Question Title: Reflux and Hydronephrosis

My questions are in regard to my daughter (born 11/90)
My daughter was hospitalized with a kidney infection in Feb. 1996
following her recovery, she was tested for reflux. The tests showed
bilateral reflux-grade 3. We went to a pediatric urologist and had additional tests which indicated that she also had a duplicated system (2 ureters) on the right side. With this added to the grade 3 reflux, corrective surgery was suggested.
She had surgery to reimplant the ureters in December, 1996. She was hospitalized for a week. At her first follow-up they determined that she had severe bilateral hydronephrosis along with a lot of swelling in the bladder and ureters.
They decided to do nephrostomies(?) (they inserted stents through her back and through the kidneys to hold the ureters open).
They left those stents in and instructed us to return to have them removed in three months. We returned and had the stents removed...then went back a couple months later for a follow-up only to find there was still a lot of swelling in the bladder and the ureters
In addition they found that they had neglected to remove one of the three stents they had put in. She was again put to sleep to have the third stent removed.
She has continued to have trouble with hydronephrosis. She remained on medication (Furodantin) until approximately 6 months ago at which time we discontinued the medication.
She has not had any problem with infection. She has been on a schedule of urination - every 2 and a half hours, to keep her bladder empty. We just returned for a follow-up visit 5/12 only to find that the hydronephrosis is still present.
She has had all sorts of tests, the last Voiding cysto showed no signs of reflux. The last renogram showed no obstruction. The doctor feels that when the bladder is full (or even partially full) the ureters flow is being restricted.
The doctor has ordered another renogram and states that if this shows no sign of blockage he may request an IVP to see if there is possibly a "J-hook" or other problem in the placement of the ureters.

My questions are: 1) Is there any permanent damage resulting from the on-going hydronephrosis?
2) The doctor who did the original reimplantation told us "I got the ureters in there as tight as possible"
and when the hydronephrosis started told us "Maybe we got them in too tight". Is if fair to say that
the reduced flow through the ureters is likely to have been caused by the first surgery being done
"too tight"?
3) If the renogram shows no obstruction, (as did the original renogram approx. 6 months ago) should we
move right into having the IVP done? Are we hurting anything by waiting?
4) If the IVP shows a "j-hook" or other abnormality in the placement of the ureters the doctor stated surgery
may be necessary - would we be looking at a re-do of the original reimplantation?

I understand you may not be able to answer all of these and I will also be asking her doctor these questions but would like to know what you think and would also
appreciate it if you had any other questions you think I should ask. Thank you for your assistance.

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Dear Carol,

Thank you for your question regarding your daughter. Reflux with duplicated ureter is well known phenomenon and reimplantation is the correct procedure to do when the reflux is high grade. Hydronephrosis following the reimplantation is often seen in children. However it may have been severe in your daughters case- since your doctor decided to insert stents. Now that the stents are out and the hydronephrosis is still present, I would like to know if the hydronephrosis is mild, moderate or severe. Mild to moderate hydro is noted in virtually all cases after reimplantation. However severe hydro is concerning. One also needs to know if her serum creatinine has changed at all. The fact that the renogram does not show any obstruction is very reassuring as this a very good test to diagnose obstruction. The causes of hydronephrosis are edema (swelling) from surgery, tight closure of the bladder hole around the ureter, or damage to the blood supply to the terminal ureter causing a stricture (scar tissue). A J- hooking angulation may also cause the problem. If the hydronephrosis is progressive, it indeed damages the kidney.
Both renogram and the IVP are a good idea. However if the hydronehrosis is severe a Whittaker test could be done . This is done with the percutaneous nephrostomy tube in place and pressure difference between the kidney and the bladder are calculated. This also is not a conclusive test as there is an equivocal range. If the hydro is severe and there is obstruction your daughter may require surgery to reimplant the ureter again.

This information is provided for general medical information purposes only. Please consult your physician for diagnostic and treatment options pertaining to your specific medical condition. The Henry Ford Hospital Department of Urology has experience in the evaluation and treatment of problems such as you describe. We would be most interested in helping you. You can reach us through our toll-free number (1-800-653-6568). We can also arrange local accommodations through this number if this is your need. Please bring any x-rays [and pathology slides] (not just the reports) as well as any physicians’ notes and lab test results that you may be able to obtain. These will help us greatly.
HFHS M.D.-SS.
*Keyword: reflux, ureter, hydronephrosis

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