Is ultrasound a safe alternative to voiding cystourethrogram for vesicoureteral reflux screening of siblings?

BACKGROUND Siblings of children with vesicoureteral reflux (VUR) have an increased incidence of VUR compared with the general population. Younger siblings are at greatest risk. If untreated, VUR can lead to urinary tract infection ( UTI), hypertension, renal scarring, and reflux nephropathy. Routine screening of siblings with a voiding cystourethrogram (VCUG) is widely advocated; however, not all urologists, or indeed parents, support the use of this invasive procedure in asymptomatic children. Ultrasound is a less invasive alternative, but its efficacy as a VUR screening tool is largely unknown. OBJECTIVE To investigate the use of a minimally invasive and observational approach to screening for sibling reflux, using renal ultrasound. DESIGN AND INTERVENTION This was a single institution's experience of VUR screening in siblings. At this institution, screening with VCUG is routinely recommended for all siblings < 2 years old; however, since 1984, ultrasound has been used to screen siblings > 5 years old, and siblings whose parents refuse invasive screening with VCUG. Asymptomatic siblings who were screened with ultrasound between 1984 and 2003 were identified by chart review. Exclusion criteria were a history of UTI or other voiding disorders, and abnormal urine-study results. If ultrasound detected a discrepancy in renal size, signs of renal scarring, hydronephrosis, or hydroureter, or a change in renal pelvis size, the child was referred for VCUG. Children with normal ultrasounds who developed UTIs were also referred for VCUG. Long-term follow-up data were obtained by telephone. OUTCOME MEASURES The primary endpoint was the incidence of VUR in the screened population. RESULTS One hundred and seventeen siblings ( 66 male, 51 female) were included, with a median age of 6 years ( range 2 months to 15 years). Overall, 11 (9.4%) siblings underwent VCUG: nine because of abnormal ultrasound scans, and two because they developed a UTI. VCUG results were negative in the two siblings with UTI. VUR was detected in five of the nine siblings (55.6%) with abnormal ultrasound scans; VUR ranged from grade I to grade III, and was bilateral in four siblings (80.0%). Siblings with a diagnosis of VUR were managed with antibiotic prophylaxis, and followed with serial VCUGs. Four children remained asymptomatic, and demonstrated spontaneous resolution of reflux; one child's reflux failed to resolve spontaneously, and was managed with surgical reimplantation. After an average of 8.3 years ( range 2 months to 19 years), long-term follow-up information was available for 85 of the 117 (72.6%) screened siblings, all of whom had a normal initial ultrasound scan, and had never been assessed with VCUG. None reported experiencing UTI symptoms or unexplained febrile illnesses, and none had been diagnosed with hypertension or renal dysfunction. CONCLUSION The authors conclude that, in select, older, asymptomatic siblings, ultrasound screening can identify children for whom further investigation with VCUG is warranted.