What Is Anti-Urinary Reflux Surgery?
When the kidneys make urine (pee), it leaves through urine tubes (called ureters) and goes down to the bladder. In a normal urinary system, the urine tubes enter the bladder at a slant or angle. This angle gives muscle support from the bladder to hold the tubes shut when the bladder squeezes to go pee. In many children with reflux, the urine tubes meet up with the bladder with minimal muscle support. Thus pee goes back up the urine tubes to the kidney when the bladder squeezes to go pee. Anti-urinary reflux surgery helps stop this backward flow.
The surgeon makes an opening in the bladder and reaches inside where the urine tube meets the bladder. He or she then carefully disconnects the urine tube from where it meets up with the bladder and pulls it further down into the bladder. The tube is then reattached at an angle, with part of the bladder surrounding the outside of the tube to support it. By giving the urine tube more muscular support and having it enter the bladder at an angle, the surgery will stop the reflux.
There are three possible ways the surgery may be done:
- Open surgery – A small cut (a few inches wide) is made in the lower belly. The surgeon then opens the bladder to work directly on the ureters. This is the most common way to do the surgery.
- Laparoscopic surgery – Three small cuts are made in the lower belly. The surgeon holds two long, thin tools and a tiny camera inside the holes and operates using the tools from the outside of the belly. This approach can be done with success rates equal to those of open surgery.
- Robot-assisted surgery –This approach allows the surgeon to do surgery through small incisions but using the robot allows for very fine control of surgical instruments.
Anti-urinary reflux surgery is done to stop urine from going back into the kidney after it reaches the bladder. This condition is called vesicoureteral reflux. Most children with reflux do not need surgery as they may eventually outgrow the reflux. While waiting to see if a child will outgrow reflux, they may receive daily antibiotics to try to prevent infections (prophylaxis). Over time, urine reflux can cause repeat kidney infections, which may lead to kidney scarring and damage, high blood pressure, and other problems.
If medication does not stop the infections or kidney damage, a doctor may recommend anti-urinary reflux surgery. The operation is done to try to prevent repeated kidney infections. Ideally, by stopping the infections, the surgery can also prevent kidney scarring and high blood pressure.
Anti-urinary reflux surgery is not an emergency surgery. Your child will be scheduled for the operation in advance. A nurse from Nationwide Children’s will call 1-3 days before the operation to give instructions and the exact time of the surgery.
The nurse will let you know when to arrive, when your child needs to stop eating or drinking, and any other information you need to know for the operation. If your child also has constipation, you may need to arrive the day before the surgery to do a bowel cleanout. This will give the surgeon more space to work during the surgery. No matter what technique the surgeon uses, anti-urinary reflux surgery requires an overnight stay at the hospital.
- Your child will be put to sleep using medicine (general anesthesia). A catheter will be put in place and left in place overnight. Small younger patients may be able to have the surgery done under spinal/regional anesthesia, in order to avoid general anesthesia.
- Your child will receive antibiotics to help lower the chances of infection from the operation.
- The surgery will last about 2-3 hours. A surgery nurse will come out from time to time to let you know how your child is doing.
- Your child may have a drainage tubes such as an urethral catheter left after surgery.
- After surgery, your child will be taken to the recovery room and then up to the urology floor. Pain medicines will be given as needed, and your child will most likely be sent home the next day.
You can expect the following recovery after anti-urinary reflux surgery:
- The skin is usually closed with internal, absorbable stitches and skin glue. These disappear on their own and do not require any special removal or care.
- Your child can wash by sponge bath for the 2 days following the surgery. Regular bathing and showering is allowed after 2 days.
- Within 1 week of a laparoscopic or robotic surgery, pain should be gone and your child should feel well enough to go back to normal activities.
- If your child had open surgery, your child may take a bit longer to feel back to normal and can return to normal activity (including sports) by 1 month after surgery.
Your child will also need to return to the hospital for an ultrasound about 1 month after the operation to make sure the kidneys are not swollen. The only way to know for sure if reflux is stopped is to perform a voiding cystourethrogram, which requires a catheter to be placed. Since the success rates of the surgery are so high (98%), a voiding cystourethrogram may not be done unless there are signs of a problem or after discussion with your specific doctor.
You should call the doctor or seek medical attention for your child after anti-urinary reflux surgery if your child:
- Has a fever of 101° F or higher before you come back for the scheduled follow-up visit
- Passes blood clots in the urine
- Complains of severe pain in the belly, side or back that isn’t helped by the pain medicine they are given at discharge
- Has vomiting where they cannot stay hydrated
- Has symptoms of a urinary tract infection (UTI)
For children who have repeated kidney infections, anti-urinary reflux surgery can be very beneficial. By stopping the reflux, the surgery can help prevent kidney future infections, kidney scarring, function loss and other complications. Children can also avoid the stress and discomfort of the testing required for following up on ongoing reflux and infections.
In general, the risks of anti-urinary reflux surgery include those of any operation, such as anesthesia side effects, infection, redness, swelling, bleeding, or failure of the procedure to fix the problem. Urine could also leak into other areas of the body and cause some irritation.
Anti-urinary reflux surgery can have its own complications, as well. These include scarring at the site where the urine tube is reattached to the bladder. In some cases, children may develop a blockage that requires another operation to open the tube. The follow-up ultrasound will check for kidney swelling, which could mean there is a blockage in the urine tube. Some of these problems may need to be fixed with another surgery. However, these complications are very rare.
- Why are you suggesting surgery instead of medicine?
- Is there already damage to my child’s kidneys? If so, what does that mean for my child’s current and future health?
- Is minimally invasive surgery an option?
- What surgical technique do you recommend for my child and why?
- How will we know if my child’s surgery is successful?
The urologists at Nationwide Children’s Hospital are very thoughtful about which child truly needs surgery and the majority of children with reflux do not need it. When surgery is required, we have the ability to perform the procedure in several ways. We work with families to determine which option is best for the child. In addition, we are one of very few places nationally that can do this operation without general anesthesia.