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Pediatric Surgery (Pg 68-81) - page 19 / 33





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Radionucleotide cystogram: VCUG with a radioisotope, is more sensitive to small degrees of reflux.

Renal ultrasound and IVP can detect dilatation of upper urinary tract but cannot alone diagnose reflux.

Treatment of VUR:

Goal is to prevent UTI and renal damage.

In kids 80% will eventually resolve, use antibiotics until resolved, reculture every 3 mo, with every fever and all urinary symptoms. VCUG, renal ultrasound, creatinine, BUN, height, weight and bp annually.

Surgery if repeat UTIs, poor compliance, failed management, or loss of renal fxn.

Ureteral implantation, lengthens the intramural portion of the ureter, immobilizing ureteral meatus, supporting ureter.

Mild reflux: can inject Teflon or collagen into bladder wall at the ureteral orifice, too new for FDA approval.  There is concern about mobilization of the Teflon to the brain or lungs.

Glenn-Anderson technique for VUR: makes a long submucosal tunnel for the ureters

Cohen procedure for VUR: cross trigone tunneling of the ureters

Politano-Leadbetter technique for VUR:  ureter is totally mobilized from bladder, then brought to a new orifice created superolaterally

Other anomalies:

Extrophy: improper development of abdominal wall, pelvic girdle, and anterior bladder wall.  Posterior bladder wall exposed, pubic symphasis separated. Uncommon, 3:1 in males, leads to incontinence, UTI’s, increased risk of adenocarcinoma of bladder.  Total reconstruction needed.

Uracheal persistence: can be an umbilical sinus, abdominal wall cyst, diverticula off of bladder or fistula from bladder to umbilicus.  Excise to treat. Assc with adenocarcenoma.  Can not tell congenital from acquired.


Penetrating: gunshot, stab, instrumentation

Blunt: rupture, intra/extra peritoneal extravasation, usually other pelvic and abdominal injuries accompany, presents with severe suprapubic/pelvic pain, unable to void


Cystogram to check for bladder rupture: contrast in bladder, image, take a post-drainage image, 15% diagnosed post drainage

Retrograde urethrogram to check for urethral tear


Small extraperitoneal rupture: 1-2 wks with foley

Intraperitoneal or large extraperitoneal rupture will need surgery

Inflammatory disease

Bacterial cystitis:

irratative voiding symptoms: dysuria, frequency, urgency, nocturia, possible hematuria.

More common in women- fecal contamination

In men due to retention, incomplete voiding

E. coli 80% of UTI’s

Evaluate: UA.

If not responsive to antibiotics then cystoscopy and radiography

Carcinoma considered if irritation persists with UA is neg.

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