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Operated for VUR. Diagnosed reflux grade IV. Undergone DMSA. What can be done?

Jul 2016
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Practicing since : 1971
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My baby (son) is 3yr 4months old at present.He has been operated for VUR in the right ureter at age of 7months.As he was detected reflux Grade IV in right ureter and Grade II in left ureter.
Follow up MCU shown GradeIV in both the ureter.But the urosurgeon( he is not paediatric urologist) advised that it is not worrisome as it is only indicative and as the baby is not completely fit so it is showing higher grade.
He has recently undergone DMSA scan ( after recovering from last UTI in XXXXXXX 2013) and the result shows that right kidney is 33% and left kidney is 67% working.
My query is that can he be recovered from this condition through medication...

For your information he is ALREADY resistent to

1.Septrans--Prophylactic antiboitic
2.Niftrans---Prophylactic antiboitic(which we came to know recntly after his fever in XXXXXXX 2013)
3.Presently he is on Sporidex 125mg/5ml Syrup.(5ml daily at bedtime)
I had attached the following reports for your study and comment.

1.DTPA scan report done in September 2011.
2.USG KUB report done in July 2012
3.USG KUB report done in April 2013
4.DMSA scan report done in XXXXXXX 2013.
Posted Tue, 6 Aug 2013 in Urinary and Bladder Problems
Answered by Dr. P. T. Patil 17 hours later
Thanks for your query. Based on the facts and report s of your son that you have posted it appears hat that your 4 years old son has undergone surgery of
re- implantation his right ureter for grade 5 VUR.

His recent ultrasound scanning and DMSA scan shows satisfactory improvement in his Rt kidney which is revealed as reduced dilatation of calyxes and ureter as well compared to before surgery.
It takes 4-5 years for kidney to regain near normal function which is certain to happen.
The antibiotics that have prescribed are to prevent infection and it has no role to play in improving the basic cause of his problem that is VUR .

Please continue taking prophylactic antibiotic as per urine culture report done periodically every 3-4 months.

Please do not worry he will have near normal kidney function in future.

Hope I have answered your query .Please feel fre to ask if you have more questions i shall be happy to help you.
Thanks and Regards.

Above answer was peer-reviewed by
Follow-up: Operated for VUR. Diagnosed reflux grade IV. Undergone DMSA. What can be done? 28 hours later
Dear Sir,

Thanking you for your advise which boosted me morally as a distressed father.

In continuation please find attached other reports for your reference and comment.

1.USG of mother on 20th Feb, 2010(Date of birth of child)
2.Discharge summary of mother and baby after birth.
3.Preoperation IVP., MCU
3.Reports during stay in hospital.
4.Followup MCU
5.Advise from Nephrologist(latest)
6.Blood and Urine report as suggested by Nephrologist.

Kindly go through the same and give your expert opinion on which I am depending much.

Kind Regards

Answered by Dr. P. T. Patil 6 hours later
Thanks for writing again.I have gone through all the reports and am sure that he will have normal kidney function on left side and Function on Rt side will also improve gradually as the child grows.Every thing has been done on correct lines .

Please take care to take prophylactic antibiotics to prevent renal infection and follow instructions of your Nephrologist.
Thanks and Regards.
Above answer was peer-reviewed by
Follow-up: Operated for VUR. Diagnosed reflux grade IV. Undergone DMSA. What can be done? 18 hours later
Respected Sir, Thanking u once again for reconfirmation.Yesterday when I met the Nephrologist with his latest urine and blood report(already sent to you) he commented that the result is not giving good indication and suggested to do MCU once again on Monday.In case d MCU result show reflux grade high in left side then he suggested to do reimplantation on left side also to save this kidney as nothing can b done on d right one..this is confusing to me...That's why I'm trying to correlate as u r suggesting positve but he is just on d opposite side..Hope you can advise me more on this. Kind Regards XXXXX
Answered by Dr. P. T. Patil 4 hours later
Thanks for fresh query.
The follow up MCU which you have posted was done 2 years back(March 2011)
Normally the anatomical changes (Hydronephrosis) that occur due to long standing obstruction take very long time to get resolved and also depend upon he type of surgery done(Whether anti reflux surgery was done by creating a intramural tunnel at new hiatus or just -a simple re implanting the ureter at neo hiatus.I have made the comments with assuming that
re- implantation of the ureter is done by creating a intra mural tunnel .
Any way go ahead and get his MCU done and post me the findings of the test.
Thanks and Regards.
Above answer was peer-reviewed by
Follow-up: Operated for VUR. Diagnosed reflux grade IV. Undergone DMSA. What can be done? 2 days later
Respected Sir,

As advised by you in your last mail please find attached latest MCU report done on 15th july, 2013 which shows Reflux Grade V in right side.The result of operation is zero/worse.

His Nephrologist is advising to use deflux injection rather than reopening it after discussion with paediatric surgeon.

Kindly let us have your opinion on this issue.Also advise what regular checkup is required for my baby to keep him fit and what to do in case he gets infection again.

Your valuable advise is highly helpful till now.

Kind Regards

Answered by Dr. P. T. Patil 2 hours later
Thanks for writing again.(No recent MCU report attached to your query.)

I really felt sorry for the results of anti reflux surgery are not encouraging.Now you have to monitor your child carefully especially to avoid him from getting UTI.In case he gets fever please get his urine culture done and treat with appropriate antibiotic as per culture report.

His DMSA scan done twice has not revealed any damage to his kidneys so far.which i think as a positive sign.

In children with VUR one has to have patience and hope for good recovery.

As regards your query about deflux injections the results of this modality are not longer lasting and not satisfactory.
Thanks and regards.

Above answer was peer-reviewed by
Follow-up: Operated for VUR. Diagnosed reflux grade IV. Undergone DMSA. What can be done? 13 hours later
Respected Sir,

Sorry for the unintentional error in attaching the file.
Please find attached MCU report.
I am depending on your advise much in this case.
Do you think resurgery is a good option for the right side which has already been operated.As 2 paediatric surgeon has denied to do the surgery to avoid additional complication health wise for the baby.Kindly note that he has undergone DMSA scan once only in XXXXXXX and unfortunately no body advised earlier for the same.
Also suggest on the diet he should be kept and blood test need to be done on regular interval.

Kind Regards

Answered by Dr. P. T. Patil 2 hours later
Thanks for posting MCU report.
It revealed grade 5 reflux on Rt side and good that his earlier reflux which was grade 2-3 on Lt side has resolved and there is no reflux on Lt side now.
Please do not be in hurry wait for 1 more year and repeat MCU and DMSA scan .If there is no improvement you can certainly think of getting him operated by a qualified experienced Paediatric Urologist.
You can monitor him by doing routine urine test every month and renal function test like Blood Urea and serum creatinine every three months to assess kidney function.
Please do write to me whenever you need my help.
Thanks and Regards.
Above answer was peer-reviewed by
Follow-up: Operated for VUR. Diagnosed reflux grade IV. Undergone DMSA. What can be done? 2 hours later
Respected Sir,

Thanking you for your valuable advise.I will follow accordingly.But is it possible for you to suggest any paediatric urologist as it is very difficult to find the same in our region(eastern India).Here paediatric surgeons do re implantation operation and I'm confused to hear that 2 paediatric surgeon( quite experienced) has suggested to avoid reoperation on right side to avoid further complication in that side.
As I can understand that you are having huge experience hence you can give me the confidence and the right decision which I can take, may be waiting for 1 year as advised by you.As I am not able to think positively and want to prepare myself from now on due to the financial impact which may come.
Also any diet restriction has to be followed for the kid...kindly also advise on the same.Any Vitamin supplement, probiotic which may help in building up the immunity to fight any bacteria development...

Trust you will give your careful guidance in this case.

Kind Regards

Answered by Dr. P. T. Patil 1 hour later
Thanks for fresh query.
Please give him high protein diet with anti oxidants like 3-4 Almonds every day.with sufficient vitamins like B-complex.
There is no restriction as far as diet is concerned.
Give him prophylactic antibiotics as a routine and get his routine urine tests done .
Do his MCU and DMSA scan after one year if there is improvement in his kidney function on Rt side we can continue the same treatment for another 2-3 years and wait for resolution and improvement.
However if kidney function deteriorates as confirmed on DMSA scan we will have to think of redo surgery .with consultation of a experienced Paediatric Urologist.
I do not have knowledge about the Paediatric Urologist in Eastern India but I can help you and guide you if you are prepared to consult some one in Bombay.

Please do not worry ,one has to accept whatever comes in our life and to face the situation with courage and boldness .
Thanks and Regards,
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