What is ureteral reimplant surgery?

Ureteral reimplant surgery changes the way an abnormally positioned ureter connects with the bladder. Ureters are the tubes that carry urine from the kidneys to the bladder. Normally, the ureter enters the bladder, which is made out of muscle, in such a way that urine is allowed to enter the bladder but not allowed to back up to the kidney. When the ureter enters the bladder abnormally, the muscle backing of the bladder doesn't completely cover the ureter and urine flows back toward the kidney. This condition is called vesicoureteral reflux.

Are any artificial parts used in ureteral reimplant surgery?

No. The original ureter is surgically re-positioned or reimplanted in the bladder wall. The end of the ureter is surrounded by bladder muscle in this new position, which prevents urine from backing up (refluxing) toward the bladder.

Where is the incision?

A small incision is made in the lower abdomen, below the bikini line. All stitches are dissolvable. Occasionally, there may be one stitch in the skin to secure a catheter that will be removed. A clear plastic dressing that will be removed two days after surgery will cover the incision. Little pieces of tape, called "steri-strips," along the incision eventually will curl up and fall off. You may begin bathing your child after the dressings have been removed and all catheters are no longer in place.

Are any tubes left in place after the surgery?

A bladder catheter is usually placed to be sure urine is draining well while the child heals. This is removed two to three days after surgery or after the epidural catheter is removed. A catheter in the ureter, which comes out through a small incision in the abdomen, may be left in place. Once it's removed, a small gauze bandage can be placed over the site, which should heal very quickly. Fluid may leak from the site for a day or so, which is normal.

How long will the surgery take?

The surgery takes about two to three hours. The surgical operating room nurse will give updates on the status of your child's surgery.

Will my child receive pain medication?

Many children get caudal or epidural nerve blocks — pain medications administered through tubes in the back — so they wake up without pain. Alternatively, your child may be a good candidate for a patient controlled analgesia (PCA) pump. This involves infusion of the pain medication intravenously to maintain a more consistent level of pain medication. Please ask your anesthesiologist what is the best form of pain control for your child.

You will be given a prescription for oral pain medication, usually Tylenol with codeine, when your child is discharged from the hospital.

Will my child have problems urinating after surgery?

After this type of surgery, it's common for children to experience bladder spasms or intermittent cramping, urinary frequency, urinary incontinence and to lose small amounts of blood-tinged urine. If the symptoms become a problem, a medication called Ditropan (oxybutynin) may be prescribed. It won't eliminate all spasms, but should decrease discomfort. Having your child sit in a shallow tub of warm water or placing a damp, warm washcloth on the perineum (the skin between the anus and genitals) may also make your child more comfortable.

Older children may be upset if they experience loss of urine control, especially if the urine is tinged with blood. Your child could wear light mini-pads in his or her underwear until this problem resolves. In some children, the urinary frequency and bloody urine may continue for two to three weeks. This is normal. Reassure your child that control will return as the bladder heals.

Are there any problems I should look for?

Please contact the Pediatric Urology office at (415) 353-2200 if you have any concerns about your child's progress after surgery, or if your child exhibits any of the following symptoms:

  • Temperature greater than 101° F
  • Excessive bleeding from the incision (some spotting or blood stains on the dressing is normal)
  • Extreme irritability
  • Inability to tolerate liquids
  • Continuous vomiting
  • Inability to urinate

Do the medications have side effects?

Ditropan (oxybutynin) may cause flushed cheeks, warm skin, dry mouth and decreased appetite. A poor appetite is not unusual, but you should frequently offer your child fluids — a few sips every 15 minutes or so — to maintain adequate urine output. Offer popsicles, Jell-O and soup, if your child enjoys these. Smoothies made of blended fruit and yogurt are a terrific source of vitamins and usually are well tolerated. You may need to be patient and persistent about getting your child to drink fluids.

Your child may be given Morphine, Droperidol or Demerol while in the hospital. Droperidol or Compazine may be given for nausea, vomiting and pain. These medications may make your child drowsy. Some children react to pain medication by becoming overexcited and nervous or developing a rash. If this happens, tell the nurse and the medication will be changed.

Before discharge, the medication will be switched to Tylenol with codeine (Tyco). This comes in both tablet and liquid form. The codeine part of this medication makes some children constipated, so it's important to encourage your child to be as active as possible, and to provide plenty of liquids, fruit and vegetables. Gradually, you can start to manage your child's discomfort with plain Tylenol or Children's Motrin. Within a few days to a week after discharge you should begin to notice your child feeling more like him or herself.

What is the follow-up after surgery?

Children are usually discharged on the second to fourth day after surgery, depending on their recovery. If your child has a drain or catheter, please make an appointment for one week after surgery to remove it. If there is no drain, schedule an appointment for four to six weeks after the surgery. Children usually have an ultrasound at the time of the follow-up appointment. You may be given the Ditropan and Tylenol or Tylenol with codeine to relieve spasms during this time before your return visit.

It's important that your child continue the low-dose antibiotics. The antibiotics given at the time of hospital discharge should be completed by your return visit and your child should resume taking his or her pre-operative maintenance antibiotic daily.

One month after the surgery, your child will be scheduled for an ultrasound of the kidneys. This test tells us if there is any blockage at the site of the surgery. It doesn't let us know if the reflux is corrected; only a cystogram can show that. Four to six months after the surgery, your child should have a voiding cystogram (VCUG). If both of these tests are normal and reflux has resolved, your child may discontinue the low-dose maintenance antibiotics. Your child should then visit us for a follow-up in one year for a blood pressure test and to check the kidneys with another ultrasound.

Will my child have any more urinary tract infections after the surgery?

Some children are particularly prone to urinary tract infections for unknown reasons. They may continue to get infections even after a successful surgery. However, the difference is the infected urine doesn't back up into the kidney. This should prevent kidney damage. These children typically don't have a fever with the infections. If you suspect that your child has an infection, please notify your child's pediatrician or the Pediatric Urology office at (415) 353-2200.