Antibiotic prophylaxis and wait until toilet trained age

Dear Dr Hossain,

make sure that the post urethra is not dilated and you are not missing PUV. If the infant had a UTI I'l consider a circumcision (to reduce the risk of UTI) +- Bil STING.

Can it have some sense to think about a refluxing ureterostomy? In a so little boy sting may be difficult to achieve

Agree with antibiotic prophylaxis and waiting.

Is a boy or girl? if it is a boy PUV must be excluded and adhesions liberated or circumcision performed.

Boy or girl, obstucting ureterocele must be excluded too.

If no obstruction, ATB and wait.

If breakthrough UTIs, Deflux to cure or reduce the grade of reflux

Antibiotic prophylaxis to prevent recurrent UTIs and if breakthrough UTIs, consider Deflux procedure. If remains UTI free, repeat Renal US+/-DMSA scan and VCUG at 1 yr, also follow renal function. If scarring present and no improvement in VUR, consider Deflux or reimplantation to avoid further scarring. If no scarring, would continue prophylaxis and follow.

first rule of urethral obstruction (PUV)

if no obstruction, give prophylactic antibiotic and wait 4 to 6 months and follow

If persistent urinary infection or renal scarring develops is necessary to consider the ureteral reimplantation

No PUV ,the child is a boy of two months age.We have no Deflux.I have started prophylactic antibiotic and considering for circumcision.

OK, just keep monitoring, if infection persists or develops scar in the Control DMSA consider ureteral reimplantation

Little bladder and large ureter (ectopic implantation ? Cystoscopy?) , just wait under antibioprophylaxis, renal scintigraphy (function survey) every 6 months and surgical reimplantation after 1-2 years

Merits investigations. I would consider Grade IV & Grade V VUReflux (higher grades) to be completely a different surgical entity as compared to lower grades of VUR (I / II & III - essentially medical). Thus in this case I would be aggressive. Urine exam (routine and culture) followed by an MCU study (micturating cystourethrogram) under cover of antibioitc scheduled one day prior to a CYSTOURETHROSCOPY study. A Renal Scan (DMSA) is in in order as well even if no scars - as baseline). The reason I would be aggressive at least in investigations is because as I mentioned earlier, I would consider Gr IV & V VURelfux an entirely different entity. Further more I would like to be sure there is no anatomical abnoramlities namely paraurethral diverticulums / bladder outlet obstrucitons (which need early surgical interventions). Furthermore these can be so easily missed on an Ultrasound study esp if done with a period of starvation or after child having urinated. Hence need to be aggressive at least in investigations.

Done all possible investigations,no scaring in DMSA ,only VUR5 and UTI.

In every VUR , we should focus on the voiding pattern of the patient. We all have seen patients with VUR due to abnormal voiding (dysfunctional voiding, Neurogenic bladder,......). Indeed in this case , I think about Megacystis Megaureter and incomplete prune-belly syndrome.

In contemporary management, cystoscopy has no rule,except prior to endoscopic treatment.

AB, culture and DMSA follow are good but with very close monitoring because he has high grade bilateral VUR in early infancy. I think any doubt in their adherence to this close follow up should be translated to intervention.

Is there any role of Refluxing ureterostomy or vesicostomy ?

If possible please look for a spina bifida , i had such a case like You concerning VUR.

As old urologist it is the question to make a small suprapubic fistula to improve th function of the kidneys - as far as possible. If the parenchym of kidney is o.k. than You should make as soon as possible an antireflux plastic as You make it usualy, first on the side with less function and wait some month to do the same on the other (better functional) side. Drugs and awit and see is in a case where operation can only be seen "as causal therapy" not so good advice.

I think that we must consider two important points : 1- most of these young infants will expriense cure or significant improvement of VUR until 12mo old and 2- the success rate of interventions is low , and complications rate is high in infancy.

in conclusion I belive that F/U with close monitoring of baby ( with U/A , U/C , growth and BP measurments) and prophylactic AB plus DMSA scan in 6mo of age is all of that need.

This ptient will surely require suregry.. But defer it till 1 year!! Keep the patient on anti-biotic prophylaxis, Reglar DMSA (for fresh scarring), Blood Renal profile!! In case of scarring, operate otherwise wait till 1 year then operate!

I would first recommend an antibiotic therapy of the UTI followed by an contineus antibiotic prophylaxis. Despite the high grade VUR, your patient is in a moderate risk group (because of age, no toilet-taining, male). A spontaneus resolution may be higher in males, that why you should follow-up him closely (recurrent UTI, worsening of the renal function etc.) and repreat the full evaluation after 12 months. In case of breakthrough infection, I would recommend an surgical intervention.

Disappearance of Higher Grades of VUR is known to surgeons but does not happen in every case ;the need for observation for spontaneous disappearance is emphasized. The indications for surgery is well known

Kindly note following points:

1) VUR by itself is not threatening or damaging. Its the triad of obstructive uropathy / bacteruria and VUR that is threatening.

2) Beyond four years no prophylaxis is of merit. Why is it so?

3) By the age of four years a definitive plan if at all surgical must have been instituted; Beyond four the damage is already done (again answer is in relation to the second point)

4) Need to worry about effectively untreated VUR in case of pregnant females which may lead to substantial morbidity. However other than pregnancy, in rest of adults VUR is not worrisome at all if there is no continued obstruction or bacteruria. This is extrapolated from the fact that in Renal Transplantation the Ureter is re-implanted in a simple fashion with no attempt at providing anti-VUR mechanism.

AT the end I reiterate my stand:

Gr IV & V VUR is surgical entity; paediatricians should be made aware of same.

Gr I-III is medical and can be managed by paediatrician after due investigation and at least one / two paed surgical / urologic consultation

It is adebatable case in spite of presence of scientific guidline recommendations . the taloiring of these gudlines are always depends on the experienceof urologist.

I think for this case to is to follow up strictly by culture and senstinty test to choice the best antibiotic for treatment and prophlaxis, montoring of renal function with diagnosis of renal scar by DMSA, Cirumscision is recommended with searching of any neurological causes. Surgery better to delay for 1-2 years old

At first wait and see

I want to focus on exclusion of spina bifida occulta and other occult neurologic lesions i.e teethered cord+ Doing urodynamic. Exclusion of neurologic cause is mandatory before embarking on VUR surgery. If there is neurogenic bladder patient may need other type of surgery as Metrifanof other than ureterovesical re-implantation

grade v VUR is almost always a surgical diagnosis, and I would not expect a significant improvement. The exact therapeutic strategy (reimplantation of the ureter or injection at the ureteric implantation site in the bladder) will depend on the exact anatomy in this child.

Assess the bladder for trabeculation. Assess the pt for neurogenic bladder. If none, the bilateral Grade V will require surgical intervention. If the patient can afford it multiple deflux injection is the method of choice at this age as reimplantation is not easy and the floppy upper ureters may give problem post op. Yes, antibiotic prophylaxis is needed. Radioisotope study : MAG3 Scan should be done to document the baseline function of both kidneys.

Deflux in grade V is fooling the patient if not onself (the surgeon). I reiterate my earlier stand - Grade IV & V is a different entity as compared to I, II and III. While the first three are medical, the IV and V are surgical entities and should be monitored by a surgeon. Surgical consult in all cases does not necessarily translate into surgical intervention.

Prempuri has presented his success with multiple Deflux injection for Grade V contrary to our initial understanding. It is well documented. This success have been replicated in other centres. But it will incur cost. I will not be sharing something uncertain and amounting to a fool's exercise. I appreciate comments but not labelling. Grade 1 and II does not need any treatment. Grade IV and V requires multidisciplinary team approach both by surgeon and paeds nephrologist. I appreciate variety of management by colleagues around the world but no downgrading please.

I think I have been misunderstood. I literally meant "fooling" ourselves (as surgeons) and not labelled anyone as foolish. Let me explain. Multiple sittings of Deflux would not amount to definitive treatment esp in GR IV & V Reflux where the child is "ill". People have gone to the extend to say that GR IV & V reflux would disappear on its own managed conservatively; we may consider no Surgery in children that are not unwell and followed up very carefully with scans and urinalysis. However in "sick kids"are we as surgeons to believe that? Multiple Deflux sittings done in relatively less "ill" children where in choice of Surgical Rx and NO real Sx Rx may have similar end effects!! No arguement with that - but how is one to know without objective evidence?

Unfortunately as surgeons we get late referrals when child has been ill for a while. I tell my paediatric colleagues to make early references by convincing them that "early surgical consult need not lead to surgical intervention in every case".

Also pls understand that this is an infant 45 days old and likelihood of child getting "sicker" with every febrile episode not mention damage to kidneys. Radical surgery needs to wait till child older. In the meantime we have to protect the child and developing kidneys esp if there are multiple episodes of UTI. Desperate situations call for desperate measure.

In fact this is ideal case for Detrusorrhapy (which was abandoned due to high recurrence rates)- one side at a time (first on side with more severe reflux ) esp if one could accomplish same by laparoscopy otherwise open surgery - Incision is very small (half of Pffanesteil) without need to mobilize too much of bladder thus avoiding denervation. takes about an hour, with minimal hospital stay. Detrusorrhapy is thus ideal as this would not only help tidy over the untoward effects of reflux on developing kidney while child and kidney grows, but also may end up as definitive Rx esp in smaller infants.

Thank you for your explanation. Let me share with you our experience. We had similar cases. None of our neonates or infant less than 3 months old with Bilateral Grade V VUR is asymptomatic till they are beyond one year old. Somehow they will present with recurrent UTI and some episodes are life threatening despite being on oral antibiotic prophylaxis. I am not advocating surgical intervention at 45 days old. For Dr Zahid Hossain, if your patient does present with UTI eventually (let us know if your patient does not have UTI till over one year old), we have had success with Single injection of Deflux per VUO in bilateral Grade V. We also had success at bilateral reimplantation in patients less than 6 months old with history of recurrent urosepsis. As we practise Cohen's reimplantation, the limitation would be the length achieved when crossing the trigone. The tortuous ureters needs to be straightened as much before reimplantation otherwise the upper floppy and dilated ureter can kinked the distal end of the ureter as in one of our patients who presented with worsening hydronehprosis on one side and required a post op insertion of double J stent (antegrade insertion) after the temporary ureteric stents were removed. I am sure there are experience out there where patients with severe VUR grade V bilaterally do not have UTI till older age. That would be good news for the surgeons there.

Hello Dr.Dayang Abdul Aziz /Dr.Jahoorahmad Patankar,

Many many thanks for your knowledgeable discussion and informations.My patient is now about 9months,he had already two documented UTI but no scaring yet.We have no DEFLUX..I like to do bilateral reimplantation(Plitano-Leadbetter method) with ureteric tailoring and D-J stent in-situ for 4 weeks.What do you think?

Could you mail us the latest MCU images pls.

Dr Hossain, May I know the differential function of each kidney please? and whether patient has signs of neurogenic bladder from the ultrsound and the MCUG? These 2 informations will change the treatment plan. Personally I am not an expert at PL Method. I imagine both ureters are very dilated and tortuous for you to keep the double J longer.

Differential function:Rt.kidney-48%,Lt.kidney-52%,No sign of neurogenic bladder except occasional dribling of urine,MCU shows refluxing megaureter,nodiverticulum,no trabeculation bladder size seems to be adequate for the age.S.creatinine-0.6mg/dl.We have no scope to do Urodynamics in small children to exclude neurogenic bladder.

Always do a cystoscopy before you embark upon reimplantation. You may choose any of the reimplant procedures you are comfortable with - ureteric stents for 4-6 weeks and indwelling catheter anywhere 7-10 days; may be removed earlier if you are comfortable esp in female child.

Thank you for the info on the function of kidneys. The stent is useful for at least one month. In my practice, in cases like this, i will repeat ultrasound before removing the stent. There should not be worsening of hydronephrosis. I usually repeat the MCU and MAG3 scan after 6 months. I do repeat the ultrasound abt 1 month post removal of stent in cases with ureters like this. Good luck.

Many many thanks for your valuable advice.

You're most welcome. Hope this helps.

Antibiotic therapy and VCUG at 1 year of age ( except breakthrough infections).

I think must exclude infravesical obstruction as ureth. valves then proceed .