Collaborative Review – Pediatric Urology Vesicoureteral Reflux: Current Trends in Diagnosis, Screening, and Treatment Jonathan C. Routh a, *, Guy A. Bogaert b , Martin Kaefer c , Gianantonio Manzoni d , John M. Park e , Alan B. Retik f , H. Gil Rushton g , Warren T. Snodgrass h , Duncan T. Wilcox i a Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA; b Department of Urology, University Hospitals Leuven, Leuven, Belgium; c Department of Urology, Indiana University and Riley Hospital for Children, Indianapolis, IN, USA; d Fondazione IRCCS Ca’ Granda - Ospedale Maggiore Policlinico, Milano, Italy; e Department of Urology, University of Michigan, Ann Arbor, MI, USA; f Department of Urology, Children’s Hospital Boston, Boston, MA, USA; g Division of Urology, Children’s National Medical Center, Washington, DC, USA; h Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA; i Division of Urology, University of Colorado, Denver, CO, USA 1. Introduction From a historical perspective, urinary tract infection (UTI) in general and acute pyelonephritis (APN) in particular have long been linked with patient morbidity [1]. By the mid- to late 20th century, vesicoureteral reflux (VUR) had come to be understood as a link between UTI, APN, renal scarring, and end-stage renal disease [2,3]. With advances in the safety and efficacy of antimicrobials [4] and an improved understanding of the likelihood of spontaneous resolution [5], by the 1970s, continuous antibiotic prophylaxis (CAP) had become standard initial management of patients with VUR [6]. For those with recurrent or breakthrough UTI or unresolved VUR, surgical management by ureteroneocys- tostomy was the treatment of choice [7,8]. In the 1980s, surgical management for select patients became less invasive with the development of endoscopic injection (EI) as an alternative treatment [9,10]. However, an evolving body of literature raised doubts regarding these treatment options. The first two major EUROPEAN UROLOGY 61 (2012) 773–782 available at www.sciencedirect.com journal homepage: www.europeanurology.com Article info Article history: Accepted January 3, 2012 Published online ahead of print on January 11, 2012 Keywords: Vesicoureteral reflux Pediatrics Screening Diagnosis Treatment Abstract Context: Vesicoureteral reflux (VUR) is present in approximately 1% of children in North America and Europe and is associated with an increased risk of pyelonephritis and renal scarring. Despite its prevalence and potential morbidity, however, many aspects of VUR management are controversial. Objective: Review the evidence surrounding current controversies in VUR diagnosis, screening, and treatment. Evidence acquisition: A systematic review was performed of Medline, Embase, Prospero, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, clinicaltrials.gov, and the most recent guidelines of relevant medical specialty organiza- tions. Evidence synthesis: We objectively assessed and summarized the published data, focus- ing on recent areas of controversy relating to VUR screening, diagnosis, and treatment. Conclusions: The evidence base for many current management patterns in VUR is limited. Areas that could significantly benefit from additional future research include improved identification of children who are at risk for VUR-related renal morbidity, improved stratification tools for determining which children would benefit most from which VUR treatment option, and improved reporting of long-term outcomes of VUR treatments. # 2012 European Association of Urology. Published by Elsevier B.V. All rights reserved. * Corresponding author. Division of Urologic Surgery, Duke University Medical Center, DUMC Box 3831, Durham, NC 27710, USA. Tel. +1 919 684 6994; Fax: +1 919 681 5507. E-mail address: jonathan.routh@duke.edu (J.C. Routh). 0302-2838/$ – see back matter # 2012 European Association of Urology. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.eururo.2012.01.002