| What are abnormalities in kidneys that may be found in pediatric uro? | single kidney, normal kidney, more than 2 kidneys and horseshoe kidney.
All live normal life, difference is shapre.
We may have abnormal ureter pathway, abnormal kidney position, in these cases (especially horseshoe) we have a higher risk of renal calculi and uteropelvic junction stenosis (UPJ) |
| How is development of horseshoe kidney? how are duplicities? How are bifidities? | Fused kidneys, first found in pelvis then go up and stop at inferior mesenteric artery
Other abnormality is duplicities (double pelvis, double ureters could be uni or bilateral gives many openings to bladder, we also have bifidity (2 ureters from each kidney merge before they reach bladder (1 bladder opening))
All these live |
| What is UPJ stenosis? | Congenital disease non functional static segment.
Narrowed signal leading to no peristalsis of ureters
Cause: denervation (degenerated Aurebach plexus) or muscular stimulation problem |
| How is clinical presentation of UPJ stenosis? How is dX? | Chronic flank pain (especially after drinking increasing renal pressure)
Dx: Adults (dx by pain if no imaging)
Peds (Intrauterine US, resolves 76% by itself, we see infrarenal obstruction leads to hydronephrosis increase renal pressure causing parenchymal distention (if hydronephrosis with narrow ureter this is UPJ, if dilated ureter this is reflux))
Can be incidental dx |
| What do we do post intrauterine US for dx of UPJ stenosis? | Renal scintigraphy verify obstruction and assess kidney and splenic function to normalize creatinine, normal is divided 50-50 between both kidneys
In peds, if pt felt pain while doing the imaging this confirms dx of obstruction |
| What is tx of UPJ stenosis? | If pt symptomatic: Surgery
2 types: Endourological (Cut by laser/cold, put double J-stent healing around area of cutting, 2 months later remove stent, risk of failure 70%)
Open surgery (open pyeloplasty risk of failure 10% choice) |
| What are CI of UPJ stenosis surgery? | a-Long Segment: If the stenosis afects a big part of the segment.
b-Severe Coagulopathy: Risk of bleeding in the surgery.
c-Immunocompromised
If recurrence after pyeloplasty best choice is endourological surgery since second pyeloplasty risk of failure is 90%) |
| What is indication for surgery UPJ stenosis? | Peds pt dx w/normal creatinine (could be normal due to compensation/mild stenosis/megaureter, then after surgery do nuclear scan for dx and F/U)
If normal kidney (no surgery, just F/U for 1 year and after 1 year repeat test if no change no surgery if change go for surgery)
If we find a stone or pt is symptomatic pain indication for surgery |
| What would you do in a case A patient did the kidney scintigraphy, and results came as follows: 13% contribution from the first kidney and 87% from the second one? | • By definition, any kidney’s function below 15% is defined as non-functional and we
should remove it. --> Indication for Nephrectomy
• The creatinine levels will not change after removal because this kidney was not
functioning and was not contributing to creatinine elimination in the first place.
• Why do we remove it and not fix it? Fixing the kidney comes with high risk of infection
and complications which might lead to sepsis while fixing it. (The kidney was not
functioning and there is a stasis of urine, so there are bacteria which means if we choose
to fix this kidney, we are allowing the bacteria to spread --> sepsis) |
| What is vesicoureteral reflux pathology? | Any defect in migration or formation of ureteral valve leads to VUR, causes dilation of ureter then supersensitivity and with time leads to hydronephrosis.
Previosly needed to grade and either observe or perform surgery, nowadays we only use medical tx |
| What are types of VUR? | Primary or secondary
Primary (insertion of ureter lateral to trigone (urogenital sinus fusion with ureteral valves) if valves defected causes reflux of urine, if ureter is lateral to trigone ureter will get into the bladder for a short distance and cause VUR normal distance is 1/5, in lateral insertion <1/5)
Could also be uni or bilateral |
| How is presentation of VUR? | Recurrent febrile UTI, (recurrent or first episode febrile UTI in male rule out VUR) cystitis is
normal to happen but febrile cystitis is abnormal.
Irritable symptoms with colic
Colic is a pain caused by the contraction of the bladder. This high pressure will push the urine
back to the kidney, causing hydronephrosis and colicky pain, then after urination and emptying,
pain is relieved. |
| What is duplicity? | Congenital condition where the kidneys have two separate drainage systems instead of one, two ureters and two renal pelvises.
The first ureter inserts laterally to the lower moiety of the kidney and drain in the normal location into the trigone of the bladder and commonly leads to reflux.
The second ureter inserts medially into the upper moiety of the kidney and will drain in an ectopic location away from the bladder which commonly leads to obstruction. |
| How is dx of duplicity? | US normal (grade 1-2) or hydronephrotic wide ureter (grade 3-5)
Voiding Cystourethrogram (VCUG) 100% diagnostic but invasive and traumatic (radio test see bladder emptying and filling by urethra
Thin cath inserted into urethra to bladder, contrast dye given visible on X ray, take images as bladder fills and during voiding observes reflux (active)
Urine analysis and US are enough, determine infection and inflammation
nuclear scan DMSA sees obstruction indicated for febrile UTIs where scars may be developed |
| How is tx of duplicity? | Recurrent urinary tract infections are managed by analyzing urine cultures and prescribing appropriate chronic long-term antibiotics based on sensitivity.
Acute pyelonephritis requires a 10-14 day course of antibiotics. (cephalosporin)
Anticholinergic drugs: Significantly reduces the number of "toilet visits."
For overactive bladder or "bladder voiding dysfunction" [instinctively we might think that it opposes the reflux problem, however it worsens it in reality, so it must be treated as well]
DMSA also assesses kidney function. If kidney function is progressively deteriorating =>Indication for surgery
If no intervention possible proteinuria thus irreversible kidney failure |
| What are indications for surgery in duplicity? | indications for surgery:
-progression of scars regardless of antibiotics administration
-ipsilateral (to the side of the reflux) kidney deterioration
Scope management/Urologic management:
For grade 3-4 and recently study tackle efficacy in grade 5.
Inject around the orifice: blocking agents such as "Macro plastique®" or Collagen. |
| What is deflux? | Deflux endoscopic treatment is a non-surgical, minimally invasive injection procedure. Doctor will use a small camera called a cystoscope (a type of endoscope used to view
the bladder) to properly place the gel (Hyaluronic Acid/Dextranome (Deflux®)).
Deflux is injected into the wall of the bladder where the ureter joins the bladder. The gel forms a bulge that acts like a valve, making it harder for urine to flow backwards."
=>efficacy 70%
NB: it is not permanent; we have to re-inject after certain time. if not effecatious go for surgery |
| What is surgery for duplicity? | Urinary reimplantation
The most known technique is Cohen
Principle:
Create a submucosal tunnel at least where the lumen/diameter is bigger than 1/5.
Reposition 1 or both ureters (under 90° angle) so that the urine doesn't backflow
Other surgical approaches: Palitano-Leadbetter (and others |
| What is ureterocele? | • Outpouching of the ureter inside the bladder, intra vesicular or extra vesicular.
• Clinical presentation: recurrent UTI (like a polyp or mass occupied lesion in the bladder) or renal colic (obstruction)
Investigation: US to see ureterocele and hydronephrosis
Lower moiety: reflexive
Upper moiety: obstructive |
| What is tx of ureterocele? | Indication of treatment depend on the symptom in case of:
• Obstruction
• Renal problem
Ureterocele discovered at old age: leave it as it is.
At a younger age, we remove it by endoscopy (puncture, stent, double j).
Surgical resection: it can do reflux; therefore, we follow it by a reimplantation |
| What is hypospadias? | Ectopic opening of the urethra. The opening of the urethra can be anywhere from the scrotum till the head of the penis.
It is common in the lower socioeconomic status (After the migration issue, we have witnessed a lot of these cases in Lebanon; Why? we don’t know).
In the case of Hypospadias, the opening is ventral. It is dorsal in the case of epispadias, |
| What is epispadias? | It is associated with dorsal hoods. The skin is not completely formed in the ventral side;
however, it is in excess in the dorsal side --> this excess skin is called the dorsal hood. This
excess skin must not be removed because it is used in the correction process later in the surgery.
Penile curvature is easily diagnosed on physical exam, we must check for two things: The
location of the opening + the dorsal hood skin.
(Be aware that the dorsal hood might be absent sometimes because the child has been
circumcised; we just consider thus the opening location) |
| How is tx of hypospadias and epispadias? | Always indication for surgery
More proximal opening harder surgery failure, either cases semen exit from urethra is affected may cause infertility
Most common hypospadias surgery is Snodgrass surgery, high risk of failure 20%, most common site of hypospadias is subcoronal
It hypospadias posterior urethra part AKA urethral plate is present while anterior is abscent
Surgery we cut glans in middle, suture sides closing the opening, remove dorsal hood, tangle excess skin around opening and close and suture
Two main concepts are blood supply and suture stay in place |
| What is cryptorchidism and ectopic testes | Undescended testes, found in urinary migratory tract don't reach scrotum ectopic tests (not found even on urinary migratory tract)
very common, high testes temperature leads to prevention of spermatogenesis.
We also have increased risk of cancer by 10 folds |
| How is dx of cryptorchidism? | Normally when a baby is born the doctor should put his hand on the scrotum and he must find a testis. When a patient comes with abdominal pain, and we find out that we don’t have a testis, so the pain is related to the site. Why pain? Since the descend makes it get stuck in the abdomen where we don’t have gubernaculum. (That connects the testis to scrotum) The testis will make torsion leading to pain. It twists every time
OR If patient came for physical exam and we do MRI we find that the testis is outside the scrotum. |
| How do we manage cryptorchidism? | We should return the testis to the scrotum. (If it is found in the abdomen and its size is acceptable and the boy is young) Best treatment age is 9 months. If the child comes after 9 months, the only benefit that we get is that we can do physical exam to detect cancer. If it is rigid, then this is cancer. However, infertility and size do not change. If we did the correction before 9 months, we may solve the infertility problem |
| Why do we descend the testicle in cryptorchidism and not remove it? | Since it is providing the testosterone.
Sometimes the cord is short. However, if the cord is long, I can get it down to the scrotum. The short one might reach the external ring. It is acceptable since I can palpate. But if we couldn’t descend it |
| What is testicular torsion? | Testicular torsion causes your testicle to twist (turn around its axis) and cuts off its blood supply.
· The gubernaculum is not present.
· Rotation of the testis around the spermatic cord by more than 546°: no more blood
supply to the testis: ischemia and necrosis and pain.
We have four hours from the onset of pain to intervene to save the testis. |
| What is Prehn's sign? | -Prehn's sign is a clinical finding that helps clinicians determine whether testicular pain is caused by epididymitis or testicular torsion.
· A positive Prehn’s sign: lifting the testes often relieves the pain of epididymitis.
· A negative Prehn’s sign: lifting the testes will exacerbate the pain of testicular torsion |
| How do we manage testicular torsion? | - In case it’s a testicular torsion: Treat it by manual detorsion (untwist the testicle by hand in an anti-clockwise manner à this will reduce the testicular ischemia) then we can go to surgery |
| How is misdx of testicular torsion? | Any acute scrotal/testicular pain with normal urinalysis should be explored surgically!!
- 2 major abnormalities in urology that can be misdiagnosed and have significant consequences: testicular torsion – obstructive pyelonephritis
- 15 y.o patient presented with persistent testicular pain and normal urinalysis à do the surgery to know the cause. If it turns out to be an infection, in this way I ruled out testicular torsion and preserved the testes = organ preservation surgery |
| How are congenital uro infections? | - Most common germ infection in urology: E. coli. In all types of infections
(epididymitis, orchitis, pyelonephritis)
- Orchi epididymitis is an inflammation of the testis and epididymis, most often of infectious origin. There are many causes for these infections. |
| How do we manage uro infections? | - When a child has Orchi epididymitis, we should investigate for any lower urinary tract anomalies such as obstruction, posterior urethral valve, hyperactive bladder, ectopic ureter…
- In case of an infection: first, we treat the acute infectious phase and then investigate the cause of the infection.
- The most effective treatment for testicular issues is ciprofloxacin BUT it’s contraindicated for children
- Ciprofloxacin works on DNA gyrase (an enzyme in cartilage) à problems in growth.
This is why it’s contraindicated in children. What do we give instead? 3rd generation cephalosporin (good penetration)
- The choice of antibiotics (in UTIs) depends on two factors: concentration in urine and penetration into tissue.
- For testes, best treatment is 3rd gen cephalosporin. For Orchi epididymitis the duration of treatment is normally 10-15 days. After treating the infection, we search for the cause. |
