What is reflux?
Vesicoureteral reflux describes a condition where the urine goes backwards from the bladder into the tubes ("ureters") that usually bring urine from the kidneys. This occurs when there is an abnormal insertion of the ureter through the bladder wall into the inside of the bladder. Some children with abnormally high pressures in the bladder also have reflux despite a normal insertion of the ureter into the bladder.
How do I know if my child has reflux?
Many children with reflux will develop a urinary tract infection. As part of the usual evaluation of a child with a urinary tract infection, a special study called a "voiding cystourethrogram" or "VCUG" should be performed. A VCUG is done by placing a catheter in the bladder and filling the bladder with contrast material that can be seen on an X-ray. If the child has reflux the X-ray will show the contrast material move out of the bladder and go up into the ureter (this often happens when the child urinates). About a third of the siblings of a child with reflux will also have reflux. A screening cystogram of siblings is therefore recommended even if they have not had a urinary tract infection. Other children are found to have a dilated kidney on prenatal ultrasound and a VCUG obtained after birth detects reflux.
What does reflux do?
Reflux is associated with kidney damage. A large number of children who have kidney failure have reflux. The kidney is damaged in children with reflux by infections which scar the kidney. Children with reflux are more likely to develop kidney infections; however, these infections can often be prevented by placing the child on an antibiotic. In general, almost all children with reflux should take a daily antibiotic.
Is surgery necessary?
Most children with reflux will "outgrow" their reflux without surgery and the only treatment required is a daily antibiotic until the reflux is gone. A VCUG is usually performed on a yearly basis to see if the reflux has gone away. When reflux is due to high bladder pressures, treatment should be aimed at decreasing these pressures. Children with severe reflux, or those with a urinary tract infection despite taking an antibiotic, should undergo surgery to prevent reflux and decrease the chance for any further kidney damage. Most children who don't outgrow reflux after 4 or 5 years on a daily antibiotic will undergo surgical correction of their reflux.
What types of surgery are there for reflux?
Surgery for reflux usually requires an incision made in the lower part of the abdomen just above the pubic bone. There are multiple different techniques for creating a new insertion of the ureter into the bladder (called a "reimplantation"). Some of these techniques involve opening the bladder and others can be performed without opening the bladder. Your child's surgeon should be familiar with all of these techniques in order to pick the best one based on the child's reflux and anatomy. The rate of cure following these operations is about 95%.
An alternative to an open operation involves looking into the bladder through the urethra with a lighted telescope. A material called Deflux can be injected through a needle in the scope underneath the refluxing ureter. The success rate with this technique is not as high as with the open surgical correction; however, recovery is much faster and most children will go home on the day of surgery.
What can I expect following a ureteral reimplantation?
In general, a catheter will be left in on the day of surgery and removed the following day. Most children will not require any other tubes. On occasion, a stent or catheter is placed up the ureter to prevent blockage. This tube will be removed several days after the operation. Most children will feel well enough to go home within 2 days following their operation. Children are kept on their daily antibiotic until a postoperative ultrasound is performed 4-6 weeks after the operation.
What are some of the specific complications with ureteral reimplantation?
A few children will develop blockage of the ureter following reimplantation. In general this is temporary and will resolve with drainage. Some children will have difficulty with urination or wetting following the surgery which is also usually temporary. In the rare child who has persistent reflux, a second surgery or further evaluation of their bladder to make sure that it is functioning properly may be required..