Ureteral Reimplantation Surgery to Correct Vesicoureteral Reflux

It was hard to understand when we learned that Lizzie needed a ureteral reimplantation surgery at the age of only 5 months. We had known from the beginning that she would need surgery, but we were expecting it to be at the age of 5 years, not 5 months. So how do you decide when it is time for surgery, and what should you expect when the time comes?

For us, the decision was pretty easy, since there really were no other options. Lizzie had grade 5 reflux in a duplicated system, and had 4 kidney infections (one of which was a resistant bacteria) while on antibiotics, all before the age of 5 months. We needed to do something, and do it quickly. Most doctors will try and wait until the child is 18 months old if possible. There have been studies showing that the surgery has a higher success rate after the age of 12 months, however, if there are multiple recurrent infections or damage to the kidneys, aggressive treatment may be needed. The general guidelines for surgery are the following:

• high grade reflux (grades IV & V)
• recurrent infection despite antibiotics
• the child is unable to take antibiotics (for whatever reason)
• the reflux has continued over a period of years and is not improving

If your child meets the criteria for surgery, how does the surgery correct the reflux? Children with Primary Reflux are born with a defect in the ureter(s) that allows the backflow of urine into the kidneys. Ureteral Reimplantation Surgery is a surgery performed to change the way that the ureter(s) enter the bladder. The surgeon will make an incision in the lower abdomen, and into the bladder, where they will basically sew the ureter(s) into the proper place. This corrects the valve that was allowing urine to reflux. This surgery is very successful with a 95-98% success rate.

So you have decided that surgery is the best option for your child. Now what? What should you expect, and what do you need to know?

This surgery is done under general anesthesia, which means the child is completely unconscious for the entire surgery. Many children will also have an epidural so that there is no pain for a few hours after they awaken. The surgery generally takes between 2-3 hours, but may take longer if there are duplicated ureters, or if tapering of the ureter is needed. A ureter may need to be tapered (made smaller where it enters the bladder) if it is a megaureter. This may help prevent further reflux by decreasing the size of the opening. When ureters are tapered, the child may require stents. We expected a 2-3 hour surgery with possible tapering, and were surprised when it became 5 hours. Luckily, most hospitals are well equipped keep you updated, and we were informed mid-surgery that things would take a little longer. Apparently, while they were performing the surgery, they discovered that instead of 3 ureters, Lizzie actually had 4, which meant there was another ureter that needed to be reimplanted.

It's hard to be prepared for what will happen after surgery. Most children do well with anesthesia, however some children may wake up very upset. Unfortunately you can't know which direction your child will go until after it has happened. Your child will have a catheter that may need to stay in place for 1-3 days. In our case, it was removed after 24 hours. Some children may require stents if any type of reconstruction has taken place, and some children may require catheterization for a longer period. Both of these are normal occurances after surgery.

You should discuss your child's pain management with your doctor and nursing staff before the surgery. You should know what drugs they will be taking, how much will be given and how often your child will/can receive it. On a more personal note here, we had wonderful nurses that made sure Lizzie was comfortable and getting the medicine that she needed, but I have spoken to other parents that have had a very difficult time. You may also want to discuss any other medications your child might need, such as medication for bladder spasms. It is common for children to experience bladder spasms after surgery. Spasms seem to be worse in older children. Lizzie had mild, but frequent bladder spasms and was given Ditropan to help control them. She also struggled with dehydration. Keeping your child hydrated is very important after the surgery. It not only helps recovery, but also helps keep the bladder flushed and for us, helped minimize the bladder spasms. There may also be blood in the urine for a few days up to many weeks. As long as it is not getting worse, it is normal in most children.

When your child gets out of surgery, you can expect them to be very tired and a little out of it for a while. He/she will have a small incision in the lower abdomen (see picture) which is closed with steri-strips that will either dissolve or fall off over time (in Lizzie's case, we eventually peeled them off). As another side note, you can no longer see Lizzie's scar unless you know exactly where to look, so her scarring has been minimal Your child will usually remain on a course of antibiotics for 7-10 days, at which time they will remain on a prophylactic antibiotic until it is verified that the reflux has resolved. Children can still get a UTI after surgery, however because of the surgery it should remain in the bladder, and not move into the kidneys. UTI is much less common after surgery, however some children are simply more prone to UTI than others. Children are usually released from the hospital 1-3 days after surgery. They will most often be prescribed a pain medication as well as a medicine for bladder spasms (such as Ditropan).

If you feel like your child is having difficulty after the surgery, do not hesitate to call your doctor immediately. If the following symptoms occur, you should call your doctor right away:

• If the child's temperature goes above 101.4 degrees F
• Excessive bleeding from the abdomen where the incision was made
• Dehydration or inability to tolerated liquids
• Vomiting excessively
• If the child is unable to urinate

About 4-6 weeks after surgery, the child should have an ultrasound to verify that there is no obstruction. After 4-6 months, your doctor may choose to have another VCUG to verify that the reflux has resolved. Children should have an ultrasound yearly to check the kidneys, and if scarring is present, blood pressure should also be checked yearly to monitor for hypertension.

Some studies have shown reimplantation to be up to 98% successful, but as with any surgery, there can be complications. General anesthesia is generally low risk in most children but can cause complications. In rare cases, obstruction and persistant reflux can occur after surgery. When obstruction occurs, it may be temporary, but the child may need to have the fluid drained from the kidney (this is often done with a nephrostomy). In some rare cases, a child may need surgery to remove the blockage, or to repeat the reimplantation. Deflux has also been found to be effective in some cases of persistent reflux. If you suspect that your child's reimplantation has not been effective, you can read more about our personal journey with a failed reimplant and what steps were taken next here.

The information on this web site should not be taken as medical advice, and you should contact your health care provider with any questions regarding your child's condition/health. The information on this site comes from the personal experience and opinions of parents, and does not come from doctors or medical experts, and should be taken as such.