Introduction: Over the last two decades, there has been a shift towards more conservative management of vesicoureteral reflux (VUR). Although there are multiple areas of consensus, the current literature is marked by controversy and divergent guidelines regarding VUR imaging, screening, and treatment. Furthermore, the practice of ordering voiding cystourethrograms (VCUG) continues to be common, particularly in infants with a history of antenatal hydronephrosis. Herein, we sought to examine inter-departmental VCUG ordering practices, and subsequent rates of VUR in infants with antenatal hydronephrosis (ANH) in a large US tertiary referral hospital.
Methods: A single academic center radiology database was used to identify all infants with documented ANH that underwent a VCUG within the first 6 months of life. Data relating to ANH, VCUG findings, VCUG requests, and ordering services were extracted from the electronic health record and analyzed. .
Results: 627 infants with ANH (207 bilateral) had a VCUG performed between 2015-2019, of which 143 (23%) confirmed VUR (bilateral in 66; with 59.6% male, mean age 2.65 months and 40.4% female, mean age 2.8 months). Overall, pediatric urology was responsible for the highest number of VCUG requests (70%), followed by nephrology (10%), pediatrics (9%), neonatology (8%), and family medicine (2%). However, in infants with low grade hydronephrosis (SFU grades I/II), 60% of VCUGs were requested and obtained by pediatrics, 18% by pediatric urology, 12% by nephrology, and 10% by family medicine. Most infants with VUR (70%; 100/143) had a follow-up VCUG scan was performed, which was done at a mean of 6 months (Range: 1-4 years). In infants with confirmed VUR and a subsequent follow-up VCUG, 33% (30/100) had resolved spontaneously (mean follow-up interval and age of 6 months, and 4.2 years respectively), 21% (21/100) underwent operative interventions, and 46% (46/100) were managed without any surgical intervention.
Conclusions: Most asymptomatic patients (77%) with a history of ANH do not have evidence of VUR on VCUG , however, VCUGs continue to be ordered in infants diagnosed with ANH irrespective of symptoms, with pediatricians more likely to order VCUG for lower grades of hydronephrosis. As VUR management has become more conservative, we recommend abstaining from requesting VCUGs in infants with asymptomatic ANH and to follow an informed, shared decision-making model based on intent to treat.
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