COMMON UROLOGICAL PROBLEMS IN CHILDREN Dr.SAEED ALHINDI,M.D,CABS,FRCSI Consultant pediatric surgeon and urologist

Topics Pelvi-Ureteric Junction obstruction (PUJ). Posterior Urethral Valve (PUV). Ureterocele.

Pelvi-Ureteric Junction obstruction the incidence 1:1000 in USA. male to female equal left kidney is more commonly affected 2:1.

Aetiology Intrinsic StenosisUreteric Folds Extrinsic Crossing Vessel

Presentation prenatal ultrasound in later pregnancy. AP diameter of the renal pelvis is a more accurate predictor of functional impairment. Urosepsis: in infants and young children.

Presentation....cont Abdominal pain, typically in children aged 5 years and upwards. Haematuria consequence of minor trauma to obstructed kidneys. incidental finding.

Investigation Ultra sound

Investigation 99mTc MAG3 (mercaptoacetyltriglycine)

Management The indications for pyeloplasty : Symptomatic PUJ obstruction, Asymptomatic obstruction with reduced function (less than 35–40%). Persisting asymptomatic obstruction which shows no evidence of resolution (on ultrasound and 99mTc MAG3), despite stable differential function. Open or Laparoscopy.

Follow up. Ultrasound 3-6 months and isotope renography (MAG3) at 12 month. Dilatation often persists for a long time, despite a technically successful pyeloplasty.

Posterior Urethral Valve (PUV). Early urinary bladder outflow obstruction leads to abnormalities in bladder wall with an increase in the collagen element aberrations in the nerve supply and renal dysplasia.

Presentation 80% are detected on prenatal US. In neonate: bladder outflow obstruction (palpable bladder) Gram-negative sepsis and renal failure Urinary ascites occurs as an occasional Respiratory failure

Presentation....cont In older children: Renal failure such as growth retardation urinary infections or voiding symptoms enuresis

Investigations Prenatal US: ‘keyhole sign’ Postnatal US Micturating cystourethrography (MCU) provides( definitive diagnosis)

Keyhole sign

management Team work Fetal vesicoamniotic shunting?? Urethral or suprapubic drainage for 7 days electrolyte balance and renal function 72h Antibiotic Endoscopic valve ablation Diversion for markedly impaired renal function

prognosis 30% with impaired renal function in the long term,(15-20%) required transplant Primary renal dysplasia. bladder outflow obstruction Urinary infection, with vesicoureteric reflux.

Follow up long-term follow-up. serial US DMSA (dimercaptosuccinic acid) scintigraphy Cystography at 1y unless deterioration Urodynamic study at least at 5 y may need intervention at any time for incomplete relief of bladder outflow obstruction and bladder dysfunction (non-compliance, instability

Ureterocoeles prenatal ultrasonography in 60%. During infancy, the most common presentation is urinary infection. Duplex-system ureterocoeles occur in 0.02% of individuals, 80% are female. 10% of cases the lesion is bilateral. Incidental.

Classification Duplex ectopic ureterocoele.Single-system orthotopic ureterocoele.

Investigations Ultrasound Dilated distal ureter and associated ureterocele visualised on US.

DMSA Left upper renal pole is non-functioning. Minimal function in the thin rim of renal parenchyma overlying the grossly dilated right upper pole.

MCUG

Management Management is influenced by: the mode of presentation the presence of any associated or secondary effects of the ureterocoele.

Endoscopic ureterocoele incision In prolapsing, or risks obstructing the bladder outlet. As a temporising measure in patients presenting with gross upper polar sepsis.

Upper pole heminephroureterectomy In cases where upper polar function is severely compromised

Follow up Serial US MCUG MAG 3 and DMSA

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