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Surgical Management of Lower Urinary Tract Obstruction.

Surgical Management of Lower Urinary Tract Obstruction. Prof. O.B. SHITTU. CONSULTANT UROLOGIST. Pre- Test. ‘Gold standard’ investigation for the diagnosis of Posterior urethral valves Isotope renal Scintigraphy Urethrocystoscopy Retrograde urethrogram (RUG)

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Surgical Management of Lower Urinary Tract Obstruction.

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  1. Surgical Management of Lower Urinary Tract Obstruction. Prof. O.B. SHITTU. CONSULTANT UROLOGIST.

  2. Pre- Test • ‘Gold standard’ investigation for the diagnosis of Posterior urethral valves • Isotope renal Scintigraphy • Urethrocystoscopy • Retrograde urethrogram (RUG) • Voiding cystourethrography (VCUG) • Cystometrograph.

  3. Answer True or False Pre-natal diagnosis and treatment of Posterior urethral valves make the long term outcome better

  4. In a child with posterior urethral valves, initial catheterisation is best done with • Foley catheter • Infant feeding tube • Coude catheter • De Peezer catheter • Malecot catheter

  5. Which of the following is not part of the lower urinary tract • Fossa navicularis • Prostatic urethra • Pelvi-ureteric junction • Bladder • Bulbar urethra.

  6. Aetiological Factors. • Congenital causes • Bladder neck stenosis • Posterior urethral polyp • Posterior urethral valves • Congenital urethral stricture • Meatal stenosis/stricture

  7. Aetiological Factors. • Acquired causes • post-traumatic strictures Fall-astride/pelvic fracture • Catheter induced stricture • Stones • Phimosis/Para-phimosis

  8. Posterior Urethral Valves. • POSTERIOR URETHRAL VALVES ARE OBSTRUCTING MEMBRANES WITHIN THE LUMEN OF THE URETHRA, EXTENDING FROM THE VERUMONTANUM DISTALLY. • OCCUR ONLY IN BOYS. • COMMONEST CAUSE OF BLADDER OUTLET OBSTRUCTION AT UCH, IBADAN.

  9. Posterior Urethral valves.

  10. Posterior Urethral Valves: Epidemiology. • INCIDENCE: 1/ 5000 – 8,000 male infants. 1/1,250 by recent foetal Uss. • GENETICS: debatable, but have been seen in siblings.

  11. Posterior Urethral Valves: Clinical presentation. • PRE-NATAL PRESENTATION: Distended, thick walled foetal bladder. Hydronephrosis. Oligohydramnios. Most of the amniotic fluid after the 16th/52 of gestation depend on the foetal urine. Oligohydramnios would suggest primary renal impairment or obstruction.

  12. Posterior Urethral Valves:Clinical presentation. • POST- NATAL DIAGNOSIS: TIME AND MODE OF PRESENTATION WOULD DEPEND ON THE SEVERITY OF THE CONDITION. • RESPIRATORY DISTRESS. • URAEMIA AND SEPSIS. • ABDOMINAL DISTENTION. • DIFFICULTY WITH MICTURITION.

  13. Posterior Urethral Valves:Clinical presentation. • TREAT ACUTE, ASSOCIATED PROBLEMS. • RELIEVE UPPER TRACT OBSTRUCTION. • INVESTIGATE TO ESTABLISH DIAGNOSIS. VCUG- ‘Gold standard’

  14. Poterior Urethral Valves:Clinical presentation. • Features that can be seen on VCUG. • Dilated,thick walled, trabeculated bladder • Elongated and dilated prostatic urethra with narrow bladder neck. • Folds of valves could be seen as filling defects from the area of the verumontanum. • VUR, diverticula, pseudoresidual, etc. • Valves unilateral reflux and renal dysplasia syndrome. (VURD)

  15. MCUG in a Child.

  16. Posterior Urethral Valves: Treatment. • PRIMARY VALVES ABLATION. • VESICOSTOMY AND DELAYED VALVES ABLATION. • TEMPORARY UPPER TRACT DIVERSION.

  17. Posterior Urethral Valves:Long term management. • VESICO URETERIC REFLUX. • Prophylactic antibiotic cover. • Ureteric re-implantation.

  18. Posterior Urethral Valves: Long term Management. URINARY INCONTINENCE: • INCOMPLETE VALVE ABLATION. • URETHRAL STRICTURE. • NON-COMPLIANT BLADDER. • RENAL INSUFFICIENCY.

  19. Posterior Urethral Valves: Long-term renal insufficiency. • POLYURIA • SALT-LOSING NEPHROPATHY • METABOLIC ACIDOSIS • RENAL OSTEODYSTROPHY • GROWTH RETARDATION

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