This page explains about ureteric re-implantation and what to expect when your child comes to Great Ormond Street Hospital (GOSH) to have this procedure.
The urinary system consists of the kidneys, the bladder and ureters. The kidneys filter the blood to remove waste products and form urine. The urine flows from the kidneys down through the ureters to the bladder. From here it passes through another tube called the urethra to the outside when urinating (peeing).
The ureters tunnel through the wall of the bladder at an angle to form a flap that acts as a valve. There is also a ring of muscle (sphincter) at the junction of the bladder and the urethra that stops urine leaking out in between pees. When peeing, the muscles of the bladder wall squeeze the urine out of the bladder, at the same time as the muscles in the sphincter need to relax to let the urine flow down the urethra.
The valves between the ureters and bladder prevent urine flowing backwards into the ureters, so that all the urine in the bladder is passed in one go, as the urine cannot travel anywhere else. As the urine leaves the bladder at a high pressure, the valves stop this high pressure being passed on to the kidneys.
What is ureteral re-implantation and why might my child need it?
In some children, the ureters do not join the bladder in the correct place and this can cause a condition called vesico-ureteric reflux (VUR). If the ureters do not join the bladder in the correct place, these valves can fail, allowing urine to flow backwards from the bladder to the kidney. Depending on the severity of the VUR, sometimes the urine can flow backwards as far as the kidneys. This can damage the kidney and eventually lead to kidney failure.
The ureteric re-implantation operation involves disconnecting the ureters and re-attaching them in the correct place.
What happens before the operation?
You will receive information about how to prepare your child for the operation in your admission letter. We will also invite you to come to a pre-admission clinic. This is an outpatient appointment where you will be able to discuss the operation with the team before coming in to hospital. Your child will also have various tests and investigations during this appointment. This avoids any delays on the day of the operation.
On the day of the operation, your child should not have anything to eat or drink before the operation, for the amount of time specified in the letter. It is important to follow these instructions; otherwise your child’s operation may be delayed or even cancelled.
Your child’s surgeon will visit you to explain about the operation in more detail, discuss any worries you might have and ask you to give your permission for the operation by signing a consent form. An anaesthetist will also visit you to explain about the anaesthetic and pain relief after the operation. If your child has any medical problems, such as allergies, please tell the doctors. Please also bring in any medicines your child is currently taking.
What does the operation involve?
The operation is carried out under general anaesthetic and lasts between 1½ and 2 hours, so you should expect your child to be away from the ward for about 2½ hours. The usual hospital stay is between two and four days.
The surgeon will make an incision (cut) in your child’s lower abdomen (tummy) and disconnect the ureters. He or she will then reattach them to the bladder in the correct place. The end of the ureters joining the bladder will then be surrounded by muscle, which will strengthen the valves, reducing the chances of urine flowing back to the kidneys.
What are the risks of this operation?
All the doctors who perform this operation are very experienced, and so risks are kept to a minimum.
All surgery carries a small risk of bleeding during or after the operation, or of infection. There is sometimes bleeding when the surgeon removes the ureters during the operation. This is usually only slight, but if a lot of blood is lost your child may need to be given a blood transfusion.
After the operation, the new valve is sometimes too strong and it is difficult for urine to pass from the kidney through the ureter and into the bladder. We will check for this using a scan. This is rare, and usually corrects itself without needing further treatment. However, a small operation may sometimes be needed to re-open the valve.
Every anaesthetic carries a risk of complications, but this is very small. Your child’s anaesthetist is a very experienced doctor who is trained to deal with any such complications. After an anaesthetic some children may feel sick and vomit, have a headache, sore throat or feel dizzy. These side effects usually do not last long and are not severe.
Are there any alternatives to the operation?
If your child has VUR and needs their valve to be repaired, there is one alternative to surgery. STING is an injection which is given into the valve in the bladder, with the help of cystoscopy
(a tube containing a small camera and a light which is inserted into the bladder). STING is quicker but sometimes less effective than an operation, so it may not be suitable for all children. Your doctor will advise you further about this.
What happens after the operation?
Your child will recover from the anaesthetic and operation on the ward and will be able to eat and drink soon afterwards, if he or she feels like it. He or she will usually have a catheter (a narrow tube inserted into their bladder) to drain away their urine, and an intravenous infusion (drip) to give fluids and medication. The catheter will be taken out after a few days.
It is quite common for children to have bladder spasms when a catheter is in place. Bladder spasms can show up as tummy pain or discomfort in the penis or bottom area. This is quite normal. We will give you medication to deal with the bladder spasms.
Your child may have had an injection of 'nerve block' during the operation, which will reduce any pain felt afterwards. The nerve block will be 'topped up' for a few days following the operation. Your child may be able to use other forms of pain relief, so please discuss this with the anaesthetist before the operation. A few days after the operation, paracetamol or ibuprofen will be enough to deal with any remaining discomfort.
It is also quite normal to leak a small amount of urine, which may have a little blood in it. This will gradually improve.
When you get home
- You should encourage, but not force, your child to drink.
- Your child should not have a bath or shower until a scab has formed over the wound site. When a scab has formed, try to avoid long baths as this may cause the scab to soften and fall off too early.
- The wound site may be closed by Steri-strips® (plastic strips which are stuck on the skin and used, like stitches, to close wounds). The Steri-strips® usually fall off of their own accord. If they have not fallen off within a week, you can soak them off using a wet flannel.
- As there is a small risk of infection, your child will need to take antibiotics until he or she returns for their outpatient appointment. The hospital will supply the first few doses, but you will then need a repeat prescription from your family doctor (GP). The doctor will see your child about 12 weeks after the operation. We will arrange the date before you go home.
You should call the hospital if:
- your child is in a lot of pain and pain relief does not seem to help
- the wound site looks red, inflamed and feels hotter than the surrounding skin
- there is any oozing from the wound your child has a lot of blood in his or her urine
- your child is not passing any urine or poo
Last reviewed by Great Ormond Street Hospital: October 2010
Ref: 2010F0517 © GOSH Trust October 2010
Compiled by the the Department of Urology in collaboration with the Child and Family Information Group.
This information does not constitute health or medical advice and will not necessarily reflect treatment at other hospitals. If you have any questions, please ask your doctor. No liability can be taken as a result of using this information.