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Common problems in Pediatric Urology

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

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Common problems in Pediatric Urology

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  1. 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

  2. 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 Dr. Khalid Fouda Neel

  3. Antenatal HydronephrosisCauses • Pelviureteric junction obstruction (41%) • Ureterovesical junction obstruction (23%) • Vesicoureteric reflux (7%) • Duplication anomalies (13%) • Posterior urethral valves (10 %) • MCDK • Others (6%) Dr. Khalid Fouda Neel

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

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

  6. Surgical Treatment of UPJOIndications 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? Dr. Khalid Fouda Neel

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

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

  12. Duplication Anomalies Dr. Khalid Fouda Neel

  13. MCDK Dr. Khalid Fouda Neel

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

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

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

  19. Management • Late: Management of secondary complications (VUR, valve bladder, CRF...) Dr. Khalid Fouda Neel

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  21. Vesicoureteric Reflux Dr. Khalid Fouda Neel

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  23. 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. Dr. Khalid Fouda Neel

  24. 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. Dr. Khalid Fouda Neel

  25. 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. Dr. Khalid Fouda Neel

  26. Vesicoureteric RefluxMedical 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. Dr. Khalid Fouda Neel

  27. 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). Dr. Khalid Fouda Neel

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

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  34. ENDOSCOPIC INJECTION Dr. Khalid Fouda Neel

  35. 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****) Dr. Khalid Fouda Neel

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

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  39. Neurovesical DysfunctionManagement • 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 Dr. Khalid Fouda Neel

  40. Neurovesical DysfunctionIndications 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 Dr. Khalid Fouda Neel

  41. 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 Dr. Khalid Fouda Neel

  42. External Congenital Anomalies Dr. Khalid Fouda Neel

  43. THANK YOU Dr. Khalid Fouda Neel

  44. Voiding Dysfunction • Lazy voider • NNBSD • Pseudo-incontinence (vaginal voider) Dr. Khalid Fouda Neel

  45. Non-Neuropathic Bladder Sphincter DysfunctionNNBSD • 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 Dr. Khalid Fouda Neel

  46. 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 Dr. Khalid Fouda Neel

  47. Nocturnal EnuresisKeys 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 Dr. Khalid Fouda Neel

  48. Nocturnal Enuresis Dr. Khalid Fouda Neel

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