ABSTRACT
OBJECTIVES: Although minimally invasive procedures have created a groundswell, supportive of early intervention as on expedient alternative to surveillance, we present a patient-driven model of care that weighs risk and benefit for each individual. METHODS: A practice review was performed for the period 2000-2006. The records of all patients diagnosed by, or referred to, our group (three full-time Pediatric Urologists with a regional service population of 1.7 million) were included in on analysis of vesicoureteral incidence, initial management, and surgical approach. RESULTS: During the review period, the incidence of newly diagnosed VUR increased at a rate of 4% per year, with 66% of these accrued from evaluation of prenatal hydronephrosis and asymptomatic siblings of known reflux patients. The number of children with VUR and a significant component of DES also increased over time. During this period of higher case volume, surgical intervention failed to increase significantly but did show a dramatic procedural shift toward minimally invasive techniques for all providers and probable delayed intervention in a substantive number of cases until endoscopic treatment was freely accessible between 2002-2004. CONCLUSION: Our patient-driven model respects current literature and clinical experience, while acknowledging that our understanding is still currently in evolution. As our knowledge grows, from well-designed prospective study, we adopt new techniques and retire archaic practices. At this point in time, however, we find evidence lacking to support adoption of a procedure-driven algorithm in the care of VUR.
Subject(s)
Vesico-Ureteral Reflux/therapy , Algorithms , Child , Female , Humans , Male , Vesico-Ureteral Reflux/complicationsABSTRACT
Objectives: Although minimally invasive procedures have created a groundswell, supportive of early intervention as an expedient alternative to surveillance, we present a patient-driven model of care that weighs risk and benefit for each individual. Methods: A practice review was performed for the period 2000-2006. The records of all patients diagnosed by, or referred to, our group (three full-time Pediatric Urologists with a regional service population of 1.7 million) were included in an analysis of vesicoureteral incidence, initial management, and surgical approach. Results: During the review period, the incidence of newly diagnosed VUR increased at a rate of 4% per year, with 66% of these accrued from evaluation of pre-natal hydronephrosis and asymptomatic siblings of known reflux patients. The number of children with VUR and a significant component of DES also increased over time. During this period of higher case volume, surgical intervention failed to increase significantly, but did show a dramatic procedural shift toward minimally invasive techniques for all providers and probable delayed intervention in a substantive number of cases until endoscopic treatment was freely accessible between 2002-2004. Conclusion: Our patient-driven model respects current literature and clinical experience, while acknowledging that our understanding is still currently in evolution. As our knowledge grows, from well-designed prospective study, we adopt new techniques and retire archaic practices. At this point in time, however, we find evidence lacking to support adoption of a procedure-driven algorithm in the care of VUR (AU)
Objetivo: Aunque los procedimientos mínimamente invasivos han creado un clamor popular apoyando la intervención temprana como una alternativa conveniente a la observación, presentamos un modelo de manejo centrado en el paciente, que valora la relación riesgo-beneficio en cada individuo Métodos: Realizamos una revisión de la práctica clínica en el periodo 2000-2006. Las historias clínicas de todos los pacientes diagnosticados por nuestro grupo o derivados a él (tres urólogos pediátricos con dedicación completa, con una población de referencia de 1,7 millones de habitantes) se incluyeron en un análisis de la incidencia de reflujo vesicoureteral, el manejo inicial y el abordaje quirúrgico. Resultados: Durante el periodo de revisión, la incidencia de reflujo vesicoureteral de nuevo diagnóstico aumentó con un ritmo del 4% anual, con un 66% de los casos provenientes de la evaluación de hidronefrosis prenatales y hermanos asintomáticos de pacientes con reflujo conocido. El número de niños con reflujo vesicoureteral y un componente significativo de síndrome de eliminación disfuncional también ha aumentado con el tiempo durante este período de mayor volumen de casos; el número de intervenciones quirúrgicas no ha aumentado significativamente, pero se ha visto un cambio dramático de procedimientos hacia técnicas mínimamente invasivas y un probable retraso de la intervención en un número sustantivo de casos hasta que el tratamiento endoscópico fue libremente accesible entre 2002-2004. Conclusiones: Nuestro modelo dirigido al paciente respeta la literatura actual y la experiencia clínica, y a la vez reconoce que nuestro conocimiento hoy está todavía en evolución. A medida que crece nuestro conocimiento, a partir de estudios prospectivos bien diseñados, adoptamos nuevas técnicas y retiramos las viejas prácticas. En este punto del tiempo, sin embargo, encontramos una falta de evidencia para apoyar la adopción de un algoritmo dirigido por el procedimiento en el cuidado del reflujo vesicoureteral (AU)
