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Thursday, July 24, 2014
Urinary and Genital Disorders (Children)
Duplicate Collection System Surgery
Hi! I have a 1 year old daughter. In utero we discovered that she had an enlarged left kidney and ureter- most likely a duplicate kidney with duplicate ureter. At one week old we had a VCUG-it showed 2-3 grade reflux. She started amoxicillin. We stopped taking it at 10 months. At 12 months we did another VCUG and ultrasound. Vcug showed no reflux at this time. But the ultrasound showed markedly dilated ureter with an upper pole pooling –possible obstruction. To add to the findings she has always had leakage of the urine and a new symptom after we had stopped antibiotics-greenish discharge (intermittent in appearance and quantity. Was tested it twice-came back as normal vaginal flora). We were told that she has a duplicated system -with a duplicated ureter going somewhere outside the bladder - they don’t know where. (In the first VCUG she didn’t reflux in that ureter) We were told we don’t need any further testing and need to have an open surgery done-remove top part of her kidney (the twin) and partially ureter(a half way down). If we don’t plan to have it done right away we need to be put back on antibiotics. She never had an infection/UTI.
So, we are against the of use of antibiotics. But would like to wait a little longer for the surgery. Is the surgery a must in her situation? I know it is a standard approach. What is the increased chance of the UTIs? Is there any risk to her kidneys if she doesn’t have any UTIs? How complicated is this surgery and what is the outcome? How do they know that the portion of the kidney they going to remove is small and how is it going to affect the rest of her kidney? It looks like they wouldn’t know a lot of details until they get inside. It is very worrisome to me. We want to use very conservative approach and do minimally invasive procedures. Do we have to remove the part of the kidney? The urologist thinks that it is nonfunctional. But how can he know exactly? And the most important question can there be any mistake in findings and is there any alternatives to surgery? Thank you for your time.
PS If I have to do surgery I am considering taking her to Boston or Cincinnati children’s hospital because of their robotics. Is one of them better than the other?
It sounds like she has an ectopic ureter, which can drain into the urethra or vagina. In most cases we perform a kidney scan to determine how well the obstructed upper half of the kidney is functioning. The ultrasound study, which I assume she had, provides guidance on how much of the functioning kidney is present, but a scan is more definitive. Surgery is almost always necessary. Without surgery, most girls have either urinary infection, continuous urinary leakage, or both.
If you feel uncomfortable having it performed at this age, it is usually safe to wait. However, if she is having infections or has significant function in the upper half of the kidney, then it is preferable to perform the surgery earlier. Nevertheless, even if the upper half is not functioning, at 1 year of age, surgical correction is generally quite safe. The options include:
1) Upper pole nephrectomy, in which the non-functioning half of the kidney is removed. This has a success rate of 95%, with approximately 2% having a small fluid collection at the upper border of the kidney (does not cause problems, generally), and 3% risk of injury to the healthy lower half of the kidney.
2) Upper to lower ureteroureterostomy, in which the obstructed upper ureter is drained into the normal lower ureter. This procedure can be performed up near the kidney, or down low near the bladder.
With regard to open vs. minimally invasive surgery, both approaches are quite successful. My personal opinion is that laparoscopic surgery with or without the da Vinci robot is preferable to a flank incision. Those of us who are committed to performing minimally invasive surgery in children with urological anoamlies think that it is far preferable over performing the operation through a large incision in the flank. The need for pain medication is a little less and the hospital stay slightly shorter with laparoscopy.
There are two approaches with laparoscopy--standard laparoscopy and da Vinci surgery using the robot. Neither has been shown to be superior, although suturing is much easier with the da Vinci robot than with standard laparoscopy, if reconstructive surgery is planned (e.g., upper to lower ureteroureterostomy).
I am uncertain where you live. There are several excellent pediatric urological centers that perform da Vinci surgery, including Boston and Cincinnati. Also, Children's Hospital of Philadelphia, University of Chicago, and our own center at Henry Ford Hospital/Children's Hospital of Michigan in Detroit are highly experienced, regularly perform da Vinci surgery on children, and lecture at national courses on techniques we have developed.
Jack S Elder, MD, FACS, FAAP
Clinical Professor of Urology
School of Medicine
Case Western Reserve University