understanding and treating major urological problems in children

Understanding & Treating Major Urological Problems in Children

Dr. Vivek RegePediatric Surgeon & Pediatric Urologist

Bhatia Hospital

Saifee Hospital

Fortis Hospital, Mulund

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Major Urological ProblemsMajor Urological Problems

• May have non specific presentationMay have non specific presentation• May have a presentation of minor natureMay have a presentation of minor nature• May be silent – child does not have any May be silent – child does not have any

complaint at allcomplaint at all• May have a complaint not related to urinary May have a complaint not related to urinary

systemsystem• May lead to a wrong diagnosis & treatmentMay lead to a wrong diagnosis & treatment

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COMMON PRESENTATIONS

• URINARY TRACT INFECTION(S): PUJ, VUR, PUV, DUPLICATION

• ABDOMINAL PAIN RECURRENT: PUJ, VUR, PUV

• ABNORMAL VOIDING: PUV, DIVERT., AUV, HYPOSPADIAS

• INCONTINENCE & ENEURESIS: PUV, ECTOPIC URETER

• ABDOMINAL DISTENSION : PUJ, WILMS TUMOR, ASCITES

• FEVER OF UNKNOWN ORIGIN: PUJ, VUR, PUV, DUPLEX

• FAILURE TO THRIVE INFANTS: PUV, VUR, OBSTR. UROPATHY

• DIFICULTY OR STRAINING TO PASS URINE: PUV; URETEROCELE

• INGUINAL HERNIA FEMALES: INTERSEX - TFS


Pelvis

Normal

NormalNormal

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Hydronephrosis

Dilatation of the urinary collecting system. It is the result of impediment in antegrade urinary

flow or retrograde reflux of urine

DILATATION IS NOT = OBSTRUCTION

Important to detect presence and severity of obstruction


Progressive Hydronephrosiswww.drvivekrege.com

HYDRONEPHROSIS

OBSTRUCTIVE• PUJ Obstruction 44%• UVJ Obstruction 21%• MCDK• Ureterocele• Ectopic Ureter• Duplications• PUV 9%• Urethral atresia• Sacrococcygeal Teratoma• Hydrometrocolpos

NON OBSTRUCTIVE• Physiological dilatation• VUR 14%• Prune Belly Syndrome• Renal Cyst• Megacalicosis

12%12%


Investigations

• Sonography• MCU• IVU• CT /MR Urography• Radio Nuclear Scans


Ultrasound of kidney - Hydronephrosis

Pelvis

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2 month old child

• Came with complaint of abdominal distension

• I felt a lump on examination

• No urinary complaints

• Passing urine regularly without diff.

• Otherwise very healthy child

• Ultrasonogrphy done


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Radio Nuclear Scans

DTPA /MAG -3 / EC Scans• Most important functional scan for s/o

obstruction

• Differential renal function: Normal 50-50

• Retention of radioactive contrast at 30 mins

• If more amt is retained in kidney more severe the obstruction on that side


DTPA Scan shows obstruction & 38 % function

After 30 mins

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Principal of surgery

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Obstructive HydronephrosisObstructive Hydronephrosis

• Longer obstruction exists more back pressure Longer obstruction exists more back pressure on the kidneyon the kidney

• Thinner the kidney due to pressure, lessor Thinner the kidney due to pressure, lessor tissue working as a kidneytissue working as a kidney

• Function decreases if obstruction unrelieved, Function decreases if obstruction unrelieved, then only option is removal of kidneythen only option is removal of kidney


Antenatal Diagnosis –Results of Early Surgery

• Obstruction relieved early infancy – creatinine clearances improved and reached normal range

• Obstruction relieved 1 – 2 years – function improved but less

• Obstruction relieved after 2 years, function deteriorated with time

• Repair < 1 year – maximal improvement of function


UreterPelvis

Exposure of PU Junction

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Suturing of Pelvis & Ureter

Ureter

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LUMP IN ABDOMENLUMP IN ABDOMEN

Lump discovered accidentally by parent –changing, bathing. First investigation should be a Sonography –it gives information like:

Lump is solid or cystic; Organ of origin; Local spread & extent ; Major vessels engulfed/ infiltrated by mass or free; Metastasis in the

liver already present or not.Other investigations will be specific.

Lump seen & felt in right flankLump seen & felt in right flank

USG: Cystic Renal Lump

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KK

Boy presented with a mass in the abdomen & pain.

No urinary complaints, fever or hematuria.

Mass was in left flank, hard, large size as seen.

Operated by: Dr. Vivek RegeOperated by: Dr. Vivek Rege

Left Kidney Cancer TumorLeft Kidney Cancer Tumor

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WILMS TUMOUR –KIDNEY TUMOR

VESICO URETERAL REFLUX

Definition:

Abnormal passage of urine from the bladder into the ureter(s) to varying distances .

Types of Reflux:

• Primary : Congenital anomalous v – u junction

• Secondary : Reflux is secondary to other anomaly


Incidence of VURAsymptomatic(silent) children: 1%

–18.5%

UTI presentation : 29 – 50%

Females > Males

Males + UTI > Females


VESICO URETERAL REFLUX

Primary

Congenital inadequacy of valvular mechanism at

the U-V Junctionwww.drvivekrege.com

Primary Reflux

Normal mechanism has – • oblique entry of the ureter

• submucosal –intramural length of ureter

• Ratio of tunnel length : diameter of ureter-3:1

• Ureterotrigonal longitudinal muscles

• Active ureteral peristalsis


Secondary RefluxDue to anatomic or functional abnormalities• Posterior urethral valves• Prune belly Syndrome• Anorectal Malformations• Myelodysplasia• Dysfunctional voiding• Associated urinary tract anomalies


International Classification

www.drvivekrege.comHydronephrosis without obstructionHydronephrosis without obstruction

PresentationPresentation

• Urinary infectionUrinary infection

• Urinary infection with feverUrinary infection with fever

• Burning urination, painful urinationBurning urination, painful urination

• Foul smelling urineFoul smelling urine

• Young infant not thriving Young infant not thriving

• Suspected on antenatal ultrasoundSuspected on antenatal ultrasound


Effects of Reflux• Urinary tract infections recurrent• Renal scar formation• Renal growth stops• Renal function drops• Hypertension • Somatic growth drops


Surgical options for Reflux

• Transvesical surgery opening bladder

• Extravesical surgery without opening bladder

• Combined approach

• Endoscopic injection

• Laparoscopic surgery


Bladder opened and both Ureteric openings seen

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Left Ureter dissected and mobilised

L. Ureter

R. UreterR. Ureter

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Left Ureter also mobilised

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Submucosal tunnel for the Ureter with scissor

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Both Ureters sutured and DJ stents placed


RAJSHEKHAR - VURPreop Postop


PARTIAL DUPLICATION – Y OR V TYPE

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PARTIAL DUPLICATION

7 year old boy brought with complaints of:

• Pain in the left loin region –last 10 days

• Fever high since last 20 days no rigors or chills

• Redness noticed in the left flank region


ULTRASOUND – DILATED PELVIS LOWER MOIETY

PELVIS

PELVIS


CT SCAN DUPLICATION RENAL

Pelvis


CT SCAN - DUPLICATION

Dilated Pelvis


CT RECONSTRUCTION OF RENAL DUPLICATION

U

L

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RENAL DUPLICATION - IVU

Dilated Pelvi calyceal system – lower moiety

Non dilated Ureter from upper pelvis

Upper pelvis


Dilated Pelvis - lower

P-U Junction

Upper U.

Lower U.


EXPOSURE OF DUPLICATED SYSTEM

Ureter

Junctionwww.drvivekrege.com

PelviureterostomyPelviureterostomy

REPAIR OF PUJ OBSTRUCTION – LOWER REPAIR OF PUJ OBSTRUCTION – LOWER


Complete Duplications

• Complete duplications with Ureterocele- two pelvis, two ureters

• Complete Duplication only two pelvis, two ureters


COMPLETE DUPLEX

• Upper pole – Ureterocele

• Lower pole - ? Reflux

• Ureter upper – dilated, obstructed

• Ureter lower – may be dilated due to reflux

THERAPY

• Relieve obstruction

• Ureter calibre normal

• Reimplantation with tapering/ Nephroureterectomy-upper

Duplication + ureterocele

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7 year old boy –7 year old boy –

•Recurrent UTIRecurrent UTI

•Failure to thriveFailure to thrive

USG done showed :USG done showed :

Ureterocele in bladderUreterocele in bladder

Dilated ureterDilated ureter

Duplication upper tractDuplication upper tract


IVU• Duplication left side

• 2 Pelves , 2 Ureters

• Dilated ureter of upper moiety ending in a Ureterocele

• Ureter lower moiety non dilated


Ureterocele

Complete Duplication on left

Intravesical obstructing Ureterocele


MCU

•Smooth bladder seen

• Urethra normal calibre

• Reflux into non dilated ureter –lower moiety

Cystoscopy

• Ureterocele seen

•Second ureteric orifice


• Cystoscopy with deroofing of ureterocele

•Relief of obstruction of ureter

• Later final reconstruction done after 6 months of decompression when ureter has come to normal size

•Transvesical double reimplantation of ureters

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Recurrent UTI in a 2 year old girl

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Bilateral Duplication of the upper urinary tract –

Each side shows :

2 Pelves

2 Ureters going right down to the bladder.

Right ? PUJ obstruction

Left ? Obstruction at VUJ

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•A 10 year old boy who came as an A 10 year old boy who came as an emergency after an accidentemergency after an accident•Had fallen while riding his cycle and Had fallen while riding his cycle and later had passed large amount of blood later had passed large amount of blood in his urine.in his urine.•After stabilizing him ,we suspected an After stabilizing him ,we suspected an injury to kidney due to fall, but injury to kidney due to fall, but Sonography showed normal kidneys but Sonography showed normal kidneys but a lesion in his bladder from where he a lesion in his bladder from where he had bled , so we further investigated himhad bled , so we further investigated him

Bladder opened and large Ureterocele seen on left side

Ureterocele

Ureterocele

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Ureterocele seen on left and the right ureteric orifice cannulated

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Refluxing ureteric orifice seen

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After disconnecting the double ureters - turbid urine from the obstructed(left) ureter

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COMPLETE DUPLICATION – NO URETEROCELE

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COMPLETE DUPLICATION

• 3 year old girl –pain in abdomen last 1 month

• Pain in right flank mod. Colicky

• Dysuria since 1 month

• Mild fever – no rigors or chills

• Vomiting only once

• Eneuresis last 3 – 4 days

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2 Ureters seen till arrows- none belowwww.drvivekrege.com

Extravesical approach – both ureters identified entering the bladder

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Antenatal Diagnosis

Left Duplication of upper urinary tract picked up at 32 weeks in a fetus- dilated upper pole pelvis seen with dilated ureter

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Ultrasonography:

Upper part pelvis dilated

Ureter also seen to be dilated

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THERAPY • First stage Left Ureterostomy of only the dilated ureter at 2 months 19961996

• Long term chemoprophylaxis for VUR into lower ureter

• Waiting for decompression & reimplantation for 1 year

•Transvesical double reimplantation of both ureters – one for obstruction, other for reflux

• Closure Ureterostomy after 6 weeks

• Follow up till 20142014 –no dilatation; excellent function

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PresentationPresentation

11 year old boy presented with the complaints of 11 year old boy presented with the complaints of dysuria, straining to pass urine and recurrent dysuria, straining to pass urine and recurrent urinary infections. No specific examination urinary infections. No specific examination finding. Child looked perfectly healthyfinding. Child looked perfectly healthy

The child was sent for investigations like Urine, The child was sent for investigations like Urine, CBC and radiological investigations like USG CBC and radiological investigations like USG kidneys, Ureters, and bladder. The bladder kidneys, Ureters, and bladder. The bladder showed a classical posteriorly placed showed a classical posteriorly placed diverticulum.diverticulum.

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USG – Bladder with diverticulum seenUSG – Bladder with diverticulum seenwww.drvivekrege.com

MCUMCU•Full bladder seenFull bladder seen

•Diverticulum seen Diverticulum seen on the right side on the right side and posterior and posterior aspectaspect

•No reflux seenNo reflux seen

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BladderBladder

DiverticulumDiverticulum

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Forceps placed in the diverticulumForceps placed in the diverticulum

Ureteric holeUreteric hole

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POSTERIOR URETHRAL VALVESPOSTERIOR URETHRAL VALVES

TYPES OF VALVES PRESENTATIONSPRESENTATIONS Straining to pass urineStraining to pass urine

Poor stream of urinePoor stream of urine

Dribbling of urineDribbling of urine

DysuriaDysuria

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RADIOLOGYPOSTERIOR URETHRAL VALVES

VOIDING :

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ULTRASONOGRAMULTRASONOGRAM::

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Endoscopic view of the valves(B)

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BeforeBeforeAfterAfter

Why?Why?

• Urinary infections treated like cough coldUrinary infections treated like cough cold

• No follow up investigationsNo follow up investigations

• Minor urinary complaints ignoredMinor urinary complaints ignored

• Proper examination not doneProper examination not done

• Relevant investigations not doneRelevant investigations not done

• Parents also don’t want “unnecessary” Parents also don’t want “unnecessary” investigationsinvestigations

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ProblemsProblems

• Most, if not all anomalies present from birthMost, if not all anomalies present from birth

• Diagnosed late due to symptoms or signsDiagnosed late due to symptoms or signs

• Can result in complications & loss of functionCan result in complications & loss of function

• Could have been avoided if picked up earlyCould have been avoided if picked up early

• Could have been picked up if prenatal Could have been picked up if prenatal sonography had been done and followed upsonography had been done and followed up


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understanding and treating major urological problems in children

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