June 1st....SURGERY

Okay, So after a long day with Kynlee yesterday and discovering she will need to have to surgery to fix her VUR. She had a VCUG yesterday morning reveiling that her VUR has gotten worse not better. We then met with Dr. Strand following her VCUG and he checked her kidneys and they looked great. I have attached some information off of Childrens.com to share about what is going on with her. I hope you all find this informative. Her surgery is scheduled for June 1st at 7:30am and she will have to stay overnight in the hospital and hopefully be released the next day if all goes well. The exciting part is that she will be staying the night on the floor I work on. Yay! my friends will be her nurses and that makes the choice to do the surgery easier on me. Even though no mother wants their child to undergo any type of surgery, EVER.

Vesicoureteral Reflux (VUR)

What is vesicoureteral reflux (VUR)?

Vesicoureteral reflux occurs when urine dwelling in the bladder flows back into the ureters and often back into the kidneys. The bladder is the hollow, muscular organ that stores urine before urination occurs. The bladder has three small openings; two connect the ureters where urine is drained down from the kidneys, and one connects the bladder to the urethra where urine exits the body.

The ureters are funnel-shaped tubes that carry urine from the kidneys. Ureters enter the bladder at a diagonal angle and have a special one-way valve system that normally prevents urine from flowing back up the ureters in the direction of the kidneys. When a child has vesicoureteral reflux, the mechanism that prevents the back-flow of urine does not work, allowing urine to flow in both directions. This condition is most frequently diagnosed in infancy and childhood. A child who has vesicoureteral reflux is at risk for developing recurrent kidney infections, which, over time, can cause damage and scarring to the kidneys.

What causes vesicoureteral reflux?

There are many different reasons why a child may develop vesicoureteral reflux. Some of the more common causes include:

• VUR commonly occurs in children whose parents or siblings have the irregularity.
• Children who are born with neural tube defects such as spina bifida may have VUR.
• During infancy, the disease is more common among boys because as they urinate there is more pressure in their entire urinary tract. In early childhood, the irregularity is more common in girls.
• VUR can occur in children with other urinary tract abnormalities such as posterior urethral valves, ureterocele, or ureter duplication.
• VUR is more common in Caucasian children than in African-American children.

What are the symptoms of vesicoureteral reflux?

The following are the most common symptoms of vesicoureteral reflux. However, each child may experience symptoms differently. Symptoms may include:

• urinary tract infection (urinary tract infections are uncommon in children younger than 5 years and unlikely in boys at any age, unless VUR is present)
• trouble with urination including:
  • urgency
  • dribbling
  • wetting pants
• an abdominal mass may be detected from a swollen kidney
• poor weight gain
• high blood pressure

The symptoms of VUR may resemble other conditions or medical problems. Always consult your child's physician for a diagnosis.

How is vesicoureteral reflux diagnosed?

VUR can often be detected by ultrasound before a child is born. If there is a family history of VUR, but your child has no symptoms, your child's physician may elect to perform a diagnostic test to rule out VUR. Diagnostic procedures for VUR may include:

• voiding cystourethrogram (VCUG) - a specific x-ray that examines the urinary tract. A catheter (hollow tube) is placed in the urethra (tube that drains urine from the bladder to the outside of the body) and the bladder is filled with a liquid dye. X-ray images will be taken as the bladder fills and empties. The images will show if there is any reverse flow of urine into the ureters and kidneys.
• renal ultrasound - a non-invasive test in which a transducer is passed over the kidney producing sound waves which bounce off the kidney, transmitting a picture of the organ on a video screen. The test is used to determine the size and shape of the kidney, and to detect a mass, kidney stone, cyst, or other obstruction or abnormalities.
• blood tests

What is ureteral reimplant surgery?

Ureteral reimplant surgery is a procedure to change the way an abnormally positioned ureter, the tube from which urine leaves the kidneys, connects with the bladder. An abnormally positioned ureter can produce vesicoureteral reflux, the backflow of urine from the bladder into the ureter and up to the kidney. Normally, the ureter enters the bladder, which is made out of muscle, in such a way that urine is allowed to enter the bladder but not allowed to back up to the kidney. Reflux occurs when the ureter enters the bladder abnormally. As a result, the muscle backing of the bladder doesn't completely cover the ureter and urine flows back toward the kidney.

Are any artificial parts used in ureteral reimplant surgery?

No. The original ureter is surgically re-positioned or reimplanted in the bladder wall. The end of the ureter is surrounded by bladder muscle in this new position, which prevents urine from "backing-up" or refluxing, toward the bladder.

Where is the incision?

A small incision is made in the lower abdomen (below the bikini line). All stitches are dissolvable. Occasionally, there may be one stitch in the skin to secure a catheter that will be removed. A clear plastic dressing that will be removed two days after surgery will cover the incision. Little pieces of tape, called "steri-strips," along the incision eventually will curl up and fall off. You may begin bathing your child after the dressings have been removed and all catheters are no longer in place.

Are any tubes left in place after the surgery?

A bladder catheter usually is placed to be sure urine is draining well while healing takes place. This is removed two to three days after the surgery or after the epidural catheter is removed. A catheter in the ureter may be left in place that comes out through a small incision in the abdomen. Once it is removed, a small gauze bandage can be placed over the site, which should heal very quickly. Fluid may leak from the site for a day or so, which is normal.

How long will the surgery take?

The surgery takes about two to three hours. The surgical operating room nurse will give updates on the status of your child's surgery.

What can I expect after the operation?

Many children will have caudal or epidural nerve blocks - pain medications administered through tubes in the back so they wake up without pain. Alternatively, your child may be a good candidate for a patient controlled analgesia (PCA) pump. This involves infusion of the pain medication intravenously to maintain a more consistent level of pain medication. Please ask your anesthesiologist what is the best form of pain control for your child. A prescription for pain medication - usually Tylenol with codeine -- that can be taken orally will be given at the time of hospital discharge.

Will my child have any problems urinating after surgery?

It is common after this type of surgery that a child experiences bladder spasms or intermittent cramping, urinary frequency, urinary incontinence and losing small amounts of blood-tinged urine. If the symptoms become a problem, a medication called Ditropan (oxybutynin) may be prescribed. It won't eliminate all spasms, but should decrease discomfort. Having your child sit in a shallow tub of warm water may provide relief. Placing a damp warm washcloth on the perineum also may make your child more comfortable.

Older girls and boys may get upset if they experience loss of urine control, especially if it is blood-tinged. Your child could wear light mini-pads in his or her underwear until this problem resolves. In some children, the urinary frequency and bloody urine may continue for two to three weeks. This is normal. Reassure your child that control will return as the bladder heals.

Are there any problems that I should be looking for?

Please contact the Pediatric Urology office at UCSF Children's Hospital at (415) 353-2200 if you have any concerns about your child's progress after surgery. If your child exhibits any of the following, call our office:

• Temperature greater than 101 degrees F
• Excessive bleeding from the incision (some spotting, or blood stains on the dressing, is normal)
• Extreme irritability
• Inability to tolerate liquids
• Continuous vomiting
• Inability to urinate

What side effects do the medications have?

Ditropan (oxybutynin) may cause flushed cheeks, warm skin, dry mouth and decreased appetite. A poor appetite is not unusual but we ask that you frequently offer your child fluids - a few sips every 15 minutes or so -- to maintain adequate urine output. Offer Popsicles, Jell-O and soup, if your child enjoys these. Smoothies made of blended fruit and yogurt are a terrific source of vitamins and usually are well tolerated. You may need patience and persistence as you offer fluids. Sometimes, offering your child's favorite foods can help return an appetite.

Morphine, Droperidol or Demerol are among the medications your child may be given while in the hospital. Droperidol or Compazine also may be given for nausea, vomiting and pain. These medications may make your child drowsy. Some children react to pain medication by becoming overexcited and nervous or developing a rash. If this happens, tell the nurse and the medication will be changed.

Before discharge, the medication will be switched to Tylenol with codeine (Tyco). This comes in both tablet and liquid form. The codeine part of this medication makes some children constipated, so it's important to encourage your child to be as active as possible, and to provide plenty of liquids, fruit and vegetables. Gradually, you can start to manage your child's discomfort with plain Tylenol or with Children's Motrin. Within a few days to a week after discharge you should begin to notice your child feeling more like him or herself.

What is the follow-up after surgery?

Your child usually will be discharged on the second to fourth day after surgery, depending on your child's recovery. If a drain or catheter is in place, please make an office appointment for one week after surgery to remove it. If there is no drain, schedule an appointment for four to six weeks after the surgery. Children usually have an ultrasound at the time of the follow-up appointment. It's important that your child continue the low-dose antibiotics. You may be given the Ditropan and Tylenol or Tylenol with codeine to relieve spasms during this time before your return visit. The antibiotics given at the time of hospital discharge should be completed by this visit and your child should resume taking his or her pre-operative maintenance antibiotic daily.

One month after the surgery, your child will be scheduled for an ultrasound of the kidneys. This test tells us if there is any blockage at the site of the surgery. It doesn't let us know if the reflux is corrected; only a cystogram can show that. Four to six months after the surgery, your child should have a voiding cystogram (VCUG). If both of these studies are normal and reflux has resolved, your child may discontinue the low-dose, maintenance antibiotics. Your child should then visit us for a follow-up in one year for a blood pressure test and to check the kidneys with another ultrasound.

Will my child have any more urinary tract infections after the surgery?

Some children are particularly prone to urinary tract infections for unknown reasons. They may continue to get infections even after a successful surgery. However, the difference is the infected urine doesn't back up into the kidney. This should prevent kidney damage. These children typically don't have a fever with these infections.