A Systematic Review and Meta-Analysis of the Role of Ultrasonography for the Diagnosis of Vesicoureteral Reflux in Pediatric Patients Following Urinary Tract Infections: Technical Report

BACKGROUND Vesicoureteral reflux (VUR) may be present in as many as 40% of children without known underlying neurogenic bladder or anatomic abnormalities in whom a first urinary tract infection (UTI) is diagnosed. This article reports on a technical review investigating the diagnosis of VUR using renal and bladder ultrasonography (RBUS) to inform the development of an updated clinical practice guideline (CPG) by the American Academy of Pediatrics. METHODS The authors performed a systematic review to evaluate the diagnostic test accuracy (DTA) of RBUS for the detection of VUR in pediatric patients following either their first UTI or recurrent UTI. We performed database searches of Medline via PubMed, Embase, and Cochrane Central Register of Controlled Trials from January 1, 2008, through August 5, 2023. Eligible studies were published in English and reported on DTA for RBUS performed in pediatric patients with an acceptable reference standard. Data on study characteristics and DTA parameters were extracted from studies and pooled using meta-analysis, when appropriate. Risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation approach. RESULTS Out of 857 identified records, a total of 90 studies were included. Overall, there is low-to-moderate certainty that RBUS lacks accuracy in detecting VUR in children with their first UTI and low certainty that RBUS lacks accuracy in detecting VUR in children with recurrent UTI. The pooled sensitivity and specificity for children with their first UTI are 50% (95% confidence interval [CI], 42% to 58%) and 71% (95% CI, 62% to 78%), respectively. Accuracy does not substantially improve when restricted to the detection of high-grade (III-V) VUR (sensitivity: 66% [95% CI, 60% to 72%], specificity: 77% [95% CI, 71% to 82%]) or to children with recurrent UTI (sensitivity: 26% [95% CI, 23% to 28%], specificity: 79% [95% CI 76% to 81%]). CONCLUSION This systematic review illustrates the unreliability of RBUS as a stand-alone test in detecting VUR in a variety of scenarios. These results informed the development of an updated AAP CPG on the management of pediatric UTI. Specific areas of uncertainty identified through this review may be addressed with future research.