Continued improvement in minimally invasive antireflux operative techniques, as well as improved cystogram techniques , may affect decisions regarding reflux management. An informed decision must weigh the risks and benefits of the alternative methods of management. To this end, urologists must strive to collect better prospective and retrospective data regarding outcome in children with reflux. The answer to the question of who will benefit from an antireflux operation remains unknown. To truly answer the question, a large prospective randomized placebo-antibiotic-operation study with long-term follow-up would be needed. Such a study will not happen for all groups of children with reflux, although it may occur for particular subgroups of refluxing children. Currently, the decision to operate on a child with reflux or to continue or stop antibiotic prophylaxis is based on the physician and parent's assessment of the risks and benefits. Factored into this analysis is the likelihood for resolution. Multiple variables affect the child's risk of long-term adverse outcome and the time to resolution. Currently, treating physicians incorporate what is known about each of these factors for a given child when counseling parents regarding their overall assessment of risk for that particular child. The future development of nomograms to assess an individual's risk of adverse outcomes should facilitate counseling regarding management options. Factors in this analysis should include age, gender, the history of urinary tract infections, renal scars, bladder and bowel function, as well as reflux grade. Nomograms assessing the probable time to reflux resolution may be improved by incorporating factors in addition to reflux grade. Such factors may involve age, gender, stature, bladder volume and pressure at the onset of reflux, and bladder and bowel function. Improved predictability of the time to resolution of the reflux should assist in treatment decisions and optimize the time for follow-up studies [29,38].
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