RECENT ADVANCES IN PAEDIATRIC UROLOGY

RECENT ADVANCES IN PAEDIATRIC UROLOGY

Harshad Punjani
Hon. Paediatric Urologist, Bombay Hospital Institute of Medical Sciences, Mumbai 20.

Twentieth century has been the century of discoveries and innovations. Paediatric urology has not remained the mute observer to this.

Foremost advance which I consider the most important is recognition gained by Paediatric urology as a speciality in our country. So far paediatric surgeons felt it was logically their perview to do paediatric urology since affix paediatric was attached while urologist felt it was their piece of cake since last word was urology. Colleagues both specialities have now come to the understanding that it belongs to one who dedicates time to learn, understand and master the techniques to treat couplicated problems in children.. More important is that referring physician has become wise and known whom to refer to.

Antenatal diagnosis of urinary tract abnormalities has brought a seachange in our understanding of congenital urinary tract obstruction and has allowed us to study the natural progress of the disease since its inception. Many questions have been raised once the antenatal diagnosis is made.

— Is antenatal intervention required?

— Is early induction or caesarean section required to treat obstructed
..... kidneys?

— How frequently will the child need screening?

— Is surgery required and if yes, when?

Antenatal intervention is a logical offshoot of antenatal diagnosis of urinary tract obstruction. The purpose of antenatal intervention is not only to prevent mortality but also to avoid the creation of a crippled child. The large majority of correctable foetal malformations are best treated after delivery. Few antenatal procedures which have gained popularity are:

1) vesico-amniotic catheter shunting.

Principle of the procedure is to drain the foetal bladder into the amniotic space.

2) Open foetal surgery

Bilateral ureterostomies, vesicostomy

3) Foetal endoscopic surgery

These procedures are done at very specialised centres and they have yet to convince their necessity except in few cases.

Laparoscopy for diagnosis and treatment of various paediatric urological conditions is another recent advance. After gaining a firm footings in adult, laparoscopy has marched forward to paediatrics. Absolute indication of laparoscopy is in nonpalpable undescended testes, which cannot be located on sonography, CT scanning, MRI scan, angiography has become obsolete after introduction of laparoscopy. Laparoscopy not only diagnoses with almost 100% accuracy but help to mobilise intra-abdominal portion of testis. Laparoscopy also helps to decide whether procedure needs to be done in stages or testis is atrophic and needs orchidectomy. First stage of procedure of exploration for intraabdominal testis and orchiectomy if indicated can be accomplished laparoscopically, thus avoiding large abdominal scar and extensive dissection.

Other indications for use of laparoscopy are in diagnosis of intersex, dismembered pyeloplasty for pelvi ureteric junction obstruction, and nephrectomy for non functioning kidneys. Experts have done almost every operation laparoscopically. Except in undescended testis and intersex diagnosis, laparoscopy has not been accepted widely so far. In children surgery is done through small incision and kids healing is very fast. So the advantage of laparoscopy is not very evident as in adults.

It is now known that undescended testis must be brought down by 1st birth day and not later than 2nd birthday. It has been proved beyond doubt that undescended testis undergo rapid damage after the age of one year.

Vesico-ureteric reflux (vu Reflux) is the commonest cause of recurrent urinary tract infection, in tinytots.

During my residency in paediatric urology in 1978, surgical reimplantation was the only treatment available. Extensive Europian studies have shown that uretero-trigonal complex matures as age advances and in many vu reflux will correct itself. Physician just needs to closely follow up the child and see that urinary infection does not occur. Child is kept on low dose chemoprophylaxis. It has also been shown that reflux without infection does not damage the kidney. Observation with chemoprophylaxis has given rewading results.

— In Grade I and II V.U. reflux will correct itself in 90%

— In Grade III it will correct upto 45% and
— In Grade IV and Grade V it will correct between 10 and 25%
— Parents and child must be co-operative.

— There should not be multiple breakthrough infection and further damage
..... to Kidney.
— Socio-economic condition of the family need consideration.

Endoscopic correction of VU reflux is also becoming popular. Various bioadaptable materials are being used. In this procedure an inert, bio-acceptable material is injected under the ureteric orifice at the level of lamina propria-endoscopically. It is a short procedure and patient is discharged the same day. Success rates are very high and depends on the grade of reflux. Various materials are used like Teflon, Collagen, Silicone micro-implants, polyvinyl alcohol, Detachable balloon etc. Most commonly used material in our country and Ireland is Teflon. It has its own disadvantage of migration and granuloma formation.

Introduction of neonatal and infant size cystoscopes with irrigating and working channel for endoscopy procedures have revolutionalised the treatment of obstructive lower urinary tract pathology. Commonest condition is posterior urethral valves. Just 10 years before smallest cystoscope that was available was 10 Fr. size. Urethra needed to be dilated or perineal urethrostomy required to fulgurate the valves. Now 4.5 Fr. and 6 Fr. size cystoscope can work easily in the newborn.

Introduction and use of urodynamic studies have helped us to study neurogenic bladder and bladders in posterior urethral valve cases. Proper management of bladder in these cases have reduced recurrent infection, given socially acceptable contenence at low intravesical pressure and avoided damage to kidneys. Thus bringing down the incidence of renal failure.

REFERENCES

Arger PH, Coleman BG, Mintz MC, et al. Routine fetal genito urinary screening. Radiology 1985; 156 : 485-89.

Bruno AW, Lavin JP, Nasrallah PF. Ultrasound experience with prenatal genitourinary abnormalities. Urology 1985; 26 : 196-202.

Appelman Z, Golbus MS. The management of fetal urinary tract obstruction. Clin Obstet Gynecol 1986; 29 : 483-87.

Quintero RA, Hume R, Smith C, et al. Percutaneous fetal cystoscopy and endoscopic fulguration of posterior urethral valves. Am J Obstet Gynecol 1995; 172 : 206.

Manning FA, Harman LR, Lange IR, et al. Antepartum chronic fetal vesicoamniotic shunts for obstructive uropathy a report of two cases. Am J Obstet Gynecol 1983; 145 : 819-22.

Malone DS, Quiney DJ. A comparison between ultrasonography and Laparoscopy in localizing impalpable undescended testes. Br J Urol 1985; 57 : 185.

Bloom DA. Two step orchidopexy with pelviscopic clip ligation of spermatic vessels. American Academy of Paediatrics 59th Annual Meeting. Bosten Oct. 1990.

To Section TOC