Learning from history or the rationale for considering surgical correction of vesicoureteral reflux

History reminds us of valuable lessons learned in the treatment of vesicoureteral reflux (VUR). Rates of reflux nephropathy (RN) have decreased remarkably over the past 50 years, owing in various degrees to more rapid detection of urinary tract infection (UTI) in infants and children, improved medical therapy and timely surgical intervention. Reflux nephropathy once accounted for 22% of all pediatric renal transplantations, and now accounts for less than 6%.1 Despite this improvement, 8.5% of chronic renal disease in North American children is still due to RN.2 In some series, there is a history of childhood pyelonephritis with subsequent renal scarring in up to 15% of adult renal transplantation.3 Therefore, the modern day debate on the optimal management of VUR has significant merit in terms of preventing RN, and its impact on pediatric and adult populations. During the 1950s, Hutch was the first to suggest a link between VUR, pyelonephritis and renal scars based on his work on adult paraplegics, and the benefits of ureteral reimplantation.4 Politano, Leadbetter, Paquin and others improved upon the concept of an adequate length, detrusor-backed submucosal tunnel, cementing ureteral reimplant as a time-tested cornerstone in the management of VUR. 5,6 Reported contemporary success rates of antireflux surgery range from 96% to 98%.7 The VUR treatment paradigm shifted from surgery towards medical management during the late 1970s. Lenaghan and colleagues showed a natural tendency for most VUR to resolve spontaneously. 8 This work, coupled with the work of Smellie and colleagues,9,10 which showed a low rate of new scar formation on daily low dose antimicrobial prophylaxis, provided the rationale for the expectant VUR treatment we have seen for the past 3 decades. The rationale of preventing UTIs and pyelonephritis, while the refluxing kidney is at risk, formed the basis of the 1997 American Urological Association expert panel on VUR,11 where surgery is reserved for patients who failed on antibiotic prophylaxis and with high-grade reflux.