Common problems in Pediatric Urology Dr. Khalid Fouda Neel, FRCSI Associate Professor of Urology and Consultant Pediatric Urology College of Medicine and King Khalid University Hospital King Saud University

Common problems in Pediatric Urology Hydronephrosis in children Pediatric Uro-Oncology UTI Neuropathic bladder in children Voiding dysfunction and Nocturnal enuresis External congenital anomalies Pediatric Urolithiasis 17 April 2017 Dr. Khalid Fouda Neel

Antenatal Hydronephrosis Causes Pelviureteric junction obstruction (41%) Ureterovesical junction obstruction (23%) Vesicoureteric reflux (7%) Duplication anomalies (13%) Posterior urethral valves (10 %) MCDK Others (6%) 17 April 2017 Dr. Khalid Fouda Neel

Evaluation of Hydronephrosis All patients should be on prophylactic Amoxcicillin 20 mg /kg/Day 17 April 2017 Dr. Khalid Fouda Neel

Presentation of UPJO Incidental in Neonates Incidental in Children Symptomatic: UTI Pain Mass Hematuria Stone 17 April 2017 Dr. Khalid Fouda Neel

Surgical Treatment of UPJO Indications of Surgery Symptomatic patients Incidental finding in neonates: Worsening hydronephrosis “Pattern” Reduced differential renal function Bilateral disease Poor family compliance Poor hospital setup****** Incidental finding in children? 17 April 2017 Dr. Khalid Fouda Neel

Obstructive pattern in Renal scan and IVU is not an indication for surgery by itself 17 April 2017 Dr. Khalid Fouda Neel

17 April 2017 Dr. Khalid Fouda Neel

17 April 2017 Dr. Khalid Fouda Neel

17 April 2017 Dr. Khalid Fouda Neel

Ureterovesical Junction Obstruction Same principle of management of UPJ IVP might be helpful > 6 months 17 April 2017 Dr. Khalid Fouda Neel

Duplication Anomalies 17 April 2017 Dr. Khalid Fouda Neel

MCDK 17 April 2017 Dr. Khalid Fouda Neel

Posterior Urethral Valves Presentation: Antenatal UTI Urine retention in neonatal life Poor urinary stream Uremia 17 April 2017 Dr. Khalid Fouda Neel

17 April 2017 Dr. Khalid Fouda Neel

17 April 2017 Dr. Khalid Fouda Neel

Management Early: Diagnosed bilateral hydronephrosis antenatally: 1. catheterization 2. prophylactic antibiotics 3. confirm diagnosis 4. stabilization 5. cystoscopic fulgration of PUV 17 April 2017 Dr. Khalid Fouda Neel

Management Not diagnosed antenatally: 1. catheterization 2. Treatment of infection 3. stabilization 4. cystoscopic fulgration of PUV 17 April 2017 Dr. Khalid Fouda Neel

Management Late: Management of secondary complications (VUR, valve bladder, CRF...) 17 April 2017 Dr. Khalid Fouda Neel

17 April 2017 Dr. Khalid Fouda Neel

Vesicoureteric Reflux 17 April 2017 Dr. Khalid Fouda Neel

17 April 2017 Dr. Khalid Fouda Neel

Normal anti-reflux mechanism “flap valve” 1. Oblique course as it enters the bladder. 2. Proper muscular attachments to provide fixation. 3. Posterior support to enable its occlusion. 4. Adequate submucosal length. 17 April 2017 Dr. Khalid Fouda Neel

Resolution of reflux 87% of Grade I } 63%5 of Grade II } over 3 y. period 53% of Grade III } of follow up 33% of Grade IV } Resolution rate is 30 to 35% each year. 17 April 2017 Dr. Khalid Fouda Neel

Management Decision depend on: 1. Chance of spontaneous resolution (Age and grade at presentation). 2. Breakthrough infection. 3. Renal scarring and renal function. 4. Compliance with medication. 17 April 2017 Dr. Khalid Fouda Neel

Vesicoureteric Reflux Medical Management In patients with UTI, and VUR can be suspected, the child should be continued on prophylactic antibiotics after Rx till the VCUG is done. If you decided this patient is for conservative management, he/she is to continue meticulously on prophylactic antibiotic with surveillance with C/S, U/S and DMSA. 17 April 2017 Dr. Khalid Fouda Neel

Typical indications of antireflux procedure 1. Breakthrough infection despite prophylactic antibiotics. 2. Noncompliance with medical treatment. 3. Severe reflux (IV and V) especially with renal scarring. 4. Failure of renal growth (renal U/S). 5. New scar formation. 6. Deterioration of renal function (Renal scan). 7. Reflux in girls at puberty. 8. Reflux with congenital anomalies (ureterocele, diverticula). 17 April 2017 Dr. Khalid Fouda Neel

Antireflux procedure 1. Sting 2. Intravesical reimplant. 3. Extravesical reimplant. 4. Laparoscopic reimplant. 17 April 2017 Dr. Khalid Fouda Neel

17 April 2017 Dr. Khalid Fouda Neel

17 April 2017 Dr. Khalid Fouda Neel

17 April 2017 Dr. Khalid Fouda Neel

17 April 2017 Dr. Khalid Fouda Neel

17 April 2017 Dr. Khalid Fouda Neel

ENDOSCOPIC INJECTION 17 April 2017 Dr. Khalid Fouda Neel

Urinary Tract Infections * After treatment of the acute febrile infection ; the child should receive daily administration of a prophylactic Antibiotic agent until full radiological evaluation of urinary tract is done (****hospital setup****) 17 April 2017 Dr. Khalid Fouda Neel

17 April 2017 Dr. Khalid Fouda Neel

Neurovesical Dysfunction Causes 1. Neural tube defects. 2. Anorectal malformation. 3. PUV. 4. High grade neonatal reflux. 5. Non-Neuropathic Bladder Sphincter Dysfunction. 17 April 2017 Dr. Khalid Fouda Neel

17 April 2017 Dr. Khalid Fouda Neel

Neurovesical Dysfunction Management Proactive vs. reactive management All patients with anomalies which might cause Neurovesical dysfunction showed be periodically screened If there are any initial signs of bladder dysfunction prompt management should start RUS, VCUG, C/S, Urodynamic study 17 April 2017 Dr. Khalid Fouda Neel

Conservative management should start first Neurovesical Dysfunction Indications for Surgical Reconstruction & Diversion Conservative management should start first Conservative management failed to protect the upper tract Conservative management failed to gain normal bladder compliance Poor family/child compliance Refractory incontinence 17 April 2017 Dr. Khalid Fouda Neel

3 y Female, known with spina bifida was not seen by a urologist before Came with history of Rec. UTI Paraplegic, constipated Normal renal function 17 April 2017 Dr. Khalid Fouda Neel

External Congenital Anomalies 17 April 2017 Dr. Khalid Fouda Neel

THANK YOU 17 April 2017 Dr. Khalid Fouda Neel

Voiding Dysfunction Lazy voider NNBSD Pseudo-incontinence (vaginal voider) 17 April 2017 Dr. Khalid Fouda Neel

Non-Neuropathic Bladder Sphincter Dysfunction NNBSD Triad of incontinence , UTI, and constipation Squatting and urge incontinence Management depend on the severity Severity start from only mild diurnal incontinence to sever bilateral VUR with CRF Urodynamic study is helpful Treatment spectrum from behavior adjustment to major reconstructive surgery 17 April 2017 Dr. Khalid Fouda Neel

Nocturnal Enuresis 15% of all children at the age of 5 The incidence is declined by 1-2% /year 2% has NE at the age of 15 1% of adults population 17 April 2017 Dr. Khalid Fouda Neel

Nocturnal Enuresis Keys for Effective Management Child motivation Monosymptomatic VS multisymptomatic R/O voiding dysfunction Small bladder capacity VS normal bladder capacity Convert the patients to the normal habits Proper selection of the mode of the management Following proper steps The physician should be convinced 17 April 2017 Dr. Khalid Fouda Neel

Nocturnal Enuresis 17 April 2017 Dr. Khalid Fouda Neel