Monica Stipanovich – Vesicoureteral Reflux

The youngest of Jon and Judy Stipanovich’s three children, Monica Stipanovich is a happy, lively 3 1/2-year-old with a head of blonde hair like corn silk.

These days, her liveliness is broken only occasionally by a bit of well-placed shyness around strangers, when she might hide behind her mom’s legs. But that wasn’t always the case.

Every so often, Monica would complain—using what communication skills she possessed—of pain in her abdomen. When this happened, her pediatrician, Elaine Joseph, MD, would ask whether Monica had a fever. Her temperature, though, was always in the normal range, her appetite was normal and she was as active as ever. Judy says, “We tried a variety of things to help her feel better—different brands of soap, diaper ointment, diapers, laundry detergent—but nothing worked.” 

Once Monica was potty trained, it became clear that something was wrong. Her urine appeared cloudy—something parents wouldn’t notice when their child was still in diapers. Jon and Judy took her back to Dr. Joseph in March of this year. She did a urine culture and determined that Monica was suffering from a bladder infection. She also wanted Monica to be seen by a pediatric urologist, and the Stipanoviches took her to Steven G. Docimo, MD, former chief of Pediatric Urology at UPMC Children's Hospital of Pittsburgh. “Even on your first visit for a urinary infection,” says Judy, “they want you to see a urologist.”

Dr. Docimo ran tests, including ultrasounds, and determined that Monica was dealing with more than a bladder infection. He found megaureter1 on Monica’s right side and that her right kidney was significantly smaller than her left, probably resulting from an infection that had stunted the kidney’s growth. He also was able to detect vesicoureteral reflux in the otherwise normal left kidney. This is a condition in which urine flows backward, from the bladder to the kidney.

“A child with vesicoureteral reflux is predisposed to kidney infection,” says Dr. Docimo. “Over time, that can worsen and result in kidney damage.” Reflux occurs in approximately two percent of children, but it is found in one-third of children who have had a urinary tract infection.

Depending on its severity, in some cases, vesicoureteral reflux can resolve itself. But given that the reflux was not Monica’s only problem and because it was putting her only fully functioning kidney at risk, Dr. Docimo decided the best course of action would be surgery. While many urologic surgeries can be peformed with minimal invasiveness, Monica’s situation was too complicated or a minimally invasive procedure. She was put under general anesthesia for the operation, which was scheduled for May at UPMC Children's main campus, then in the Oakland section of Pittsburgh.

Before beginning, Dr. Docimo performed a cystoscopy, a visual examination of the bladder through use of an instrument called a cystoscope. This isn’t a step all urologists would take, but Monica is fortunate Dr. Docimo did, because he discovered that she had another bladder infection. So Monica was brought back out of the anesthesia, and her surgery was postponed by three weeks. In the meantime, she was prescribed oral antibiotics to fight her bladder infection.

On May 22, Monica’s surgery went off without a hitch. Dr. Docimo made a “bikini” incision, opened her bladder and freed the right ureter from inside. The ureter was so large, it had to be approached from outside the bladder to get enough length for reconstruction. He then was able to taper the ureter, decreasing its size. Prior to surgery, its diameter measured 1.5 centimeters outside the bladder, which Dr. Docimo decreased to three millimeters.

Dr. Docimo then reimplanted the ureter in the bladder, tunneling the ureter through the bladder wall. Now the ureter works correctly as a one-way valve, allowing urine to pass from the right kidney to the bladder. This improves drainage of the kidney, decreases the chance of future infection and, hopefully, will prevent further damage to the kidney.

On Monica’s left side, Dr. Docimo performed practically the same operation, with the exception of reducing the ureter’s size. Again, he tunneled the ureter through the bladder wall, which solved the reflux problem. 

Jon and Judy Stipanovich had been prepared for a three- to four-hour wait while Monica was in surgery, but her operation actually lasted five hours. “The surgery took longer than expected because of the dilation of Monica’s right ureter. Tapering it was more complicated,” says Dr. Docimo.

Monica remained in an inpatient unit at Children’s for two days following surgery. Dr. Docimo had inserted two catheters—one in the right ureter and one in the bladder.

One side effect of the catheterization was that Monica experienced bladder spasms. “On the first day, the spasms almost catapulted her out of the crib,” says Judy. Monica was given medication to help control the spasms, but as the medication wore off the spasms returned. Still, says her mom, Monica never complained about the incision or the tubes, and on the third day after surgery she was discharged. 

Even once she was home, the tubes and bags didn’t bother Monica. She didn’t let them get in her way. “Once we got home from the hospital, she was off and running right away, even with the tubes,” says Judy. In fact, when the time came, two weeks after surgery, to remove the catheters, Monica resisted—she wanted to keep the bags.

Since Monica’s surgery in late May, she has returned for follow-up visits with Dr. Docimo to take stock of how she’s recovering. During her most recent visit in late August, she had a test called a voiding cystourethrogram (VCUG). The VCUG is an X-ray test in which a catheter is passed into the full bladder—its purpose is to detect reflux of urine. Monica passed the VCUG with flying colors, and if her next ultrasound shows no problems, she probably won’t need to return.

As relieved and grateful as Jon and Judy Stipanovich are about that, Monica may not be quite so thrilled that her visits to the Pediatric Urology Department have come to an end. She may hide every time she spots Dr. Docimo, but she talks about him constantly and always wants to know when she’ll see him again.