Figure. Controversies in Vesicoureteral Reflux Management cross fire moderator and panelists.

Nowhere in pediatric urology is a topic as heavily debated as vesicoureteral reflux (VUR). Despite being quite a common finding, found in up to 30% of children with a history of urinary tract infections,¹ there is a fair amount of controversy as to its workup and management. As such, the topic lent itself nicely to a friendly debate kicking off the Sunday morning plenary session of the 2023 AUA Annual Meeting in Chicago. It was a cold and rainy morning on April 30, from which urologists in attendance of the AUA could warm up through the heated discussion that arose as Drs Erin McNamara of Boston Children’s Hospital, Tony Khoury of Children’s Hospital of Orange County, Vijaya Vemulakonda of Children’s Hospital Colorado, and Julian Wan of C.S. Mott Children’s Hospital at the University of Michigan took strong stances on either side of 3 tough clinical scenarios involving VUR. Christina Ching of Nationwide Children’s Hospital of Columbus, Ohio, had the pleasure of moderating.

In the first scenario, we specifically discussed care in those with VUR found upon workup for abnormal prenatal imaging as opposed to that found as a result of urinary tract infections. We discussed how distal ureteral width may impact one’s decision to evaluate for VUR, with a 7-mm or more cutoff helping identify those patients in whom a voiding cystourethrogram should be performed and antibiotic prophylaxis initiated.²

In the second scenario, we discussed the contribution of bowel and bladder dysfunction to the complexity of VUR and how this can impact the plans for surgical intervention.³ There was agreement that bowel and bladder dysfunction should be managed aggressively as much as possible prior to any more invasive treatment, as its poor management can alter the outcome of surgery.

In the third scenario, we discussed uncorrected VUR in a teenage female with considerations related to follow-up and potential impact during pregnancy.⁴ There was general acknowledgment that such a patient needed continual monitoring and it was imperative the patient establish a good relationship with a medical provider as they continue to transition to adulthood. The importance of monitoring renal health in one at risk for or with known reflux nephropathy is necessary. This includes regular blood pressure monitoring, annual urinalysis, blood work (when necessary), and nephrology referral. Another important theme of this scenario was informed decision-making between urologist, patient, and patient family.

In summary, the outcome of the AUA2023 cross fire debate on VUR highlighted the importance of nuanced care and demonstrated the complexity of a diagnosis of VUR. Not all VUR in children is the same; and even within any one patient, VUR can be a dynamic process. Ultimately, patient-tailored care is important with an assessment of risk factors beyond just that of the finding of VUR alone. Close attention should be paid to the clinical context of having found VUR and the needs of the patient and their family.