BL High Grade VUR, what next?

4 year male with B/L high grade reflux with poorly functioning right kidney, what should be done next, B/L reimplantation?, Continue Chemoprophylaxis, Or Left Re-implant with right nephrectomy? 

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  • Dr. Anil Takvani
    Dr. Anil Takvani
    29 Oct 2020 08:55:55 AM

    Thanks for very interesting case Sumeet.

    I would have certainly avoided CT scan, as you can see it has not added anything which can help you in making diagnosis or in treatment dilemma.CT IVU has exposed this kid to significant radiations without any additional benefits. IVU and CT IVU, these investigations have no role in investigation algorithm of VUR.
    DTPA is also waist and adds radiations once you did an excellent VCUG depicting bilateral VUR with no evidence of refluxing and obstructing megaureter.
    In my view this is a case of bilateral primary VUR.
    Right side kidney has dysplasia/hypoplasia related to high grade reflux as it is global shrunken kidney with some evidence of pyelonephritic lesions.
    Left is grade 2/3 reflux.
    As patient has couple of history of febrile UTI, He is >4 year and DMSA shows evidence of pyelonephritic changes I will go ahead with ureteric reimplantation.
    I will do bilateral reimplantation. Right may require tapering. Right kidney may cause trouble in forms of hypertention in future, for that will keep patient in regular follow up, which otherwise also necessary.
    Right side lesion is representative of hypoplasia/dysplasia associated with high grade reflux and this seen almost exclusively in male children. In addition there can be focal photopenic polar areas representative of edema/scar. In circumstances of absent reflux on left side I would have not done anything in patient except circumcision.

  • Sumeet Gopal Agrawal
    Sumeet Gopal Agrawal
    29 Oct 2020 09:52:00 AM

    Thanks a lot sir for ur reply and detailed explanation.

    Yes sir CT IVU was unnecessary, it was advised by general surgery, under whom pt was admitted for fever.

  • Dr. Anil Takvani
    Dr. Anil Takvani
    29 Oct 2020 10:22:04 AM

    Sumeet, I can understand. 

    But please talk to your surgeon and pediatrician friends or referrals not to do CT if it is not compulsion.  
    We have to take this matter as our one of the purpose to march towards write and best practices in field of pediatric urology...

  • Sumeet Gopal Agrawal
    Sumeet Gopal Agrawal
    29 Oct 2020 12:56:38 PM

    Ok sir, will discuss with them. Thanks

  • Dr Prashant Mulawkar
    Dr Prashant Mulawkar
    29 Oct 2020 07:32:48 PM

    Dear Anil,

    I think I will also do his circumcision. 
    Regarding the type of reimplantation:
    If tapering is required: Politano leadbetter kind of reimplant
    If no tapering is required: Cohen
    What do you say?

  • Venugopal P
    Venugopal P
    02 Nov 2020 11:06:27 AM

    Dear All,

    Excellent case presented by Sumeet and an apt reply from Anil. I would like to know from Sumeet whether the child had UTI subsequent to the one mentioned 3 yrs ago and the C&S provided a recent one. Such Informations are needed to form a proper decision of proper management. For long, I have left such grossly refluxing Ureters with poor renal function alone if there was no associated rUTI. By performing reimplantation without evidence of RUTI serves no purpose. If the child has Bil Reflux as in this case but devoid of rUTI (if it is so), the grade of Reflux on the better functioning side has to be assessed properly. There are several studies addressing that VCUG may not provide the actual grade in HG refluxes. Leibowitch (1985) when he developed the grading system for VUR had subdivided each grade into 3 (a,b,c) but later it was changed into grade 1 o 5 for convenience. According to Leibowitch, (a) of the higher grade simulates the (c) of the former grade. Hence to assign the proper grade at times is difficult. I would err to a higher grade under such situations as it is safer.

    If one studies the VCUG pictures provided, there is no doubt that the Rt Side Kidney shows evidence of ‘Flowerpot Sign’ but is it representative of Hypoplastic/Dysplastic Kidney. If you draw the axis of Renal Calyces to Vertebral axis, it becomes obvious that the angle is not that obtuse as usually seen in Hypoplastic/Dysplastic kidneys. In the olden days, we use to call Hypoplastic Kidneys as a small kidney with parenchyma forming a cap on an enlarged renal pelvis. This case to my mind denotes a Globally Contracted Kidney due to Scar.

    The most important question is whether a reimplantation is of benefit in such Kidneys, be it Hypoplastic/Dysplastic. The answer has been provided by Anil and Mulawkar. I personally would defer reimplantation on Rt Side unless the child has frequent UTI. As regards Lt Side, as It is the much better functioning side, I would offer reimplantation.

    The question often arises as to when one considers reimplantation on one side, why not the other side as well as it is also grossly refluxing. I would like our pundits to offer their views on this issue.

    In 29th April 2015, we had a discussion on the importance of ‘Flowerpot sign’ in High Grade Reflux, wherein Anil had mentioned thus: ‘Having massive reflux, Global reduction in renal size( global lesion ) against polar lesion/lesions and no history of urinary tract infection/infections. These changes in kidney (VCUG,  DMSA) of these patients are because of abnormal renal blastema induction with abnormal differentiation OR disordered organogenesis related of ureteric bud’. I do not know whether he has since changed his mind as regards such Refluxes with Small contracted poorly functioning kidneys.

    I am posting the article addressing the issue of Flowerpot sign and its relevance in understanding VUR.

    With warm regards,



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  • Dr Prashant Mulawkar
    Dr Prashant Mulawkar
    03 Nov 2020 08:45:26 PM

    Respected Sir,

    This is a difficult case to manage and to decide about. When we reimplant the left side, one alwaus thinks why not reimplant the right side. There have been instances of contralateral de novo reflux once ipsilateral side is treated. 
    I think cystoscopic appearance may give some clue as to how his bladder has been behaving. 
    Unfortunately the followup has been pathetic. The child has been manages incompletely by many clinicians and there are a lot of missings pieces of this puzzle. Will try to dig out the missing links once he comes back.

  • Sumeet Gopal Agrawal
    Sumeet Gopal Agrawal
    07 Nov 2020 08:53:54 AM

    Respected Venugopal sir,

    Thanks for ur detailed reply. 
    This pt had 1 episode of febrile UTI requiring hospital admission and iv antibiotics few months back. Thereafter he was put on chemoprophylaxis, but again he had febrile UTI recently.

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