Robotic Surgery Corrects VUR in Young Girl
Parents Find Compassion, Support and Leading-Edge Care at Comer Children's Hospital
Bending down to reach the level of three-year-old Reese, pediatric urologist Mohan Gundeti, MD, told the little girl, "I have good news for you; you are no longer a patient."
Four months earlier in the spring of 2012, Gundeti performed complex robot-assisted surgery on Reese to correct vesicoureteral reflux (VUR), a condition that threatened the health of one of her kidneys. VUR occurs when urine in the bladder backs up into one or both of the ureters, the narrow tubes that carry urine from the kidneys to the bladder. Children who have VUR are at risk for recurring kidney infections, which can lead to permanent scarring, high blood pressure and kidney failure.
When Reese was just a few months old, her parents Tim and Angela brought their infant daughter to a suburban emergency room because she had a fever of almost 104 degrees. After a urine culture determined Reese had a kidney infection, doctors recommended she have a voiding cystourethrogram (VCUG). This specialized X-ray detects abnormalities in the urinary tract by examining it in real time as the bladder fills and empties.
VUR is staged on a grading system that ranges from 1 to 5 -- the higher the number, the greater the severity of the condition. In Reese's case, the VCUG showed she had grade 4 to 5 VUR on one side. Urine was flowing up her right ureter, allowing bacteria to enter her right kidney and cause infection. A follow-up renal (kidney) scan showed she already had some scarring on the kidney.
Tim and Angela sought the advice of Gundeti, an internationally known expert in the treatment of VUR and a pioneer in the use of robot-assisted surgery to correct the defect. The University of Chicago Medicine Comer Children's Hospital is the only hospital in the city and one of just a few in the United States that offers complex robotic laparoscopic surgery. It is also a center for teaching the technique to surgeons from around the country. In the fall of 2012, Gundeti performed a live case demonstration from Chicago for pediatric urologists attending an American Academy of Pediatrics meeting in New Orleans.
Gundeti recommended surgical intervention for Reese but told her parents that she needed to be out of diapers before undergoing the operation. "The nerves in the bladder become more mature after toilet training and are less likely to be damaged during surgery," he explained. Gundeti prescribed low-dose antibiotics to reduce the risk of urine and kidney infections in the meantime.
Choosing a Surgical Approach
When it came time to decide between traditional open surgery and minimally invasive robot-assisted surgery, Tim and Angela researched both approaches. In children Reese's age, just over three-years-old at the time, both techniques have a 95 percent success rate. However, robot-assisted surgery offers other benefits – smaller incisions, less scarring, faster recovery and less likelihood of pain from bladder spasms during recovery. Gundeti believes his patients take comfort in knowing that he has extensive experience in successful robotic surgery.
"Our number one worry was the thought of Reese having the spasms after surgery," Angela said. "We wanted her to be in as little pain as possible." They chose the robotic approach noting that Gundeti was the "go-to person" for the procedure. Nurse Beverly Dooley, APN, NP, worked alongside Gundeti to reassure the family and to address their concerns.
In April 2012, Gundeti performed the operation, called robot-assisted laparoscopic ureteral re-implantation, using the da Vinci Surgical System. Skillfully maneuvering the system's miniature tools through four tiny incisions, he repositioned and strengthened the section of the right ureter that rested within Reese's bladder. Because this technique offers high magnification of the surgical field, Gundeti's team could clearly see the nerve fibers in the bladder. "This enabled us to preserve those nerves, reducing the chance of bladder dysfunction and spasms after surgery," he said.
Reese recovered quickly from the surgery, with little pain and no bladder spasms, and went home 48 hours later. "As soon as we walked into the house, she started jumping all around our family room," Angela recalls. "It was hard to slow her down." The next day, Reese was riding her bike around the neighborhood. A follow-up VCUG in August showed the VUR was repaired.
Angela says while it was stressful and emotional to have a young child with medical needs, she and her husband appreciated Gundeti's support and understanding. "He was very patient and answered question after question," she said. "And he corrected Reese's reflux. We couldn't have asked for anything more."