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ureter problem
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ureter problem

  My child has a ureter problem.  His right kidney is 6.6 cm and the left kidney is 7.4 cm.  The left ureter is straight instead of being slightly bended.  The ureter is wide in width and the urine keeps going back to the kidney.  I was told he is in the fourth critical stage?  What is this condition called and is surgery necessary?  
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Dear Chris,
It sounds like your child has vesicoureteral reflux.  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.  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.  Laboratory studies should include a urinalysis and urine culture at each visit  In terms of radiology tests, an 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.
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
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