Journal Archives - Volume 10
Urodynamic studies provide a quantifiable measure of lower urinary tract storage and evacuation function, and are often helpful in documenting the etiology of a child’s voiding disturbance or dysfunction. Urodynamic evaluation serves as a critical tool in the early identification of children at risk for untoward upper urinary tract deterioration and serve as a useful guide for the clinical management of lower urinary tract dysfunction. With advances in the understanding of lower urinary tract dysfunction, it is imperative to have a clear, unequivocal standard terminology that provides for consistency in research methodology and data analysis. In this chapter, the authors detail the urodynamic parameters that guide the management of bladder dysfunction in children.
This chapter on bladder dysfunction and the long-term outcome of urodynamic abnormalities in boys with PUV is mainly based on author’s pioneering studies of boys, adolescents and adults. The author’s focus is on those patients who present with severe obstructive valves which affect the upper urinary tracts, often diagnosed prenatally or in the neonatal period. Based upon the observations on her pioneering studies, the author believes that with improved survival of children with valves, due to better basic care, prenatal diagnosis and an ability to transplant at an early age, more boys will experience the long-term complications seen after urethral valves. It is important that both renal and bladder function is assessed throughout life. Increasing attention to bladder dysfunction and early treatment including urotherapy, pharmacological tools, clean intermittent catheterization and bladder augmentation when needed will probably improve the long-term prognosis.
The non-compliant bladder has a diverse aetiology with a common pathophysiological pathway – increased type III collagen in the extracellular bladder matrix leading to fibrosis and poor compliance. Early recognition via appropriate urodynamic assessment may limit or reverse the deterioration in bladder function. The non-compliant bladder spans a spectrum of the more severe clinical problems encountered in paediatric urology. Poor compliance is associated with elevation of the detrusor leak point pressure ultimately leading to upper tract damage. Bladder compliance in children can be difficult to assess as it changes with bladder volume, which changes with age. In addition, detrusor pressure can be affected by rate of bladder filling and there is no reliable reference value for compliance in children. In this chapter authors have dealth wtih the aetiology, pathophysiology, assessment and management of the non- compliant bladder.
Over the last two decades the indications for bladder augmentation have expanded. Increasing use of segments of G.I.T., such as ileum, colon and stomach, has provided an opportunity to study the relationship between urothelium and the mucosa of the G.I.T. Several alternative options, such as, ureterocystoplasty, detrusorraphy and demucosalized segments have also been explored over a period of time. Availability of long term results with these procedures has provided valuable insights. This chapter lays emphasis on conditions that need augmentation, options available and complications of augmentation in children.
Gynaecologic disorders in newborns and children are not commonly encountered. In order to address the gynaecologic concern, the clinician should be aware of the normal growth and development of the genital tract as well as the pathology that may occur. In this chapter a differential diagnosis of the common presenting complaints in paediatric gynaecology is being discussed giving illustrated examples. The emphasis is on examination techniques, presenting symptoms, role of investigations and initial therapeutic management.
The primary objectives of paediatric urologists could be summarised as the saving of life, nephrons and bladder. Secondarily, they will strive to protect sexuality and fertility. All who have the care of children are concerned to prepare them for adult life at least by minimising the interruptions to education. In this context the author emphasizes the importance of ‘Transitional care’ especially, when a big ‘leap’ is involved with the child having to move from a childrens’ hospital to an adult hospital. This will be particularly true if there is no pathway of transitional care and no adult urologist who understands the long term problems of the major congenital and acquired anomalies of the child’s genito-urinary tract. In other words, if there is no adolescent urologist. The author highlights management issues in adolescent urology by giving illustrated examples on various surgical procedures carried out in childhood. A range of clinical situations have been cited which include sexual and fertility issues, bladder augmentation, hypospadias and intersex, etc.
Vesico-ureteric reflux can be an isolated finding but is usually discovered during evaluation of the urinary tract for a number of indications which include but are not limited to urinary tract infection, hydronephrosis or hydroureteronephrosis, congenital renal anomalies, possible posterior urethral valves ( PUV), bladder diverticula, hypospadias, cloacal anomalies, imperforate anus, lower urinary tract trauma, enuresis and neurogenic bladder. While reflux can occur in normally located ureterovesical junctions, it can occur in ectopic ureters and lower or upper pole moieties. In this chapter the authors discuss contrast studies as well as direct and indirect radionuclide studies in the assessment of VUR. This chapter provides illustrated examples of the technical details as well as the interpretation of these studies in various physiological and pathological states.
Chronic renal insufficiency is a multisystem disease. Factors associated with progression of kidney disease in children include older age, certain racial make-up, acquired renal disease, baseline GFR and systolic hypertension. Attempts should be made to diagnose and treat immunologic, infectious and obstructive causes of kidney disease. In this chapter the authors emphasize the importance of adherence to recommended health maintenance evaluation, high index of suspicion and applying preventive measures.
Across the world, the prevalence of paediatric end-stage renal disease ranges between 5 and 10 cases per million children per year and the preferred method of renal replacement therapy for almost all of these patients is renal transplantation. As greater knowledge of the immune response to allograft tissue has been obtained, improved anti-rejection prophylaxis and treatment of acute rejection has been associated with better long-term survival of renal transplants. Compared to adults, renal transplantation in children provides added technical, immunologic and metabolic challenges. These differences must be taken into account when designing and selecting immunosuppressive regimens for paediatric recipients.