Utereral Reimplantation or Subtrigonal Injection
Ureter = the tube that transports urine from the kidney to the bladder
Reimplant = to disconnect and reconnect in a different area and in a different fashion
Trigone = the place in the bladder where the ureters enter
Ureteral reimplantation or subtrigonal injection
are procedures that are performed to cure a condition
known as vesicoureteral reflux (VUR). Reflux is when
urine flows from the filled bladder back up toward the
kidneys. Although this abnormal flow usually only occurs
during bladder squeezing (urination or voiding), it may
even occur during bladder filling in patients with more
severe reflux. In people without VUR, once urine enters
the bladder from the ureter, it is prevented from refluxing
by a valve-like mechanism at the end of the ureter.
It is not truly a "valve" but rather that the
end of the ureter gets pinched in the muscular wall
of the bladder while the bladder is squeezing.
The most common presentation of VUR is a febrile (with fever) urinary tract infection. During the evaluation, the VUR is detected by a voiding cystourethrogram (VCUG). This is the special contrast dye procedure (that your child already had) involving a catheterization of the urethra and bladder.
Reflux is graded on a scale of 1 to 5 (5 being the most severe). The grade is determined by the voiding cystourethrogram (VCUG). As a general rule, the higher the grade, the less likely it is that the VUR will disappear on its own without a procedure. All grades of reflux detected at a very young age (i.e. a newborn) are more likely to resolve without a procedure than when it is detected in an older child (i.e. a 3 year old). Grade does not correlate with repeated infections, however. All grades of reflux can cause infections that are equally harmful to the kidneys if a child is not maintained on antibiotics. Reflux can be one-sided, both sides, and be worse on one side than the other. Even in the absence of a symptomatic infection (one with fevers and/or pain, frequency, burning, urgency), persistent VUR of infected urine injures the kidneys over time. Therefore, once VUR is diagnosed, it is important that the child remain on antibiotics every day until the VUR disappears, is surgically corrected, or the physician determines that it will no longer be harmful to the kidneys.
Subtrigonal injection surgery is a short, minimally-invasive ambulatory procedure. Formal reimplantation requires an incision on the lower abdomen and usually a one or two night stay in the hospital. Not all cases of VUR are appropriate for subtrigonal injection. Your surgeon will have discussed the pros and cons of each with you so that you fully understand why one procedure has been recommended over the other. There are no concrete rules. Your surgeon will explain why he or she believes your child is better off with one or another procedure.
As with any procedure in which anesthesia is administered, you will be asked not to feed your child anything (including any liquids) after midnight on the evening prior to the surgery. If your child is on medications that must be taken, you will have discussed this with us and/or the anesthesiologist and instructions will have been given to you. The procedure will not be performed if your child is on, or has recently been taking any medication that may interfere with his ability to clot his blood. The most common of these medications are aspirin-like compounds and all related pain relievers, fever reducers, or anti-inflammatory compounds(whether prescription or over-the-counter). Please refer to the attached list and tell us if he has taken any of these within the past 10 days. If his medication is not on the list, alert us immediately so that we may ensure optimal procedure safety. We will have reviewed any of the current medications with you during the pre-operative/pre-procedure consultation. You are obligated to inform us if anything has changed (medication or otherwise) since your previous visit.
To review the basics of what we discussed in the office: Like any other procedures done on young children, these procedures are performed under general anesthesia (complete sleep).
Subtrigonal Injection: A small cystoscope (telescope) is passed through the urethra (tube through which urine leaves the bladder) and into the bladder. Each ureteral orifice (hole through which urine enters the bladder from the ureter) is identified. There are different substances available that are approved for injection. The material used will depend on each surgeon's preference and experience. A small amount of the bulking agent is injected into a specific area near the ureteral orifice to help tighten the diameter of the hole. The amount injected will depend on the surgeon's assessment at that time. Once injections are complete, the scope is removed and your child is awakened.
Formal Reimplantation: In this procedure, an incision is made from either left to right or up-and-down on the lower abdomen. The urinary bladder is opened and the ureteral orifices are examined. The ureters are detached from the bladder and then reimplanted (reattached or reinserted) into a newly made hole in such a manner as to prevent VUR. There are several variations with respect to the method and location of the new site for the ureter. They are all effective and depend on each surgeon's experience and preference. Once the reimplantation is done, the bladder is sutured closed. The skin is then closed with absorbable (self-dissolving)sutures. Some surgeons will leave a little catheter (small plastic tube) coming out of the urethra for a few days so that the bladder is kept empty during the healing process. Other surgeons will leave no catheter. The incision is covered with a bandage and your child is awakened.
Your child will be in the recovery room for a short time.
Following subtrigonal injection, your child will usually be discharged the same day. There are no real restrictions, although we ask that your child restrain from any strenuous activity or rough play (including gym or physical education) for a few days.
In the first few days, it is also possible that:
- your child has a little stinging or burning with urination
- your child has a sensation in the bladder that there is a need to urinate frequently or urgently
- the urine may be clear or slightly blood-tinged
After formal reimplantation, most children are admitted for one night and discharged the following day. Depending on your child's comfort level and ability to urinate well, he/she may require a second night of hospitalization. If a catheter is left in the urethra your child may complain of urgency (a constant sensation of a need to urinate). The surgery on the bladder itself may also cause a sense of urgency because the bladder is having spasms. These spasms typically last for only a few days. He/she may have discomfort over the incision. There will be a small bandage directly over the incision. Unless otherwise specified, the dressing is to remain on until office follow-up. Some blood staining may be seen on the dressing. If the dressing becomes soaked, or you see active blood oozing, please contact us. Your child may shower the day after surgery. Some surgeons will ask your child to stay out of a bath until follow-up, and others may suggest warm baths after the first few days. We ask that he/she refrain from any strenuous activity or rough play (including gym or physical education) until otherwise instructed. Some patients have almost no discomfort while others are somewhat uncomfortable for a few days; longer is rare. For discomfort, you may administer any pediatric-dose over-the-counter medicine to which he/she is not allergic (Tylenol®, Advil® or other ibuprofen product). The urine may be clear or slightly blood-tinged for a few days. If bladder spasms are a problem for more than a day or so, we might prescribe a special type of medicine to minimize the spasms. Upon follow-up in the office, we will examine your child and once again review the necessary follow-up studies. The sutures we use are often self-dissolving, and therefore just fall out with time.
*Occasionally, constipation is a problem after open surgery. While it almost always resolves spontaneously or with medicine (laxative, suppository, etc.), you should contact your surgeon before anything is administered.
Expectations of Outcome
Surgical reimplantation is the "gold-standard,"
and is very effective in curing all grades of VUR. Subtrigonal
injection is not as effective stage for stage. Nevertheless,
it is minimally invasive, has a short anesthesia time,
and has a shorter recovery time. Many surgeons will
not use subtrigonal injection for high grade reflux because
of the high failure rate.
Either of these procedures may fail immediately. If surgical reimplantation is successful, it is quite unusual for VUR to recur in the future. Conversely, a subtrigonal injection that is successful initially can fail in the future due to absorption of some of the bulking agent into the tissue.
If subtrigonal injection fails, the options are to repeat the injections or to perform surgicalre implantation. If reimplantation fails, we may perform the injections and only repeat the surgery if the injections, too, fail.
Despite the success, most urologists will recommend keeping your child on antibiotic suppression for a while longer until follow-up demonstrates no persistence or recurrence of VUR. Each urologist varies a bit in how long he/she continues the antibiotic.
Children heal quickly and respond well to surgery. Even after surgical reimplantation, most children will be back to normal activity in about one week.
Possible Complications of the Procedure
ALL surgical procedures, regardless of complexity or time, can be associated with unforeseen problems. They may be immediate or even quite delayed in presentation.
While we have discussed these and possibly others in the consultation, we would like you to have a list so that you may ask questions if you are still concerned. Aside from anesthesia, it is important that parents be made aware of all possible outcomes which may include, but are not limited to:
- Persistence or Recurrence: Despite the high success rates expected fro either of these procedures, it is possible that reflux may not go away or recur in the future. Recurrence or persistence is more common with the subtrigonal injection procedure for moderate to high grades of reflux.
- Ureteral Obstruction/Anuria: Although unusual, it is possible for the reimplant to be "too effective." In such cases, not only is urine not refluxing, it is not draining down from the kidney to the bladder. In other rare instances, the reimplant is perfect at the time of surgery but becomes scarred over time. In either of these situations, a second procedure or open surgery might be necessary. If both sides are affected, the child would not pass any urine at all, making the need for surgical correction immediate.
- Contralateral Reflux: Occasionally, only one ureter is affected by VUR. Sometimes, when surgery is done on that side only, the other side can begin to reflux after the surgery. This is due to changes in the bladder and perhaps increases in pressure in the bladder following correction of reflux on the one side.
- Bleeding: Significant blood loss is very rare during or following this operation. In unusual circumstances, a blood vessel in the bladder wall could begin to bleed after the surgery and cause significant hematuria (blood in the urine). A need for transfusion is unlikely.
- Infection: Infection is possible following any procedure. A urinary tract infection can occur with either procedure and almost always responds to antibiotics. Following surgical reimplantation, the incision can become infected. This is usually detected early and responds to local wound care and antibiotics. It is quite unusual to have to drain the infection by removing sutures.
- Urinary Retention: Sometimes after the bladder is cut open, it can fail to squeeze properly for a while. If this happens, a catheter may need to be placed in the bladder for a while to keep it drained until the function recovers. This almost always resolves with time.
- Intraperitoneal Bowel Injury: There are certain reimplant procedures in which the ureter is passed behind and above the bladder to bring it to the new reimplant site. It is possible for the small intestine (and less commonly other organs) to be injured by one of the surgical instruments when creating the tunnel (passageway) behind the bladder.
Whether identified immediately (during the surgery) or in the immediate recovery period, a pediatric general surgeon may be consulted to repair the intestine. Again, this is a very rare complication.
We provide this literature for patients and family members. It is intended to be an educational supplement that highlights some of the important points of what we have previously discussed in the office.
Alternative treatments, the purpose of the procedure/surgery, and the points in this handout have been covered in our face-to-face consultation(s).
The information contained in this document is intended solely to inform and educate and should not be used as a substitute for medical evaluation, advice, diagnosis or treatment by a physician or other healthcare professional. While Delta Medix endeavors to ensure the reliability of information, such information is subject to change as new health information becomes available. Delta Medix cannot and does not guaranty the accuracy or completeness of the information contained in this document, and assumes no liability for its content or for any errors or omissions. Please call your doctor if you have any questions.
Delta Medix, P.C.