Bilateral Grade V reflux

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  • Dr. Anil Takvani
    Dr. Anil Takvani
    05 Feb 2020 03:48:48 PM

    Dear Prashant.

    Excellent case, difficult to understand.
    Would like to have E-GFR, DMSA scan for better understanding of damages to kidneys.
    If available video-UDM or UDM oly to understand storage and emptying of bladder.
    His high PVR and persistence of huge reflux with bilateral tortuous and dilated ureters points towards bladder issues(Non neurogenic voiding dysfunction)

  • shriram joshi
    shriram joshi
    05 Feb 2020 09:45:32 PM

    Dear Prashant,

    1. This is bilateral Gr. V reflux with a normal capacity bladder, not trabeculated. Normally sited ureteric orifices do not perclude gr V reflux. VUR depends on poor intramural length. The old classification based on ureteric orifices has long been discarde of any significance. 
    2. I was wondering about an outlet obstruction, but your cystourethroscopy rules this out including any bladder neck stenosis. 
    3. The reason for his large residual urine is urine returning back into the bladder post void from the dilated upper tracts. 
    4. with near normal bladder capacity question of augmentation does not arise.
    5. DMSA scan will show you differential function and scars if any in view of recurrent uti and resistent e.coli infection. You should have this preoperatively, then growth of the kidney can be followed up with post op USG and DMSA scan.
    6. If do not correct the gr V vur with resistent ecoli, will destroy the kidney function. Hence to prevent recurrent uti you will need remodelling and reimplantation of both ureters.
    Lastly in your excellent documentation, you have not mentioned any neurological 
    deficit, so neuropathic bladder is unlikely, combining with the above 

  • Dr. Anil Takvani
    Dr. Anil Takvani
    05 Feb 2020 10:39:21 PM

    Dear Sir, 

    Do you have any doubt of non neurogenic voiding dysfunction in this case? 
    Sir, poor emptying is not only suggested by USG but we can see very large residual urine in VCUG also. 
    We need at the least Uroflowmetry in this case. 

  • Rahul Kapoor
    Rahul Kapoor
    05 Feb 2020 11:05:47 PM

    In grade V vur, high PVR can be due to flow of urine from upper tract after voiding. I feel

    So a smooth bladder suggest VUR and a trabeculated and thickened bladder suggest BOO. 

  • Dr. Anil Takvani
    Dr. Anil Takvani
    06 Feb 2020 12:04:29 AM

    I agree with Prog. S S Joshi Sir and Rahul on pseudo high residual but how to explain very high residual seen in VCUG? 

  • Rahul Kapoor
    Rahul Kapoor
    06 Feb 2020 07:49:38 AM

    So in this case we will proceed with anti reflux sugery. 

    1. Any specific preference. 
    2. How much ureter needs to be mobilises. e.g in case of tortusity some suggest to mobilise whole ureter even upto pelvis while some just manage the lower end and believe  that ureteral tortusity gets corrected with time 

  • Dr. Anil Takvani
    Dr. Anil Takvani
    06 Feb 2020 08:17:18 AM

    I think we still need to work on this case for persistence of such a huge reflux before we go ahead with bilateral tapering and reimplantation.

    Also DMSA scan is must prior to decision of surgery...
    One I am sure , we are going ahead with surgery I taper only last 6 to 7 cm of ureter, which generally goes in to the intravesical tunnel.... 

  • Dr Mitul Parikh
    Dr Mitul Parikh
    06 Feb 2020 01:12:00 PM

    This child is 7 yrs old and his S.Crt is 1.1, so his kidneys must have been damaged.

    His bladder has never undergone complete cycling due to high grade reflux and upper tracts emptying after voiding. So high grade reflux itself can lead to abnormal bladder pressures.
    After DMSA, I would go for Bilateral ureteral reimplantation with tapering.
    Is his Blood Pressure normal?

  • Dr. Anil Takvani
    Dr. Anil Takvani
    07 Feb 2020 06:44:56 PM

    Link of very relevant article from Prof. Sang Won Han of Korea.
    It has focused on bladder dysfunction associated with VUR and
    VUR as a cause of Bladder dysfunction (Last paragraph)


  • Dr Prashant Mulawkar
    Dr Prashant Mulawkar
    07 Feb 2020 08:48:34 PM

    Dear All,

    Thanks for the comments.
    Blood pressure I have not measured. Will do once he comes back
    If you see the MCU plates sequentially as shown in presentation, it is the ureters which fill first and then bladder fills.
    Although he presented with palpable bladder and high PVR, during MCU and during cystoscopy, the bladder did not get filled up well. Bot it was NOT trabeculated. It is possible that this might be due to infection.
    DRE (PR) NAD, anal tone is good, no fecoliths, no bowel complaints, so I do not suspect BBD. Neither does he have neurological findings. 
    I do not know what to expect on UDS. 
    I would be skeptical in reimplanting in this bladder

    No you need not dissect the whole ureters even if they are tortuous. Just dissect what is necessary.
    Yes, He will ned tapering, but I have not yet decided the method of tapering, but mostly it would be Hendren's to reduce the bulk of ureter.
    The boy has gone home and is expected to come back after a week. So will update later

  • Dr. Anil Takvani
    Dr. Anil Takvani
    07 Feb 2020 08:56:52 PM

    Thanks Prashant. 

    Why you are skeptical while doing reimplntation surgery in this case of yours? 

  • Dr Prashant Mulawkar
    Dr Prashant Mulawkar
    07 Feb 2020 08:57:08 PM

    Which would be the best center to do UDS for this patient? I mean to ask, who has experience in doingthis kind of UDS? (Can reply on my personal number also)

  • Ravindra Sabnis
    Ravindra Sabnis
    13 Feb 2020 07:23:21 AM

    I feel Dr. SSJ sir has sumnerised all problems & solutions extremely well.   I feel he does not need UDM - nothing will change after UDM.  He needs reimplant with tapering.  No extensive dissection of ureters.  It will be counterproductive.  Toutuocity will go once reflux stops. Favourable things in this case are - good capacity, no trabeculations.  

    If this child was in sepsis, & /or renal failure, I would have done bilat sober's cutaneous uretetrostomies.  

  • Uday Sankar Chatterjee
    Uday Sankar Chatterjee
    16 Feb 2020 10:09:30 AM

    As the patient has got high PVR and palpable bladder and normal cystoscopy, I think UDS is necessary, although high compliant ureters may create fallacy, in spite of that, in this situation high Pdet max and high Pdet Qmax might indicate BNI.

    I think Renal Scan  is necessary for monitoring GFR,; pre and follow up. In this regard, e-GFR is not so accurate in pediatric patient.

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