Alternative approaches to the prognostic stratification of mild to moderate primary vesicoureteral reflux in children

Purpose: We compared the prognostic stratification of primary vesicoureteral reflux by performing staging voiding cystourethrography in all children with a urinary tract infection or only in those with renal scarring on (99m)technetium-dimercapto-succinic acid (DMSA) scintigraphy. Materials and Methods: Staging voiding cystourethrography and DMSA scintigraphy were performed in 105 children with a urinary tract infection and reflux persistence was assessed by radionuclide cystography after a 2-year followup. Results: Staging voiding cystourethrography revealed no reflux in 51 children (DMSA positive in 3), grades I to II reflux in 21 (DMSA positive in 6) and grade III reflux in 33 (DMSA positive in 19). On followup radionuclide cystography no new reflux was detected, and it was no longer demonstrated in 23 children (8 with grade III and 15 with grades I to II reflux). The finding of grade III reflux on staging voiding cystourethrography had a 76% positive and a 92% negative value for predicting persistent reflux with an 87% predictive accuracy. Limiting the evaluation of voiding cystourethrography data to the 28 children with a positive DMSA scan the combination of renal seaming and grade III reflux had an 84% positive and an 83% negative predictive value with 83% accuracy. This approach would have prevented 77 children from having to undergo voiding cystourethrography. Conclusions: Performance of staging voiding cystourethrography exclusively in children with renal scarring on a DMSA scan resulted in predictive accuracy that was close to what was achieved by performing voiding cystourethrography in all children with a urinary tract infection. To be able to limit cystourethrography to a select population could prove to be cost-effective.