Vesicoureteral Reflux (VUR) Surgery in Children
In reflux — urine flowing backwards from the bladder to the kidney — the real aim is not to "close the reflux" but to protect the kidney. In a large proportion of children reflux resolves as they grow; surgery is for the situations in which we cannot wait for that.
Last medically reviewed: October 6, 2026 — Assoc. Prof. Dr. Müslüm Ergün
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- Procedure time
- 20–40 minutes (endoscopic) / 60–120 minutes (open)
- Anesthesia
- General anaesthesia
- Hospital stay
- Day case (endoscopic) – 2 nights (open)
- Stay in Türkiye
- 7–12 days
- Catheter duration
- None (endoscopic) – 1–3 days (open)
- Return to work
- Back to nursery or school in 1–3 weeks
- Flight clearance
- After the review appointment
About the condition
Vesicoureteral reflux (VUR) is the backward flow of urine from the bladder up the ureter towards the kidney. Normally the way the ureter runs through the bladder wall acts as a valve and prevents this. Where that mechanism has not developed sufficiently, or where pressure inside the bladder is high, reflux occurs.
REFLUX ITSELF DOES NOT HURT. In most children it is found while investigating a urinary infection with fever. The danger is not the reflux but the infection carried upwards with it: it can leave a scar in the kidney, and that scar does not reverse. The aim of treatment is therefore not to "close the reflux" but to PROTECT THE KIDNEY.
Reflux is graded: in mild grades urine passes only into the ureter; in higher grades it reaches the collecting system of the kidney and dilates the ureter. The lower the grade, the greater the chance of spontaneous resolution as the child grows. That is why the first approach in many children is observation rather than surgery.
OBSERVATION IS NOT "DOING NOTHING". It means regular urine checks, treating febrile infections without delay, relieving constipation, correcting voiding habits, and — in selected children — preventive antibiotics. If these steps are skipped, surgery will not deliver the expected benefit either.
BLADDER AND BOWEL DYSFUNCTION IS THE CAUSE MOST OFTEN MISSED. Constipation, the habit of holding urine, and an overactive bladder raise the pressure inside the bladder, which both sustains the reflux and makes infection easier. An operation carried out before toilet habits are corrected produces a worse result. This must be said plainly to families.
Surgery comes into consideration when febrile infections recur despite preventive measures, when a new scar develops in the kidney, when the reflux is high grade with little prospect of resolving with age, or when observation is not sustainable for the family. There are two main approaches: endoscopic injection through the urinary passage, and reimplantation, in which the ureter is re-joined to the bladder.
Which is chosen depends on the grade, the width of the ureter, whether a procedure has already been performed, and the state of the bladder. The endoscopic route is less invasive and requires no incision; reimplantation tends towards a more definitive result but is a larger operation. The right question is not "which is better" but "which suits this child".
Who is it suitable for?
May be suitable
- Children with recurrent febrile urinary infections despite preventive treatment
- Children in whom scintigraphy shows a new kidney scar
- Children with high-grade reflux and little prospect of spontaneous resolution
- Children whose reflux persists despite advancing age
- Families for whom preventive antibiotics are not sustainable or adherence is poor
- Children who have already had endoscopic injection but whose reflux persists
May not be suitable
- Children with low-grade reflux, no infections and an unaffected kidney — observation is the right option
- Children whose bladder and bowel dysfunction (constipation, voiding disorder) has not yet been corrected: that comes first
- Children with an active urinary infection: the infection is treated first
- Children with neurogenic bladder dysfunction, in whom that picture must be managed first
Technology used
- Child-calibre cystoscopy set
- Bulking material for endoscopic injection
- Voiding cystourethrography (VCUG) to demonstrate and grade the reflux
- DMSA scintigraphy to assess kidney scarring and function
- Ultrasound measurement of kidney and ureteric dilatation
- Paediatric anaesthetic team and child-specific pain management
Surgeon's experience
Verifiable information
- Surgeon's experience
- Assoc. Prof. Dr. Müslüm Ergün121270
Step-by-step journey
- Remotely
Review of documents
The VCUG report and, where possible, its images, DMSA scintigraphy, kidney ultrasound, records of past febrile infections, urine cultures and the antibiotics used are reviewed. Without these the grade and the state of the kidney cannot be known, and no plan can be made.
- Day 1
Examination and assessment
Examination, ultrasound, urinalysis and culture. Constipation and voiding habits are asked about in detail, because they directly affect the result. If the culture grows an organism, the procedure is postponed.
- Day 2
Procedure
In endoscopic injection the bladder is entered through the urinary passage and bulking material is placed beneath the point where the ureter opens, strengthening the valve effect; no incision is made. In reimplantation the ureter is placed within a new tunnel in the bladder wall.
- Days 2–4
Discharge
After an endoscopic procedure most children go home the same day. After open surgery the stay is 1–2 nights; if a catheter is placed, the timing of removal is explained in advance.
- Days 4–10
Review
Wound healing, urinalysis and ultrasound are assessed. The return flight is planned for after this review.
- Months 3–6
Assessment of the result
Whether the reflux has resolved is assessed with repeat imaging where the surgeon judges it necessary. The absence of febrile infection is itself an important measure of success.
Method comparison
| Criterion | Endoscopic injection | Reimplantation (open) |
|---|---|---|
| Incision | None — via the urinary passage | Yes — in the lower abdomen |
| Procedure time | Short | Longer |
| Hospital stay | Usually day case | 1–2 nights |
| Catheter | Usually not needed | May be needed briefly |
| Tendency to resolve the reflux | Lower; repetition may be needed | Higher |
| Chance of a further procedure | Higher | Lower |
| Recovery | A few days | 2–3 weeks |
| Suitability for high grades | Limited | More suitable |
This table is not a ranking. The endoscopic route places less burden on the child but is more likely to need repeating; reimplantation aims at a more definitive result but is a larger operation. If you are travelling from abroad, weigh the possibility of a second journey in that decision.
Risks
- THE PROCEDURE MAY NOT FULLY RESOLVE THE REFLUX: particularly after endoscopic injection, reflux may persist or return after a time. A second injection or reimplantation then comes into consideration. This possibility is discussed from the outset
- TEMPORARY URETERIC OBSTRUCTION: swelling or narrowing can develop at the ureteric opening after injection or reimplantation, causing dilatation of the kidney and flank pain. Most settle; a small number of children need a further procedure
- Urinary infection after the procedure
- Blood in the urine and stinging on voiding — expected in the first days
- Bladder spasms and the distress they cause after open surgery; controlled with medication
- Wound infection and, after open surgery, a permanent scar
- EVEN IF THE REFLUX RESOLVES, EXISTING KIDNEY SCARRING DOES NOT REVERSE: surgery prevents new damage, it does not repair old scars. This is the most commonly misunderstood point
- Risks of general anaesthesia
Alternatives
- Observation — the first and often the most appropriate option in low-grade reflux without infection, with regular urine and ultrasound checks
- Preventive (prophylactic) antibiotics — in selected children, to prevent febrile infection
- Treatment of bladder and bowel dysfunction — relieving constipation, voiding retraining, regular toilet times; this comes before surgery
- Endoscopic injection — a day-case method with no incision
- Ureteroneocystostomy (reimplantation) — open or laparoscopic; tends towards a more definitive result but is a larger operation
- Circumcision — may be considered in selected boys with recurrent infection as a means of reducing infection risk
Recovery
First 24–48 hours
Blood in the urine and stinging on voiding are usual. Plenty of fluids are given. Fever, inability to pass urine or severe flank pain require immediate contact.
Week 1
After an endoscopic procedure the child returns to normal life quickly. After open surgery bladder spasms may occur and are controlled with medication; strenuous activity is avoided.
Weeks 2–3
Return to nursery or school after open surgery usually falls in this period. Cycling and contact play wait a little longer.
Months 1–3
Urinalysis and ultrasound are reviewed. The absence of febrile infection is a favourable sign.
Long term
In children with kidney scarring, blood pressure and kidney function are followed intermittently for years. Girls are reminded that particular care is needed regarding urinary infection during a future pregnancy.
Frequently asked questions
Does reflux resolve on its own?
In a large proportion of children, particularly at low grades, it resolves with growth. That is why observation is often the first approach. As the grade rises and the child gets older, the chance of spontaneous resolution falls.
Will the kidney be harmed if we do not operate?
It is not the reflux itself but the FEBRILE infection carried upwards with it that can scar the kidney. In a child who does not get infections the risk is markedly lower. The real work of an observation plan is therefore preventing infection.
Why do you treat the constipation first?
Because constipation and voiding disorder raise pressure inside the bladder, which both sustains the reflux and makes infection easier. An operation performed before they are corrected gives a worse result. This step is often skipped yet it directly determines the outcome.
Will one endoscopic injection be enough?
Not always. Reflux may persist or return after a time, in which case a second injection or reimplantation comes into consideration. A plan that does not discuss this possibility from the outset is incomplete.
Will he keep taking antibiotics after surgery?
Usually for a further period, then stopped according to the review results. Do not make that decision alone; in children with a history of febrile infection the transition is planned.
Will the scar on the kidney heal?
No. Surgery prevents new damage; it does not reverse existing scarring. This is the most commonly misunderstood point, and it is why making the decision in good time matters.
Will another VCUG be done?
Not routinely in every child. Whether imaging is repeated after the procedure is decided by the surgeon according to the grade, the procedure performed and the child’s course. Unnecessary radiation and catheterisation are avoided.
Could his siblings have it too?
Reflux is known to show a familial tendency. If a sibling has a history of urinary infection, tell your doctor; routine screening of every sibling, however, is not required.
How long should we stay in Türkiye?
Usually 7 days for an endoscopic procedure and 10–12 days for open surgery. Because the review is carried out here, plan the return flight for after that appointment.
What documents should we send?
The VCUG report and, where possible, its images, the DMSA result, kidney ultrasound, the dates of past febrile infections, urine cultures and the antibiotics used. Without these the grade and the state of the kidney cannot be known.
My son is not circumcised — does that matter?
In selected boys with recurrent urinary infection, circumcision may be considered as a way of reducing infection risk. It is not a general recommendation for every child; discuss it with your doctor in the light of your own situation.
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This page is for general information only and is not a substitute for medical advice.
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