Times Health Critical Care Survey - NU Hospitals ranked 1st for City , 2nd for Regional and 3rd for National in the field of Urology. Times Health Critical Care Survey - NU Hospitals ranked 6th for City in the field of Nephrology

OVERVIEW

The Paediatric Urology division has remained at the forefront of urological care by performing extensive Endourology and also reconstructive surgery, especially with children born with exstrophy of the bladder. Short hospital stay, good postoperative analgesia and care and excellent results have made our hospital one of the institutions of choice for this specialty.

Who is a Paediatric Urologist?

If your child has an illness or disease of the genitals or urinary tract (kidneys, ureters, bladder), a Paediatric Urologist has the experience and qualifications to treat your child.

Children are not small adults. They cannot always say what is bothering them. They cannot always answer medical questions and are not always able to be patient and cooperative during a medical examination.

Paediatric Urologists are trained to focus care on the special needs of children and their parents – even on potentially sensitive and embarrassing subjects related to genitalia and voiding problems. They know how to examine and treat children in a way that makes them relaxed and cooperative. In addition, Paediatric Urologists often use equipment specially designed for children. This helps create a comfortable and non-threatening environment for your child.

If your Paediatrician suggests that your child see a Paediatric Urologist, you can be assured that he or she has the widest range of treatment options, the most extensive and comprehensive training, and the greatest expertise in dealing with children and in treating children’s urinary tract disorders.

Paediatric Urologists are medical doctors who have had:

  • At least 6 years of medical school
  • One to 3 years of surgical residency
  • At least 3 additional years of residency training in general Urology Health
  • One to 2 years of additional fellowship training in Paediatric Urology

A Paediatric Urologist must devote a minimum of 75% of his or her practice to the urologic problems of infants, children and adolescents

Paediatric Urologists are surgeons who can diagnose, treat and manage children’s urinary and genital problems. Paediatric Urologists generally provide the following services:

  • Evaluation and management of voiding disorders, vesicoureteral reflux and urinary tract infections that require surgery
  • Surgical reconstruction of the urinary tract (kidneys, ureters and bladder) including genital abnormalities, hypospadias and disorders of sex development
  • Surgery for groin conditions in childhood and adolescence (undescended testes, hydrocele/hernia, varicocele).
  • Evaluation and surgical management of kidney stone disease
  • Surgical management of tumours and malignancies of the kidney, bladder and testis
  • Evaluation and management of urological tract problems identified before birth
  • Evaluation and management of urinary tract problems associated with neurological conditions such as spina bifida.

Antenatal Hydronephrosis, which simply means fluid-filled enlargement of the kidney before birth, is detected in the foetus by ultrasound studies performed as early as the first trimester of pregnancy. In most instances this diagnosis will not change obstetric care but will require surveillance and possible surgery during infancy and childhood.

Possible Causes of Antenatal Hydronephrosis:

Blockage – This may occur at the kidney in the Uretero Pelvic Junction (UPJ), at the bladder in the Uretero Vesical Junction (UVJ), or, in the urethra (posterior urethral valve).

Reflux– Vesicoureteral reflux occurs when the valve between the bladder and the ureter is incompetent permitting urine to flow back into the kidney when the bladder fills or empties. Almost 75% of children outgrow this during childhood but need daily antibiotic prophylaxis to try to prevent kidney damage before they outgrow the reflux.

Duplications etc. Perhaps 1% of all humans have two collecting tubes from a kidney. These may show up on the foetal ultrasound. Occasionally patients with duplication have ureterocele, which is a balloon-like obstruction at the end of one of the duplex tubes.

A multicystic kidney is a non-functional cystic kidney.

Normal Variant: Many of the dilated kidneys are found to be normal after delivery. It is likely that the dilation was due to the high urine output in the foetus and also because of the changes that occur in the kidney during development. Minor dilation of the kidney before birth does not always need evaluation after the child is born.

Management during Pregnancy: In nearly all instances of Antenatal hydronephrosis, ultrasound surveillance is all that is necessary. In the rare foetus with severe obstruction of both kidneys and insufficient amniotic fluid, drainage of the kidneys or bladder by tube or operation has been performed experimentally. For most cases of Antenatal Hydronephrosis pregnancy is not affected and delivery can be performed normally.

Management after birth: Postnatal ultrasound is usually performed before the child leaves the hospital. Voiding Cystourethrogram (VCUG), which requires a catheter in the bladder, is performed to exclude vesicoureteral reflux. This occurs in 25-30% of children with antenatal hydronephrosis. Obstruction is excluded with a diuretic renal scan (requiring an IV and a catheter). The renal scan is more accurate if delayed until the baby is one month of age,

Children with vesicoureteral reflux are managed with antibiotics and surveillance with periodic ultrasound and voiding cystogram. Children with an obstruction or blockage of the urinary tract may require surgical correction. In some babies, the evidence for obstruction is marginal or the degree of blockage is mild. In these babies, the tests might be repeated after a few months.

 A multicystic dysplastic kidney doesn’t function, but the opposite kidney is usually normal. There exists an argument about whether a multicystic kidney should be removed or left alone. Unless it is causing a problem with mass effect, pain or discomfort, and if is serially found to be enlarging during follow up raising suspicion of tumour or blockage, then nephrectomy (removal of the affected side kidney) is performed. Otherwise, it is usually left alone in infancy and followed-up with ultrasound at 6 months and a year after. Follow up to care opposite normal kidney is essential.

Circumcision is one of the oldest operations ever to be performed. Sometimes it is done because of a specific problem with the foreskin (prepuce) and other times it is performed routinely. Routine circumcision was once advocated for all newborn Males. This is now performed in about 65% of new-borns. Most boys will do fine later in life if their foreskins are not removed. Some may eventually need circumcision because of narrowing at the tip (phimosis), infections (posthitis or balanitis), or irritation. The foreskin may be a source for urinary tract infections, and circumcision may be a good idea in boys with any underlying kidney abnormality as it will help in proper analysis of the urine analysis.

In very young babies, circumcision is performed in the hospital or clinic with local anaesthesia and a clamp. Although it is a commonly performed procedure. It is technically difficult. It is not uncommon for there to be some redundant penile skin after newborn circumcision. As the child grows, this will become less noticeable. Adhesions of the foreskin to the glans, or head of the penis, are also very common. If there is significant scarring, these can develop into skin bridges. Simple adhesions will usually resolve over time, but the skin bridges will require surgical correction.

Other complications of circumcision include bleeding, infection, skin separation, narrowing of the urinary opening (meatal stenosis), concealed penis and urethral fistula. Every circumcision may not look exactly like the “ideal circumcision” in the mind of the family members. The main purpose of circumcision is to remove the preputial ring to permit exposure of the glans penis. This is more of a functional purpose than a cosmetic purpose and although we try to get a cosmetic result in line with familial expectations this is not always the case.

When a circumcision needs to be revised, we generally wait until the child is 6 months of age to minimize aesthetic risks. This is also the age that we will perform a first-time circumcision if it was not able to be completed in the newborn. The procedure is done under general anaesthesia in the outpatient surgery centre or hospital. Any adhesions or other abnormalities are corrected and the excess redundant foreskin is removed. The skin is closed with small absorbable sutures.

Antibiotic ointment or Vaseline is suggested to be applied to the glans with every diaper change after circumcision. This is required for at least a few months to try to protect the newly exposed meatus from diaper irritation.

Hypospadias is a birth defect found in boys in which the urethral opening is not at the tip of the penis, but can be anywhere on the undersurface of the penis to the scrotum. Although a genetic factor exists in the development of hypospadias, no single cause has been identified. Bending of the penis on erection may be associated with this and is known as chordee. The overall incidence of hypospadias is about 8.2 in every 1,000 male births. There is some family risk of hypospadias. When we see a boy with hypospadias there is a 15% chance of finding this in another family member such as a father or brother. There are different degrees of hypospadias, some minor and others more severe. In most children, the opening of the urethra is near the end of the penis. We name the types of hypospadias according to their anatomic location, which may be near the tip of glans penis or near the anal opening (perineal). And it is necessary to determine whether or not there is associated chordee and this will determine the type of surgery needed and if the surgery can be completed in one stage or two stages.

Some children may have chordee without hypospadias. The urethral opening in these patients is in the normal location.

Reasons for Correction

Surgical correction of hypospadias involves straightening of any chordee and then an extension of the urinary tube (urethra) out to the tip of the penis (the glans). A straight penis is necessary for satisfactory sexual function. Although this may not seem to be an important matter in childhood, this is a crucial concern later in life.

Surgical Correction of Hypospadias and Chordee

There are many operations used for the treatment of hypospadias. Fortunately, the techniques have improved dramatically decreasing the number of operations needed to correct this condition. When the operation is completed, any extra skin is removed so the child will look circumcised. It is recommended that the children have surgery to correct hypospadias at about 6 to 8 months of age. Although we try and correct most children with one operation, some of the more severe cases are best managed with two surgeries. A small number of patients may also require a second surgical procedure to manage complications of the surgery. If that is necessary, the second operation is delayed for 6 to 12 months by performing the first operation early in life then both operations can be completed before the child completes toilet training. Correction of hypospadias is performed on an outpatient basis under general anaesthesia. Depending upon the severity of the hypospadias, some children will need to go home with a catheter that drains urine from the bladder and allows the new urethra to heal. This tube will be left in place for one to two weeks. This will drain into the baby’s diaper until it is removed. We also leave a bandage on the penis. Due to the nature of the surgery, there can be considerable swelling and discolouration of the penis for a period of time after the surgical repair.

Complications

Infection of the skin and urine are few of the possible occurrences. Bladder spasms are usually due to the indwelling catheter. Medications help but do not eliminate spasms. Fistula is another risk. This is a leak of urine from somewhere along the new urethra. This risk is minimal in simple repairs but may occur 10% of the more extensive operations. Fistulas are usually easily repaired with an outpatient surgical procedure, although this is done no sooner than 6 to 12 months from the time of the original operation.

Stricture or stenosis consists of narrowing due to scar tissue where the new urethra joins the native urethra or at the new opening on the end of the penis.

Labial adhesions occur when the inner folds of the female genitalia (labia) temporarily grow or adhere together. They are most common in young girls (3 months to 6 years of age). Labial adhesions are related to hormonal influence. Labial adhesions usually occur due to inflammation of the skin which makes the labia adherent or stick to each other. Poor genital hygiene and bacteria normally present in the area may contribute to labial adhesions. Keeping the area clean and dry is important in the treatment and prevention of labial adhesions.

The majority of labial adhesions are asymptomatic. Post-void dribbling may occur due to labial adhesion. Urinary tract infections are rare with labial adhesion.

The initial treatment of labial adhesions is a trial of Estrogen cream. If this is the method chosen for your daughter, then you will need to apply the Estrogen cream 2 times per day for 2 -8 weeks as directed by your urologist. Use a pea-sized amount of cream and apply the cream to the middle of the adhesion and apply slight pressure with your finger.

Occasionally, a doctor will recommend separating the labial adhesions in the office with topical anaesthetic (numbing cream). In some children, this procedure is done under general anaesthesia in the hospital.

Once the adhesions are gone, you will want to prevent them from recurring. It is important to apply a thin layer of Estrogen cream on the area every night for at least a month.

What is Neurogenic Bladder (NB)?

NB is a term used, for a dysfunctional lower urinary tract, due to causes other than primary urinary tract pathology.

What happens in normal conditions?

Except in infants and small children, who have automatic & involuntary passing of urine, the act of passing urine is completely voluntary. Urination is initiated when a person wants to pass urine and can be controlled if the situation is not conducive. This passing of urine should be free, without the need to strain, and each time should empty the bladder. When the bladder keeps filling, the sphincters tighten and prevent a leak of urine. When the bladder contracts to empty, the sphincters open to let urine out. These work in an extremely coordinated manner. Any condition other than this, any involuntary leak of urine, or difficulty to urinate is abnormal and needs evaluation. Difficulty to pass urine, or leaking of urine can be a major social handicap or nuisance to others.

The passing of urine or controlling urination is under the control of the central nervous system. Messages from the brain are sent through the spinal cord and the lumbar and sacral nerves to the bladder and sphincters. If for any reason the spinal cord or its nerves are damaged, or the normal functioning of the brain itself is affected, this control is lost. The bladder may then lose sensation, and fail to empty, or may overwork; the sphincter may or may not open appropriately.

What conditions cause NB?

Diseases such as Parkinson’s, Alzheimer’s, multiple sclerosis, large cerebral haemorrhage, dementia, spinal cord injury /tumours/transverse myelitis, or injury to the nerves by surgery, diabetes mellitus, etc., may all cause a neurogenic bladder.

How do they present?

Such patients present with one or more of the following signs and symptoms: Retention of urine, inability to control urination (frequency, urgency), urine incontinence, loss of bladder sensation, etc. Disturbance of bowel control is also very common. These are in addition to the general symptoms of neurological injury such as coma/paralysis etc.

While physical disabilities may seem very frightening, they are usually not life-threatening. But bladder dysfunction, while not very overt, is usually the cause of severe morbidity, renal failure and even mortality. It is often neglected due to lack of awareness of its ill effects.

What are the investigations required?

The clinical diagnosis of a neurogenic bladder is made on the basis of certain simple and preliminary tests such as urine analysis, an ultrasound evaluation, MCU (micturating cystourethrogram) wherein contrast filled in the bladder and x-ray films are taken; urodynamic test in which bladder pressures and activities of the sphincters are measured during filling and voiding phase and this test will allow us to further plan his/her treatment. An MRI of the spine (see the picture below) or brain is required to look any cause in the nervous system.

what are the invetigations required

How is neurogenic bladder treated?

The focus in managing a neurogenic bladder is to prevent renal damage. Renal damage occurs due to intolerably increased pressures in the bladder, causing backpressure effect on the kidneys, resulting in their slow damage without symptoms in the early stages. They also develop urine infection, stones etc. All treatment will therefore, be aimed to reduce these bladder pressures.

The treatment options will be decided after urodynamic study.

The simplest of treatment would be to teach patients to pass a catheter themselves, every 4-6 hours, depending upon the urine volumes, to keep the bladder empty and also prevent incontinence. In males and in females the technique details on how to perform are mentioned.

Medicines are also used to reduce the pressures in the bladder. Generally, the tablets will need to be taken for a lifetime, till alternative therapies can be instituted.

Surgery: is done either to reduce the pressures in the bladder by adding bowel ( small or large intestine) with an increase of capacity, or by way of inserting an artificial sphincter to prevent a constant leak of urine. Surgery is resorted to only if all other measures have failed.

Management of neurogenic bladder must include bowel management also, as an integral part of the treatment. This may include a change in dietary fibre, enemas, and laxatives.

the-treatment

What is pelviureteric junction (PUJ) obstruction?

It is a restriction to flow of urine from the renal pelvis to the ureter, which if left uncorrected, may lead to progressive renal deterioration. The blockage is always partial but the degree of the block may vary from minimal to severe. Mild cases usually don’t impair kidney function. Severe cases can cause significant impairment in kidney function. Because it impedes the flow of urine, there is a resulting enlargement of the renal pelvis (hydronephrosis).

PUJ Obstruction (PUJO) is the most common cause (48%) of significant hydronephrosis detected on prenatal ultrasound or in new-borns.

What Causes PUJO?

Most often PUJO is congenital (present from birth), usually because of an abnormality in the development of the muscle surrounding the PUJ. PUJO can also occur later in life and can be caused by other factors, including compression of the ureter by abnormal blood vessels, inflammation, stones or a scar tissue.

What are the symptoms of PUJO?

Most infants (less than 1 year) are asymptomatic, and most children are discovered because of their symptoms. Symptoms suggesting PUJO include hematuria (blood in the urine), urinary tract infection (UTI), kidney stones, failure to thrive, pain associated with nausea and vomiting, abdominal fullness/palpable mass or hypertension.

What tests are required to confirm the diagnosis?

Due to the increased use of antenatal ultrasound (during pregnancy), if any hydronephrosis is identified, the foetus will need to be monitored throughout the pregnancy. Once the baby is born, a repeat ultrasound is to be done at least a week after delivery to confirm the PUJO.

If PUJO is affecting one kidney, then further investigations can be done when an infant is 4-6 weeks of age. These tests would include blood and urine tests to find out overall kidney function and to rule out UTI.

If both the kidneys are affected by PUJO, your Urologist may get blood and urine tests at the earliest to know the status of overall kidney function. Further course would be decided based on these reports and other details on ultrasound.

A nuclear scan (DTPA renogram or EC renogram) uses radioactive isotope which is injected intravenously (IV) and this isotope is taken up by the kidneys and excreted in the urine. Using a special camera, images of the kidneys can be seen clearly. This test gives information about individual kidney function as well as degree of blockage. This test can be done above the age of 4- 6 weeks.

CT scans are rarely required to confirm this condition and are also avoided as this involves higher radiation.

Do all cases of PUJO need surgery?

No. Following are some of the common indications:

Presence of symptoms (noted above) associated with the obstruction

Impairment of overall renal function

Progressive impairment of obstructed kidney function

Development of stones or infection, or causal hypertension

What is the aim and goal of correcting this condition surgically?

The aim is to restore non-obstructed urinary flow. The primary goal of surgery is relief of symptoms and preservation or improvement of renal function.

what is the aim

What is the surgical procedure most commonly performed for this condition?

Pyeloplasty, is a surgical procedure that removes the scar tissue from the blocked area and reconnects the healthy part of the ureter to the renal pelvis, so as to create a wide opening. The success rate is higher than 95 %. Most of the time, open surgery is performed in infants. In older children and adults the same procedure can be performed laparoscopically (keyhole surgery).

A tube called ureteric stent is usually placed to drain urine from the operated kidney across the area of repair to the bladder. In addition, you may have a bladder drainage tube (urethral catheter).

Rarely a nephrostomy tube (the inner end in the kidney and coming out of a separate small incision in the flank region) is required to drain the kidney (this is done when placement of ureteric stent was not possible). Sometimes a drain tube is placed around the area of repair (outside the kidney), to drain any blood/urine collection.

What is the dos and don’ts after this surgery?

You can have regular diet, once you are able to tolerate orally. Sometimes, especially infants will have swelling of the tummy (abdomen) and this subsides in a day or two, till then I.V. fluids would be continued.

The urethral catheter is usually removed on the 3rd day morning after surgery. And you will be allowed to go home later that evening with ureteric stent (not visible outside the body) if you are doing well. Drain tube or nephrostomy tube, if placed, would be removed at appropriate times based on clinical situation.

With ureteric stent inside, you may experience urgency, frequency, burning urination, mild blood-tinged urine and flank pain for a minute or so when you are passing urine. These are expected things, but if you have severe pain or high grade fever, do contact your doctor.

You will need to repeat urine culture 2 weeks after surgery. Based on the report, ureteric stent removal would be planned, if required under cover of appropriate antibiotics based on sensitivity.

What are the possible complications if this condition is left untreated?

If left untreated, PUJ obstruction can lead to progressive loss of kidney function, kidney stones or infection.

What is the follow up after stent removal?

Renal ultrasound is obtained 3 months after pyeloplasty to ensure that the hydronephrosis is reduced or at least remaining stable. A nuclear scan (DTPA/EC) may be obtained 1 year after the pyeloplasty to provide a relative assessment of the overall renal function and drainage pattern.

When do you say surgery is successful?

Improvement in hydronephrosis on ultrasound and stabilization or improvement in function on nuclear scan (DTPA/EC). If the patient had a symptomatic presentation, resolution of flank/abdominal pain or vomiting should also occur.

What are the other complications of surgery?

Less than 5% of patients may have a recurrence of narrowing at the PUJ requiring redo surgery. Urinary leakage from the area of surgery may require placement of a percutaneous drain. Other problems include wound infection and hernia which are very rare.

what are the other

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