renal scarring

because this is the subset that needs aggressivemedical and/or surgical treatment.

D. E. Coplen, MD

Predictive Factors for Resolution of Congenital High Grade VesicoureteralReflux in Infants: Results of Univariate and Multivariate AnalysesSjostrom S, Sillen U, Jodal U, et al (Univ of Gothenburg, Sweden)

J Urol 183:1177-1184, 2010

Purpose.—We studied variables with impact on cessation of congenitalhigh grade vesicoureteral reflux in univariate analyses and provide a multi-variate model for prediction of reflux resolution.

Materials and Methods.—A total of 80 male and 35 female infants(median age 2.7 months) were included in this prospective observationalstudy. Of the cases 71% were diagnosed after urinary tract infection and26% after prenatal ultrasound. Reflux was bilateral in 70% of the patients