UroToday - A review by Dr. J. Christopher Austin showed that vesicoureteral reflux after puberty is not well documented but that those adolescents should be treated when recurrent pyelonephritis is present.

He reviewed ureteral reimplantation, endoscopic injections, and laparoscopic or robotic ureteral reimplantation in the armamentarium. He promotes endoscopic injection as "an appealing option for these patients". Other minimally invasive modalities will evolve in these patients as this disease is more readily diagnosed and treated.

Personally, I have a unique experience where teenagers and post teen women with a known history of reflux have issues regarding pyelonephritis. The majority of women presented with a history of pyelonephritis during pregnancy resulting in what was thought to be the reason for either a miscarriage or fetal demise. All these women had pyelonephritis at the time of miscarriage or demise and a known history of untreated VUR as a child. They all requested a repeat VCUG, which in every instance showed persistent VUR, unchanged from what they had as a child. Interestingly, all the grades of VUR were grade 4 to 5 in the majority with less than 10% being grade 3.

I have injected the women with grade 3 and performed robotic reimplantations on those with grade 4 and 5. It is true that I only have a numerator and no denominator to this fraction, but it has made a difference in all these women's lives where they have gone on to full-term pregnancies without pyelonephritis. Every time someone asks me "what can I make out of all this?" my answer is always, "we truly know little about the long term ramifications of high grade VUR, and delineating this complex, high risk group will be a great challenge."

Austin JC
Adv Urol. 2008:590185. Epub 2009 Feb 26.
doi:10.1155/2008/590185

UroToday Medical Editor Pasquale Casale, MD

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