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Urology (Expert Forum)
5yr old son with VUR - sting procedure
Questions in the Urology forum are answered by Dr. Stephen Liroff, affiliated with the Henry Ford Hospital. Topics covered include benign prostate disease, penis curvature, cystisis, kidney stones, pediatric urology, prostate, sexual dysfunction, urinary tract infections (UTI), and urological cancers.
5yr old son with VUR - sting procedure
by Dinah__0, Jan 17, 1999 12:00AM
My son had a right nephrectomy when he was two due to the withered condition of the kidney and the fact that it did not function. He also has VUR to both sides - grades have varied in the 31/2 years since surgery. Last October he underwent the sting procedure on a day care basis to his left side, this has failed and it is likely that they will repeat procedure - the alternative is a reimplant which I have been told is not without complications. Could you please tell me the possible reasons for the failure of the sting procedure, what the chances are for success second time around and also what are the complications of reimplant? If the reflux is not grade V, then should I wait until he is older for surgery or because of the fact that he only has one kidney do we have to operate now?
He has been on antibiotics since the age of one when this problem was first discovered - I have just been told that he is showing damage to his remaining kidney - how could this have happened when he has been on the antibiotic and never suffered a UTI since?
He finds the cystograms very, very distressing even under sedation (which did not seem to make a difference) Is there any other way to test for reflux?
Finally, he is the shortest in his class and still is wet at night - are these facts related to his kidney problems and if so is there anything I can do to help - diet etc?
Thank you so much for your time,
Dinah
He has been on antibiotics since the age of one when this problem was first discovered - I have just been told that he is showing damage to his remaining kidney - how could this have happened when he has been on the antibiotic and never suffered a UTI since?
He finds the cystograms very, very distressing even under sedation (which did not seem to make a difference) Is there any other way to test for reflux?
Finally, he is the shortest in his class and still is wet at night - are these facts related to his kidney problems and if so is there anything I can do to help - diet etc?
Thank you so much for your time,
Dinah
Doctor's Answer
by hfhs M.D.-AK, Jan 17, 1999 12:00AM
_
Dear Dinah,
. One of the most difficult decisions regarding a child with vesicoureteral reflux is deciding between medical and surgical management. Spontaneous disappearance of reflux is related to the age of the child and degree of reflux. It has been reported that 63% of grade two, 53% of grade three , and 33% of grade four reflux patients have resolved spontaneously if infection is controlled. Another study showed that in children of growing age that unilateral grade four reflux(what your child has) had spontaneous resolution 61% on the time, where as in bilateral patients resolution occurred in only 9%. Reflux that persists in adolescence or adulthood is unlikely to disappear spontaneously.
The most important issue with children with reflux is preservation of the renal function and allowing for normal and complete growth of both kidneys. This means avoiding infections of the kidneys to prevent harmful scarring. Sometimes patients are placed on longterm prophylactic antibiotic therapy as your son has. These regimens are usually safe as long they are tolerated well by the child. If your child were managed conservatively(medically) periodic follow-up studies must be done to ensure normal scar free growth.
Also a physical exam sure be performed an special inclusion of height and weight parameters and blood pressure measurements. If your sons height and weight parameters drop below the 5th percentile for age, this needs to be addressed by a medical physician. Laboratory studies should include a urinalysis and urine culture at each visit In terms of radiology tests, a IVP or ultrasound should be obtained every 18-24 months. After the initial VCUG has been performed to establish to current grade, a follow-up study should be performed to establish an interval relationship.
On the other hand surgery or reimplantation of the ureters is a very successful procedure. One should expect success rates as high as 95-98% in patients with normal caliber ureters and normal bladders. This drops to 54% when the ureter is markedly dilated which is seen in grade four reflux. The STING procedure involves injecting a bulking agent around the ureteral orifice. These procedures fails due to the lack of durability of the operation. A reimplant would a more durable choice(longer lasting).
There are several schools of thought on wether or not the reflux of sterile urine causes damage to the kidney and alters growth. The decision to proceed either with conservative medical therapy verses surgical therapy will largely be up to your Urologist and how he was trained. I don’t think there is a right or wrong decision however if inadequate follow-up could become an issue, the one time surgical procedure would probably be the safer option.
Since your son has only one kidney and is showing progressive damage I think the safest thing is to do a ureteral reimplant. This is a very successful surgery(>90% success). Also, once the surgery has been performed, you may be able to discontinue the prophylactic antibiotics once the reflux has resolved and prevent any further scarring.
Talk to your Urologist to get his or her perspective, it is important that you and your doctor are on the same team.
This information is provided for general medical educational purposes only. Please consult your physician for diagnostic and treatment options pertaining to your specific medical condition. More individualized care is available at the Henry Ford Hospital and its satellites (1 800 653-6568).
Sincerely,
HFHS M.D.-AK
*keyword:Reflux
Dear Dinah,
. One of the most difficult decisions regarding a child with vesicoureteral reflux is deciding between medical and surgical management. Spontaneous disappearance of reflux is related to the age of the child and degree of reflux. It has been reported that 63% of grade two, 53% of grade three , and 33% of grade four reflux patients have resolved spontaneously if infection is controlled. Another study showed that in children of growing age that unilateral grade four reflux(what your child has) had spontaneous resolution 61% on the time, where as in bilateral patients resolution occurred in only 9%. Reflux that persists in adolescence or adulthood is unlikely to disappear spontaneously.
The most important issue with children with reflux is preservation of the renal function and allowing for normal and complete growth of both kidneys. This means avoiding infections of the kidneys to prevent harmful scarring. Sometimes patients are placed on longterm prophylactic antibiotic therapy as your son has. These regimens are usually safe as long they are tolerated well by the child. If your child were managed conservatively(medically) periodic follow-up studies must be done to ensure normal scar free growth.
Also a physical exam sure be performed an special inclusion of height and weight parameters and blood pressure measurements. If your sons height and weight parameters drop below the 5th percentile for age, this needs to be addressed by a medical physician. Laboratory studies should include a urinalysis and urine culture at each visit In terms of radiology tests, a IVP or ultrasound should be obtained every 18-24 months. After the initial VCUG has been performed to establish to current grade, a follow-up study should be performed to establish an interval relationship.
On the other hand surgery or reimplantation of the ureters is a very successful procedure. One should expect success rates as high as 95-98% in patients with normal caliber ureters and normal bladders. This drops to 54% when the ureter is markedly dilated which is seen in grade four reflux. The STING procedure involves injecting a bulking agent around the ureteral orifice. These procedures fails due to the lack of durability of the operation. A reimplant would a more durable choice(longer lasting).
There are several schools of thought on wether or not the reflux of sterile urine causes damage to the kidney and alters growth. The decision to proceed either with conservative medical therapy verses surgical therapy will largely be up to your Urologist and how he was trained. I don’t think there is a right or wrong decision however if inadequate follow-up could become an issue, the one time surgical procedure would probably be the safer option.
Since your son has only one kidney and is showing progressive damage I think the safest thing is to do a ureteral reimplant. This is a very successful surgery(>90% success). Also, once the surgery has been performed, you may be able to discontinue the prophylactic antibiotics once the reflux has resolved and prevent any further scarring.
Talk to your Urologist to get his or her perspective, it is important that you and your doctor are on the same team.
This information is provided for general medical educational purposes only. Please consult your physician for diagnostic and treatment options pertaining to your specific medical condition. More individualized care is available at the Henry Ford Hospital and its satellites (1 800 653-6568).
Sincerely,
HFHS M.D.-AK
*keyword:Reflux
