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bladder dysfunction (?NB)with VUR
A 7 yr girl had vesicostomy when she was 2-3yrs elsewhere. MCU attached is done at that time.Now here renal parameter are normalised for her age, urine culture negative. USG done bilateral HUN is reduced. Bladder capacity not mentioned. What are the best options for her 1) Neobladder 2) Mitrofenoff( after UDS) 3)conduits
Dr Sudhakar GV09 Jan 2020 10:45:52 AM
No neurological deficits or constipation. She is healthy and has no defirmities. Yes asked for DMSA scan. I will update once it’s available Dr Anil.
shriram joshi09 Jan 2020 05:45:39 PM
dR. s s jOSHI. Reduction in the dilatation of ureters and HN implies this was bilateral VUR rather than a neuropathic bladder. MCUG picture of bladder does not support neuropathic bladder. As she is now 7 years old one can close the ureterostomy and watch upper tracts. A DMSA scan would be very helpful for differential function and scar if any.While closing the ureterostomy start disection in lower half of ureterostomy and then go to the supperor aspect. This will avoid inury to peritoneum and intestines to the apex of urinary bladder. SS.
Dr. Anil Takvani09 Jan 2020 08:26:54 PM
Sir, Vesicostomy was done. I would like to have fresh VCUG to see for reflux. Vcug will give me idea regarding reflux, bladder and PVR. Will decide further treatment based on VCUG and DMSA findings.... Thanks
Dr Sudhakar GV10 Jan 2020 08:42:52 PM
Thank you very for your valuable inputs sir. I will update u after the DMSA scan.
Venugopal P11 Jan 2020 09:11:44 AM
Dear All, The wisdom of Shyam prevails. I tend to agree with Shyam as to the diagnosis of Neuropathic Bladder. The picture provided (Pre Vesicostomy) does not suggest Neuropathic Bladder. Recent US show dilatation of lower Ureters (Rt. 11mm and Lt. 6mm) with normal thickness of Bladder. It is difficult to assess bladder when there is vesicostomy. Since there was a thought of Neuropathic Bladder prior to Vesicostomy, a detailed Neurological Examination is necessary to rule out Neurogenic Bladder. As mentioned, now the child is normalized as regards Renal Function and is devoid of Infection, one may have to consider undiversion. I would agree with Anil on the need of a DMSA Study prior to consideration of Undiversion. A Re VCUG is possible by Putting in a catheter per Vesicostomy stoma and as Anil has suggested, it could be useful. Shyam mentions Ureterostomy which it is not (I am sorry). There is no need for the procedures suggested. The vesicostomy should be closed after all the informations suggested are obtained and should be strictly followed up. If further evaluations post closure of Vesicostomy suggests progression in reflux grade or on functional parameters, then a reimplantation should be considered. With warm regards, Venu
Dr. Anil Takvani11 Jan 2020 10:14:50 AM
Thank you Venu Sir. I would like to have VCUG for following reasons 1. Refux is still there? If yes grade? As I would like to correct refux along with vesicostomy closure. 2. It will give idea about bladder appearance 3. Some guidelines on PVR. Thanks
Dr Sudhakar GV13 Jan 2020 06:18:05 PM
Both MCU and DMSA scan done . DMSA looks good function both side ( report not available to post) : Vesicostomy closure and reimplant bilaterally.
Dr. Anil Takvani14 Jan 2020 11:52:52 AM
Thanks Dr. Sudhakar for fresh VCUG. Yes we have to do for persistent reflux before we close the vesicostomy. So reimplantation with vesicostomy is an answer for your case. In this case I reqwuest member to give attention to pre and post vesicistomy VCUG. There is markedly improvement in ureteric dilatation. To the extent Bilateral reimplantation can be done without ureteric tapering. So if we conclude advantages of temporary vesicistoy in certain cases of grade 5 reflux with hostile bladder in younger age(infants) are: 1. Patient is free from recurrent FUTI. 2. Adequate rest to the kidney and possible recovery of kidneys 3. Ureteric dilation reduces in such a extent , tapering not requires in most of the such cases. 4. At times compete resolution of reflux. 5. You can see bladder is not dry in MCU and wall is much better. I will post related articles soon....Thanks
Dr Sudhakar GV14 Jan 2020 12:05:39 PM
Thank you very much,Dr Anil for ur in-depth explanation on this case
Dr Sudhakar GV27 Jan 2020 06:13:00 PM
Dr Anil Follow up this child with vesicostomy and bilateral VUR. they had second opinion where UDS was done and adviced anticholinergics for two months and then surgery.
Dr. Anil Takvani01 Feb 2020 08:03:53 AM
Dr. Sudhakar thanks.I am more or less agree with second opinion.Will try to get few experts comment on UDM findings of this patient with treatment option.regards,
Dr. Anil Takvani09 Jan 2020 08:03:55 AM
Sir, is she have any issues of spinal cord? What is focal neurological examination? I would recommend to post her clinical pictures. Also will recommend to do vcug and DMSA scan... Thanks