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Introduction

Previous reports have demonstrated that distal ureteral diameter ratio (UDR) is an objective and reliable measure predictive of spontaneous resolution in children with primary vesicoureteral reflux (VUR). Improved identification of children at risk for recurrent febrile urinary tract infections (fUTI), along with likelihood of spontaneous resolution, may impact management decisions. We evaluated the effect of UDR as a predictive factor for breakthrough fUTI.

Methods

Children with primary VUR and detailed voiding cystourethrogram (VCUG) were identified. Children were prescribed daily prophylactic antibiotics and followed with annual cystograms until reflux resolution or operative repair. UDR was computed by measuring largest ureteral diameter within the pelvis and dividing by the distance between the L1-L3 vertebral bodies. Demographics, VUR grade, laterality, presence/absence of bladder bowel dysfunction (BBD), and UDR were tested in uni and multivariate analysis. Primary outcome was breakthrough fUTI.

Results

One hundred and forty children (112 girls, 28 boys) met inclusion criteria. Mean age at diagnosis was 2.5±2.3 years, and mean length of follow-up was 3.2±2.7 years. VUR was grade 1-2 (n = 64, 45.7%), grade 3 (n = 50; 35.7%), grade 4 (n = 16; 11.4%) and grade 5 (n = 10; 7.2%). Forty children (28.6%) experienced breakthrough fUTI events. Children with breakthrough fUTI had significantly higher UDR than those without (0.25 versus 0.36; p = 0.004). Controlling for VUR grade, every 0.1 unit increase in UDR resulted in 1.7 times increased odds of breakthrough fUTI (95% CI 1.24-2.26; p<0.0001). Increased probability of breakthrough fUTI was observed with increased UDR; however increasing grade alone was not [Figure]. Forty-five children (32.1%) experienced spontaneous VUR resolution at a mean of 2.7±2.7 years. Ninety-five patients (67.9%) underwent surgical correction of VUR at a mean of 3.4±2.6 years from initial diagnosis.

Conclusions

Children with elevated distal ureteral diameter ratio are at increased risk for breakthrough fUTI independent of reflux grade. UDR was more predictive of breakthrough fUTI than either VUR grade or UDR combined with grade. UDR provides valuable prognostic information about risk of recurrent pyelonephritis and may assist with clinical decision-making.

Funding

None