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Cutaneous Urinary Diversion

Cutaneous Urinary Diversion. Cutaneous pyelostomy Renal pelvis to skin Uncommon End ureterostomy Stoma from distal ureter. Cutaneous Urinary Diversion. Loop ureterostomy Double barrel Proximal and distal ureter Intestinal diversion Bowel between skin and ureters.

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Cutaneous Urinary Diversion

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  1. Cutaneous Urinary Diversion • Cutaneouspyelostomy • Renal pelvis to skin • Uncommon • End ureterostomy • Stoma from distal ureter

  2. Cutaneous Urinary Diversion • Loop ureterostomy • Double barrel • Proximal and distal ureter • Intestinal diversion • Bowel between skin and ureters

  3. Cutaneous Urinary Diversion • CutaneousVesicostomy • Most common • Bladder to skin • Appendicovesicostomy • Continent • Intermittent cath

  4. Cutaneous Urinary Diversion • Nephrostomy • Catheter from upper urinary tract to skin

  5. Question 4 You are called to the delivery room to evaluate a female baby with this defect which is located on the lower anterior abdominal wall. What is the most likely diagnosis? • Myelomeningocele • Cloacalextrophy • Hindgut extrophy • Prune belly syndrome • Classic bladder extrophy

  6. Extrophic Anomalies • CloacalExtrophy • 1/200,000 • Rupture of cloacal membrane • Before urorectal septum completes descent to separate hindgut from bladder • Prognosis • Long-term survival 50%

  7. Extrophic Anomalies • CloacalExtrophy • Exam • Bladder • 2 widely separate halves • Bowel mucosa in the middle • Ileocecal segment • Imperforate anus • Hypoplastic genitalia • Associated findings • Omphalocele • Myelomeningocele • Hydrocephalus

  8. Extrophic Anomalies • Classic Extrophy • 1/40,000 • More common in boys • Premature rupture of the cloacal membrane • Exam • Red mucosal surface • Infraumbilical abdominal wall • Bladder as an open book • Inferior aspect ureteral orifices

  9. Extrophic Anomalies • Classic Extrophy • Exam • Epispadias • Bifid or rudimentary penis • Normal or bifid scrotum • Inguinal hernias • Widespread pubic symphysis • Hemiclitoris • Duplicate vagina

  10. Extrophic Anomalies • Classic Extrophy • Treatment • Keep bladder surface moist • Examine upper tract • Neonatal closure • Pelvic osteotomy

  11. Extrophic Anomalies • Epispadias • 55% boys • Penopubic • Widened pubic symphysis • Broad spade-like penis • Urethra opened fully on dorsal surface to bladder neck • Dorsally tethered penis • Incontinent • Other boys • Penile or balaniticepispadias • Normal continence

  12. Extrophic Anomalies • Epispadias • Girls • Rare • Incontinence • Wide urethra • Bifid clitoris • Treatment • Genitoplasty • Staged surgical correction • Renal U/S and VCUG

  13. Urinary Retention • Acute • Usually voluntary • Associated with • Severe acute cystitis • Urethritis • Meatitis • Vaginitis • Other causes • Boys • Urethral stricture • Meatalstenosis with meatitis • Girls • Ureterocele

  14. Urinary Retention • Other causes • Both • Bladder or urethral calculi • Masses - compression • Pelvic masses • Rhabdomyosarcoma • Uterine or ovarian masses • Hydro or hydrometrocolpos • Sacrococcygeal tumors • Constipation • Involvement of nerve roots • Spinal cord injury, tumor or transverse myelitis

  15. Neurovesical Dysfunction • Meningocele • Myelomeningocele • Intradurallipoma • Diastematomyelia • Sacral agenesis • Trauma • Transverse myelitis • Spinal cord tumor Congenital Acquired

  16. Neurovesical Dysfunction • Goals of management • Preserve renal function • Prevent renal damage from infection • Provide social continence • Evaluation • Radiographic or urodynamics • Several times in first year • Yearly thereafter • Warning signs • Infection • Fever • Change in continence

  17. Non-NeurogenicVesical Dysfunction • AKA Hinman-Allen syndrome • Dysfunctional voiding • Features • Day and night incontinence • Fecal soiling • UTI • Behavioral problems • Detrusor/sphincter discoordination • Consequences • Incontinence • Renal failure

  18. Non-NeurogenicVesical Dysfunction • Dysfunctional voiding • Diagnosis of exclusion • Must rule out • Tethered spinal cord • Infravesical obstruction • Treatment • Bladder retraining • Timed regimen • Biofeedback • Intermittent cath • Reverse complications • Temporary diversion • Renal function • Behavioral or psychological therapy

  19. Question 5 The parents of a newborn male with the pictured physical exam finding inquire about circumcision. What do you tell them? • With their consent, you will proceed with circumcision • You will call the urologist and have him do the circumcision • Since they are medicaid, you will not perform the circumcision since it is no longer covered • Circumcision should be delayed in case the skin is needed for reconstruction • The patient needs immediate repair

  20. Anomalies of the Male Genitalia • Hypospadias • 1/250 males • Location of meatus • Glanular • Coronal • Subcoronal • Distal shaft • Midshaft • Proximal shaft • Penoscrotal • Scrotal • Perineal • ? Chordee

  21. Anomalies of the Male Genitalia • Hypospadias • Further work up • Cryptorchidism also? • Karyotype • VCUG? • Only with severe lesions or UTI • Renal U/S? • Proximal lesions • Treatment • Delay circumcision • Repair at 6 months

  22. Anomalies of the Male Genitalia • Chordee • Ventral penile curvature • Uncommon without hypospadias • 3 possibilities • Skin tethering • Abnormal development of urethra and ventral penile structures • Congenitally short urethra • Treatment • Depends on cause • Delay circumcision

  23. Anomalies of the Male Genitalia • Penile Torsion • Congenital or acquired • Most commonly mild • Median raphe spirals around shaft • Counterclockwise • May be seen after circumcision or hypospadias repair

  24. Anomalies of the Male Genitalia • Webbed penis • Cosmetic • Transposition of scrotal skin onto the ventral penile shaft at the penoscrotal junction

  25. Anomalies of the Male Genitalia • Buried penis • Most common after circumcision • Result of thick suprapubic fat pad • Resolves with normal development • Severe cases may require surgery

  26. Postcircumcision Concerns • MeatalStenosis • Dysuria, strangury, deflected stream • Need to observe stream • Examination insufficient • Meatotomy under local anesthesia is curative • Meatal Bridge • Results from meatalstenosis in which ventral aspect recanalizes

  27. Postcircumcision Concerns • Preputial adhesions and skin bridges • Fibrinous adhesions • Incomplete retraction of prepuce in normal development • Post-Circumcision • Complications • Disfiguring • Recurrent inflammation and infection • Trapped smegma • Surgical correction is complicated

  28. Question 6 • Which of the following is the most accurate definition of micropenis in an infant? • A Penile stretch length <2cm • B Penile stretch length <1cm • C Penile length <2cm (not-stretched) • D Penile length <0.5cm (not-stretched)

  29. Microphallus (Micropenis) • Stretch length <2cm (2 S.D. below mean) • 2 Causes • Hypogonadotropichypogonadism • (Failure of hypothalamus to produce GnRH) • Primary testicular failure • Deficient testosterone production • Requires extensive workup • Include karyotype, ?MRI of brain? • 3 month trial of testosterone

  30. Diphallus • Usually associated with severe deformities of lower urinary tract and genitalia • Complete evaluation of upper and lower tract

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