A 8 month male baby presents with fever & cloudy urine. After evaluation, the following findings were documented: UTI, USG-left side moderate HDUN, MCU-VUR G-2 on right side, no PUV, IVU-left side gross HDUN, renal scan-normal. Growth of baby is normal. Now the child is on prophylactic antibiotic, having frequency of micturition but urine flow is good.
Re-implant left ureter, continue chemoprophylaxis.Follow up DTPA scan at 3 months post-op. The child will need chemoprophylaxis till his reflux disappears (may be followed up with DRCG).
It may be re-ımplant left ureter if fever and urinary infection continue chemoprophylaxis in addition if follow up DMSA appear scar .THe patient can follow by renal ultrasonograpy.Prophlaxı is necessary.
Majority of the uvj obstructions do resolve spontaneously unless the grade is 3 of the Pfiestr Hendren classification. as far as the Gr 2 VUR it is conservative treatment
I would like to have a MAG3 diuretic renogram, in order to decide a conservative management if DRF> 40, or surgical management if DRF
Re-implant the left ureter. If the child has not had penile circumcision recommending one, if not other contraindication will be important in order to decrease the risk of UTI and attendant renal scarring. Educating the caregiver on seeking medical help at the first illness which may be UTI may be more beneficial than long term prophylactic antibiotic. Also avoid constipation in this child
VCUG is not a suitable investigation to exclude posterior urethral valves. A male with unilateral reflux and dilatation on the other side is always suspected for PUV. Question is therefore: if he is clinically in perfect order, probably nothing needs to be done. If he has any sign of abdominal discomfort, straining, colics suspect PUV and do a urodynamic study or a cystoscopy to make sure that no PUV exist.
What kind of renal scan did you do, DMSA or MAG3? Scan is normal means, as I presume, that function is 50/50, also creatinin is suposed to be normal to be able to do nothing except probably trimethoprim profylaxys for a few months.
As the main question suggests, if the left side is obstructed it need a surgical repair, and at 8mo a ureteric neoimplant should be the right solution. Now, even though a GII VUR at that age could be follow with antibiotic, having the child on the table in theatre, I would recommend to inject that side and get a complete solution to the child and the family
Dear Zahid,
If there is no VD, VUR and UVJO could be managed as if they were separate.
VUR to be left alone. Good Ultrasonography with following parameters required. Kidneys-parenchymal thickness compared to opp side, Ureter(left) dilatation,bladder trabeculations and Dilatation of post urethra. If there is thinning of left parenchyma or significant dilatation of ureter where re-implantation cannot be done Cystoscopy to rule out PU valves should be done along with ureteric diversion if no PU Valves. circumcision will be welcome. After 2 years UDS should be done and followed by ureteric reimplantation.
Dear Paras, What do you mean by the statement that reimplantation cannot been done?
As the child is asymptomatic now, conservative trial may be advocated. Long term management would essentially depend on
I. US findings TPD /ureteric dimensions / parenchymal thickness
ii. DTPA scan showing the pattern of drainage - VUJ obstruction can be deduced
iii. serial imaging
iv. development of symptoms
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