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Urology (Expert Forum)
Ureteral Reimplantation or Callagen Implant for Vesicoureteral Reflux
Answered by
Kevin Pho, MD - Internal Medicine
Kevin, M.D.
Boston - MA
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.
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Ureteral Reimplantation or Callagen Implant for Vesicoureteral Reflux
by JeanneRC, Apr 18, 2004 12:00AM
My daughter will be seven in June and has been on antibiotic prophylaxis since she was 2 1/2, when the reflux was discovered. She has level 2 to 3 reflux on one side and level 1 on the other. She had only one breakthrough infection 3 years ago because we went on vacation and did not give her the antibiotic for 4 to 5 consecutive days. Through the years we have not been perfect in giving her the daily dose, and on more than one occassion have missed giving her the dosage for up to 3 days. (She's currently taking a daily dose of cephalexin 250mg/5ml susp 100ml). She has never had an infection again. She has no bladder instability, voiding problems or constipation. Her urologist recommended surgery or the collagen injection last year but I decided to wait one more year, with the doctor's consent of course, in the hopes that the reflux would correct itself.
It's been a year and the reflux has not gone away (we just received the results of her yearly nuclear VCUG) and my doctor tells me that it is unlikely at her age that it will. She has no sign of renal scarring in the ultrasound (accuracy of test?) and I am hesitant in operating her.
Are there any references or studies that show it has gone away in older children?
How many years can a child/person take a prophylaxis? Are we ruining my daughter's immune system? What are the long term side effects, if any, of the daily antibiotic for so many years?
What if I don't give her the antibiotic ever again and she does not develop a UTI? Can she still get renal scarring if no infection is detected? Doesn't the renal scarring usually happen in infancy? How much damage can happen to her kidneys at her age with a level 2-3 reflux in 1 year's time if I don't give her the antibiotic? We can do a VCUG in 1 years time if no infection occurs before then?
Isn't the reimplantation surgery only recommended for levels 4 and 5? And, because she is low grade, is the collagen a better option, if any? I'm not sure of the effectiveness of the collagen injection. What are the possible complications of the surgery VS those of the collagen injection? And how does the doctor know what type of reimplant needs to be done in surgery? This can't be seen in a VCUG, correct?
Please help!
It's been a year and the reflux has not gone away (we just received the results of her yearly nuclear VCUG) and my doctor tells me that it is unlikely at her age that it will. She has no sign of renal scarring in the ultrasound (accuracy of test?) and I am hesitant in operating her.
Are there any references or studies that show it has gone away in older children?
How many years can a child/person take a prophylaxis? Are we ruining my daughter's immune system? What are the long term side effects, if any, of the daily antibiotic for so many years?
What if I don't give her the antibiotic ever again and she does not develop a UTI? Can she still get renal scarring if no infection is detected? Doesn't the renal scarring usually happen in infancy? How much damage can happen to her kidneys at her age with a level 2-3 reflux in 1 year's time if I don't give her the antibiotic? We can do a VCUG in 1 years time if no infection occurs before then?
Isn't the reimplantation surgery only recommended for levels 4 and 5? And, because she is low grade, is the collagen a better option, if any? I'm not sure of the effectiveness of the collagen injection. What are the possible complications of the surgery VS those of the collagen injection? And how does the doctor know what type of reimplant needs to be done in surgery? This can't be seen in a VCUG, correct?
Please help!
Doctor's Answer
by Kevin Pho, MD, Apr 19, 2004 12:00AM
, Apr 19, 2004 12:00AM
Both medical and surgical management of severe reflux appear to be of roughly equal efficacy and choosing between these options is dependent upon clinical judgment. Medical therapy in such children includes daily prophylactic antibiotics which are usually continued until the reflux resolves (as determined from annual radionuclide cystography), the child reaches the age of five to seven, the time at which repeat infection, if it occurs, is unlikely to produce new scars.
Surgical correction of VUR should be individualized and is probably indicated in the following settings:
* The presence of gross reflux and ureteral dilatation in a young child (particularly if under two years of age) even without marked scarring, since new scars will develop in up to 60 percent of these cases.
* A child who becomes infected and shows new scars because of incomplete compliance with medical therapy.
* A family that elects surgery, because compliance with daily antimicrobial therapy is too difficult to achieve or adequate follow-up is difficult for geographic reasons.
* Women with continuing reflux have an increased risk of urinary tract infection during pregnancy. Since it is difficult to predict the potential morbidity in such patients, many clinicians recommend surgical correction in girls with reflux that persists at puberty.
Regarding long-term use of antibiotics - there is the risk that the bacteria may become resistant to the antibiotics. There is also the risk of a type of colitis known as C Difficile - caused by a change in the bacterial flora due to the chronic antibiotics.
Followup with your personal physician is essential.
This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.
Thanks,
Kevin, M.D.
Bibliography:
Rose et al. Diagnosis and treatment of vesicoureteral reflux and chronic pyelonephritis. UptoDate, 2004.
Surgical correction of VUR should be individualized and is probably indicated in the following settings:
* The presence of gross reflux and ureteral dilatation in a young child (particularly if under two years of age) even without marked scarring, since new scars will develop in up to 60 percent of these cases.
* A child who becomes infected and shows new scars because of incomplete compliance with medical therapy.
* A family that elects surgery, because compliance with daily antimicrobial therapy is too difficult to achieve or adequate follow-up is difficult for geographic reasons.
* Women with continuing reflux have an increased risk of urinary tract infection during pregnancy. Since it is difficult to predict the potential morbidity in such patients, many clinicians recommend surgical correction in girls with reflux that persists at puberty.
Regarding long-term use of antibiotics - there is the risk that the bacteria may become resistant to the antibiotics. There is also the risk of a type of colitis known as C Difficile - caused by a change in the bacterial flora due to the chronic antibiotics.
Followup with your personal physician is essential.
This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.
Thanks,
Kevin, M.D.
Bibliography:
Rose et al. Diagnosis and treatment of vesicoureteral reflux and chronic pyelonephritis. UptoDate, 2004.
Member Comments
by ParkerP, Jun 12, 2004 12:00AM
To: Pediatric Urology
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