Paediatrics Flashcards
Classification and etiology VUR? (9)
• Primary: incompetent or inadequate closure of UVJ
- Lateral ureteral insertion instead of oblique
- Short submucosal tunnel segment where ureter runs through bladder wall
• secondary: abnormally high intravesical pressure resulting in failed closure (NOTICE)
- neuropathic bladder,
- outflow obstruction due to posterior urethral values, dysfunctional voiding
- Trauma: previous surgery for VUR, ureteric meatotomy
- Infection: febrile UTI
- congenital ureteric abnormalities: duplex ureters, para-ureteric diverticulum, ureterocoele
Name 4 risk factors VUR
- White
- female
- age <2
- genetic predisposition
Name 3 complications VUR
• Reflux nephropathy (chronic pyelonephritis)
-Renal scarring if infected urine and intrarenal reflux
• renal ht due to renal scarring
• chronic renal failure due to bilateral VUR
Presentation VUR? (3)
- recurrent UTI
- flank pain
- chronic renal failure/ oliguria
Diagnosis VUR? (5)
• MCUG gold standard! - do once UTI treated, grade severity, exclude causes secondary VUR
. Ultrasound!- hydronephrosis or hydro ureter, renal size and scarring, bladder wall thickening (suggest secondary VUR )
• DMSA scan- diagnose acute pyelonephritis, best for detecting renal scarring
• urine dipstick signs UTI:haematuria, white cells, nitrites.
• indirect nuclear cystography for follow up, urondynamics if secondary bladder cause suspected.
Medical Treatment VUR?
- 60% of primary reflux resolve spontaneously by puberty. Thus most patients grades 1-3 treated medically.
- long term low dose antibiotic chemoprophylaxis: nitrofurantoin, nalidixic acid, tmp/smx (bactrim), trimethoprim, or amoxicillin
- regular follow up to check for UTI, state of reflux and stop when resolved
Name 5 indications for surgical treatment of VUR
- Failure medical treatment to prevent UTI
- poor compliance medical treatment
- severe reflux unlikely to solve spontaneously- grade 4 or 5
- Associated pathology ey para-ureteric diverticulum
- persistent VUR in female adolescents to prevent problems during pregnancy
- renal scarring leading to insufficiency, ht
Name and describe 2 surgical treatment options for VUR
• Endoscopic: bulking agent injectables eg Teflon, placed submucosally behind ureter to give “backing” to enable coaptation during bladder filling and contraction (mimic valve mechanism)
- STING procedure (subureteric Teflon injection)
- mild to moderate VUR
• surgical ureteroneocystostomy
- Re-implant ureter into bladder
- principles: Create valvular mechanism → ureteric compression during bladder filling and contraction; sufficient length and backing of submucosal tunnel; optimal ratio of length to diameter of ureteric tunnel 5:1
- > 90% success rate
Grading of VUR?
Based on cystogram.
• grade 1 : ureters only fill
• grade 2: ureters and pelvis
• grade 3: ureters and pelvis fill with some dilatation
• grade 4: ureters, pelvis and calyces fill with significant dilatation
• Grace 5: major dilataton and tortuosity
Classification and aetiology puj obstruction? (6)
Primary
• increased amount or abnormal sphincter-like arrangement of circular muscle at junction of renal pelvis and ureter
• increased collagen between muscle bundles, preventing cell-to-cell transmission of impulses that cause peristaltic contractions
• high insertion ureter precluding efficient drainage of renal pelvis
• extrinsic compression by blood vessel running to lower pole of kidney
Secondary (rare)
• lumen: calculus, blood clot, tumour, polyp
• wall: kinks from tortuous ureters in reflux, Tb stricture, complication stone surgery or previous pyeloplasty
Clinical presentation puj obstruction (5)
Mostly asymptomatic finding on antenatal ultrasound, cardiac catheterisation
• UTI
• cystic loin mass, especially infants
• loin pain with fluid load older children
• haematuria
• present with complications eg pyelonephritis, renal failure
Name 6 complications puj obstruction
•Pyelonephritis • renal failure • calculi due to stasis • hypertension rare • lung hypoplasia in neonates • hydronephrosis • rupture uncommon . Trauma: pathological kidney more liable
Diagnosis puj obstruction
• Ultrasound: hydronephrosis, thick renal cortex, exclude hydroureter!
• confirm with radionucleotide studies!
- mag 3 diuresis renogram with iv furosemide, “brings out’ functional obstruction at puj
- dmsa show amount of functioning cortical tissue, renal scarring
• IVP in older children/adults!
- dilated renal pelvis with normal ureter.
Treatment puj obstruction (5)
• 85% conservative treatment as long as >40% differential function on radionuclide renogram and no complications. Insert percutaneous nephrostomy tube.
• surgical if don’t meet above criteria
- pyeloplasty most commonly done: excise obstructed pant and tailor dilated pelvis - Anderson Hynes pyeloplasty
- balloon dilatation
- endopyelotomy (ureteroscopy and incise puj from inside with laser)
_Nephrectomy if < 15% differential function
