1012
Letters to the Editor
REFERENCES 1. Di Liberti J, O'Brien ML, and Turner T: The use of physostigmine as an antidote in accidental diazepam intoxication, J P~DIATR 86:106, 1975. 2. Newton RW: Physostigmine salicylate in the treatment of tricyclic antidepressant overdose, JAMA 231:941, 1975. 3. Befnards W: Audio digest, Anesthesiology 13:No. 18, 1973.
Vesicoureteral reflux To the Editor: We would like to respond to the editorial by Drs. Girdany and Price I which appeared in THE JOURNALOF PEDrATRmS.We have pointed ou t in our article2 in the same issue of THE JOURNALthat in the majority of children with vesicoureteral reflux and urinary tract infection, renal scarring does not occur. We have also noted that in children with pyelonephritic renal scarring, gross reflux is a frequent concomitant but the occurrence of infection in such urinary tracts does not often result in further observable renal damage. These observations do not suggest to us that the detection of reflux is unimportant. Though reflux may often be a transient phenomenon, there seems little doubt that persistent reflux is one of the factors predisposing to recurrent urinary tract infection. Documentation of persistent reflux obviously requires serial cystograms. If radiation is a concern, this can be minimized with radionuclide studies? In many individuals with persistent reflux, careful medical management may prevent recurrent urinary tract infections and their attendant morbidity even though actual kidney damage is not apparent, in a substantial number of such patients, reflux will spontaneously resolve with growth, though this may require several years? When, despite such management, recurrent infections continue, or when gross reflux is present with or without renal damage, it would seem advisable to perform antireflux surgery, particularly in children who face a lifetime of risk to their kidneys.5 This procedure substantially reduces the recurrence of urinary tract infection and the morbidity therefrom in addition to reducing whatever r i s k m a y exist of bacterial damage to the kidneys. Peter R. Lewy, M.D. A. Barry Belman, M.D. Children's Memorial Hospital 2300 Children's Plaza Chicago, Ill 60614
The Journal of Pediatrics December 1975
REFERENCES 1. Girdany BR, and Price SE Jr: Vesicoureteral reflux and renal scarring, J PEmATR 86:998, 1975. 2. Lewy PR, and Belman AB: Familial occurrence of nonob. structive noninfectious vesicoureteral reflux with renal scarfing, J PEDIATR86:851, 1975. 3. Conway JJ, Belman AB, King LR, and Filmer RB: Direct and indirect radionuclide cystography, J Urol 113:689, 1975. 4. King LR, Kazmi SO, and Belman AB: Natural history of vesicoureteral reflux; outcome of a trial of nonoperative therapy, Urol Clin North Am 1:441, 1974. 5. Kelalis PP: The present status of surgery for vesicoureteral reflux, Urol Clinc North Am 1:457, 1974.
Reply To the Editor." In response to Doctors Lewy and Belman's letter we are impressed with the basic points &agreement among all of us. We do not suggest that the detection of reflux has no importance. To quote from our editorial: The voiding cystourethrogram seems to detect a group of children at risk from increasing morbidity of recurring urinary tract infections. Antireflux surgery may be effective in reducing unacceptable morbidity in selected children in whom medical treatment has been unsuccessful. What of the management of familial reflux? Should each member of the family of the child with vesicoureteral reflux have cyst0graphy and excretory urography? A sensible answer is "no." We do not understand the significance of vesicoureteral reflux; its demonstration in children with normal renal function and sterile urine may further cloud the issue. It seems proper to investigate the family of any child found to have renal failure, or any family in which two or more members have renal disease of any kind. In such cases, excretory urography is a reasonable method of radiographic investigation, with cystography carried out later if abnormal changes are observed on these films? Bertram R. Girdany, M.D. S. E. Price, Jr. M.D. Children's Hospital 125 De Soto St. Pittsburgh, Pa. 15213 REFERENCE 1. Girdany BR, and Price SE Jr: Vesicoureteral reflux and renal scarring, J PEOIATR 86:998, 1975.
Letters to the Editor
REFERENCES 1. Di Liberti J, O'Brien ML, and Turner T: The use of physostigmine as an antidote in accidental diazepam intoxication, J P~DIATR 86:106, 1975. 2. Newton RW: Physostigmine salicylate in the treatment of tricyclic antidepressant overdose, JAMA 231:941, 1975. 3. Befnards W: Audio digest, Anesthesiology 13:No. 18, 1973.
Vesicoureteral reflux To the Editor: We would like to respond to the editorial by Drs. Girdany and Price I which appeared in THE JOURNALOF PEDrATRmS.We have pointed ou t in our article2 in the same issue of THE JOURNALthat in the majority of children with vesicoureteral reflux and urinary tract infection, renal scarring does not occur. We have also noted that in children with pyelonephritic renal scarring, gross reflux is a frequent concomitant but the occurrence of infection in such urinary tracts does not often result in further observable renal damage. These observations do not suggest to us that the detection of reflux is unimportant. Though reflux may often be a transient phenomenon, there seems little doubt that persistent reflux is one of the factors predisposing to recurrent urinary tract infection. Documentation of persistent reflux obviously requires serial cystograms. If radiation is a concern, this can be minimized with radionuclide studies? In many individuals with persistent reflux, careful medical management may prevent recurrent urinary tract infections and their attendant morbidity even though actual kidney damage is not apparent, in a substantial number of such patients, reflux will spontaneously resolve with growth, though this may require several years? When, despite such management, recurrent infections continue, or when gross reflux is present with or without renal damage, it would seem advisable to perform antireflux surgery, particularly in children who face a lifetime of risk to their kidneys.5 This procedure substantially reduces the recurrence of urinary tract infection and the morbidity therefrom in addition to reducing whatever r i s k m a y exist of bacterial damage to the kidneys. Peter R. Lewy, M.D. A. Barry Belman, M.D. Children's Memorial Hospital 2300 Children's Plaza Chicago, Ill 60614
The Journal of Pediatrics December 1975
REFERENCES 1. Girdany BR, and Price SE Jr: Vesicoureteral reflux and renal scarring, J PEmATR 86:998, 1975. 2. Lewy PR, and Belman AB: Familial occurrence of nonob. structive noninfectious vesicoureteral reflux with renal scarfing, J PEDIATR86:851, 1975. 3. Conway JJ, Belman AB, King LR, and Filmer RB: Direct and indirect radionuclide cystography, J Urol 113:689, 1975. 4. King LR, Kazmi SO, and Belman AB: Natural history of vesicoureteral reflux; outcome of a trial of nonoperative therapy, Urol Clin North Am 1:441, 1974. 5. Kelalis PP: The present status of surgery for vesicoureteral reflux, Urol Clinc North Am 1:457, 1974.
Reply To the Editor." In response to Doctors Lewy and Belman's letter we are impressed with the basic points &agreement among all of us. We do not suggest that the detection of reflux has no importance. To quote from our editorial: The voiding cystourethrogram seems to detect a group of children at risk from increasing morbidity of recurring urinary tract infections. Antireflux surgery may be effective in reducing unacceptable morbidity in selected children in whom medical treatment has been unsuccessful. What of the management of familial reflux? Should each member of the family of the child with vesicoureteral reflux have cyst0graphy and excretory urography? A sensible answer is "no." We do not understand the significance of vesicoureteral reflux; its demonstration in children with normal renal function and sterile urine may further cloud the issue. It seems proper to investigate the family of any child found to have renal failure, or any family in which two or more members have renal disease of any kind. In such cases, excretory urography is a reasonable method of radiographic investigation, with cystography carried out later if abnormal changes are observed on these films? Bertram R. Girdany, M.D. S. E. Price, Jr. M.D. Children's Hospital 125 De Soto St. Pittsburgh, Pa. 15213 REFERENCE 1. Girdany BR, and Price SE Jr: Vesicoureteral reflux and renal scarring, J PEOIATR 86:998, 1975.
