SURGERY IN THE PERINATAL AND PEDIATRIC PATIENT
Guest Lecturer: Peter D. Furness, III, MD, Associate Professor of Surgery and Pediatrics, University of Colorado
Health Sciences Center; Associate Chief, Pediatric Urology, The Children’s Hospital, Denver, CO
| SEVERELY DILATED URETER: URETEROURETEROSTOMY
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| Ureteral duplication: occurs in ≈0.57% of general population; women outnumber men 3:1; unilateral process more
common than bilateral
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 | Indications for surgery: high-grade reflux (usually associated with lower-pole ureter); obstruction (usually associated
with upper-pole ureter); partial nephrectomy indicated if nonfunctioning unit subtends ureter; if functioning parenchyma
present, perform common sheath ureteral reimplant
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| Ureteroureterostomy (UU): first performed in 1928; popularity hindered by concerns over ureteral disparity and
surgical technique; in 2001 review of UUs performed in 94 patients, 76% of cases had ureteral disparities, but disparities
not associated with higher rates of complication or failure; overall success rate 94%; in speaker’s experience,
of 59 children undergoing UU, 45 girls; mean age 30 mo (mean follow-up 12 mo); all patients had ureteral
disparities (23 ureteroceles, 26 ectopic duplication anomalies, and 10 high-grade reflux duplication anomalies); distal
reimplants of recipient ureters also performed; overall success rate 95%
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| Complications: ipsilateral reflux in reimplanted ureter (3 patients; 2 resolved spontaneously); 2 urinomas related to
premature removal of ureteral stent (drainage successful); 1 transient bladder neurapraxia
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| Technique: make 2-cm incision; insert cystoscope; place stent in recipient ureter to facilitate dissection; dissect and
separate ureters down to common blood supply and excise redundant ureter; perform ureterotomy on recipient organ,
then put ureter together
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| Literature review: of 235 patients undergoing UU for duplication anomalies, only 8 developed complications; success rate
97%
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| Advantages of UU: fast and easy; small incision; can be performed as 23-hour outpatient procedure; flank surgery
avoided; ureteral tailoring unnecessary
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| Disadvantages: minimal; some authors cite need for stent, but necessary with ureteral tailoring also; possible postoperative
reflux or obstruction (easily fixed)
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| PRENATAL HYDRONEPHROSIS: POSTNATAL MANAGEMENT
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| Definition of prenatal hydronephrosis: renal pelvis dilatation of 5 mm; when seen at 20 to 30 wk gestation, suggests
possible postnatal complications; 7 to 10 mm of dilatation seen any time during pregnancy also cause for concern
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| Natural history: 50% of cases resolve spontaneously
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| Ultrasonography (US) findings associated with poor outcome: bilateral anomalies; oligohydramnios; renal cysts;
megacyst; absence of bladder
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| Multicystic renal dysplasia: multiple renal cysts; no common coalescence at renal pelvis; do not mistake for pyramids
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| Predictive value of US or laboratory findings: bilateral hydronephrosis with oligohydramnios by second trimester
portends poor fetal outcome; unilateral hydronephrosis without oligohydramnios associated with 100% survival
and good urinary and pulmonary function
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| Fetal interventions: surgery to relieve bladder outlet obstruction early in pregnancy can prevent renal dysplasia, with
positive effects on renal and pulmonary function; in one study, if sequential vesicocentesis (repeated decompression
of bladder) produced decrease in urinary electrolytes and osmolality, outcome good; rising values associated with irreversible
renal damage; oligohydramnios and hydronephrosis also good predictors of outcome in other studies
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| Olighydramnios and pulmonary function: lung development starts 3 to 4 wk into gestation; continues up to 24 wk
(when surfactant production begins); animal studies link early oligohydramnios to pulmonary hypoplasia; fluid restoration
restores lung development and improves outcome; second trimester key for human pulmonary development;
pulmonary effect of late gestational oligohydramnios minimal (renal consequences vary)
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| Fetal intervention: goal to optimize renal function and restore amniotic fluid to promote pulmonary development
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| Vesicoamniotic shunt: bypasses lower urinary tract obstruction to bring urine into amniotic space; in 1997 study, failure
to restore amniotic fluid to normal associated with 100% fetal mortality; even successful shunts associated
with 50% mortality rate and 50% complication rate; complications include inability to place shunt, shunt migration,
induction of premature labor, infection, urinary ascites, and iatrogenic gastroschisis
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| Indications: bilateral process with severe persistent or progressive hydronephrosis; oligohydramnios; patient must
have normal karyotype, no other structural anomalies, favorable urine chemistry, and no overt renal dysplasia; accurate
informed consent essential
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| Contraindications: unilateral process; normal amniotic fluid; presence of chromosomal abnormalities; unfavorable
chemistries on serial examinations
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| Other types of fetal interventions: mostly experimental; small studies; interventions include fetal endoscopy and fetal
surgery (neither proven superior to shunting); pregnancy termination sometimes recommended if fetus has abnormal
karyotype or severe structural anomalies; premature delivery not helpful; extensive counseling necessary
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| Goal of management: to intervene in fetuses with congenital anomaly that, if untreated, threatens child’s well-being; results
of shunting currently no better than those obtained by chance; more studies needed before recommended as intervention;
no evidence that relieving prenatal hydronephrosis ultimately improves renal function, but early correction of
oligohydramnios can improve pulmonary function
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| Postnatal management: US indications for postnatal evaluation include 5 mm dilatation of renal pelvis at 20 to 30
wk gestation or \>7 mm dilatation at >30 wk; hydronephrosis associated with other anomalies, including Down’s
syndrome; start hydronephrotic child on antibiotics on first day of life to prevent urosepsis
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| Grading system developed by Society for Fetal Urology based on postnatal US findings: grade I—mild separation;
grade II—slightly larger separation, but no major caliectasis; grade III—caliectasis present, but parenchyma preserved;
grade IV—grossly distended hydronephrosis with parenchymal thinning; US recommended at 48 to 72 hr
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| Unilateral process: prognosis good, but follow child for potential morbidity; obtain x-rays during first month after
birth; administer prophylactic antibiotics; without oligohydramnios, survival 100%
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| Bilateral process: boy—check for posterior urethral valves with renal US and voiding cystourethrography (VCUG)
before discharge; immediate surgery recommended if possible, plus antibiotic prophylaxis; girl—cause is reflux or
bilateral obstruction of ureteropelvic junction; bilateral US and VCUG indicated before discharge if problems arise
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| Reasons for evaluating prenatal hydronephrosis: US detects anomalies, but findings nonspecific; in prospective
study of fetuses (20-26 wk gestation) with early pyelectasis (dilatation \>4 mm) followed with serial prenatal and postnatal
US and VCUG, infants with mild pyelectasis had 40% risk for postnatal uropathy; in 1994 study of 129 fetuses,
60% had urologic pathology; dilation >10 mm associated with >2-fold risk for some urologic condition; conclusion—
difficult to predict who will develop postnatal uropathy
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| Indications for postnatal VCUG: moderate-to-severe prenatal hydronephrosis; significance of mild hydronephrosis
still in question; however, 25% of mild cases progressive, and 25% receive significant postnatal diagnoses but do
not progress
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| Algorithm: for children with prenatal hydronephrosis, perform US at 3 to 5 days; if normal, repeat after 1 mo; if abnormal,
perform VCUG and administer prophylactic antibiotics; treat valves if present; if VCUG normal with grade
III to IV hydronephrosis, plan renal US at 4 wk; diagnose obstruction and proceed with surgery if differential function
on affected side <40%; if partial function present, repeat imaging studies within 3 to 4 mo; ≈80% of cases resolve
spontaneously
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| MINIMALLY INVASIVE OPEN RENAL SURGERY
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| Background: open surgery in children associated with excellent results; average length of stay for outpatient surgery
10 hr; even with incisions as large as 5 to 6 cm in anterior subcostal line, 23-hr stay possible; pediatric patients recover
faster than adults and with less pain
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| Pediatric laparoscopic renal surgery: “taken off” with advent of smaller instruments and improved laparascopic technique;
however, advantages over open surgery seen in adults still not proven in pediatric patients; 2 French comparisons
of laparascopic and open procedures showed experiences comparable, except for shorter length of stay (LOS)
associated with laparoscopy; in United States, LOS similar in both groups
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| Comparison of laparoscopic and minimally invasive open techniques at speaker’s institution: retrospective
review of 134 patients undergoing open surgery; patients placed in flank position with slight anterior tilt; transverse
skin incision used; entered retroperitoneum using longitudinal fascia/muscle-splitting incision; pyeloplasty—
identified lower renal pole, then ureter and ureteropelvic junction; surgery performed extracorporally whenever possible;
nephrectomy—decompression performed first, followed by externalization of kidney and hilar control; partial nephrectomy
done with supracostal incision to access upper renal pole; surgical times—comparable to those associated with traditional
open techniques and shorter than laparoscopic reconstructive techniques; incision length—2 cm for patients <5
yr of age; 3 cm in those aged 5 to 10 yr; \>3.5 cm in patients >10 yr; all patients discharged within 23 hr; no patient <10 yr
of age required postsurgical narcotic analgesics; success rate of pyeloplasties 96.7% (38% of patients required second procedure
for stent removal); conclusions—operative times of minimally invasive surgeries similar to those of traditional
procedures and superior to those of laparoscopic pyeloplasties; small incisions associated with shorter LOS, minimal pain,
and excellent cosmesis; surgical results excellent and comparable to those reported in literature; incision size in last 20 infants
1 to 1.5 cm; perhaps time to question laparoscopy as new gold standard (possibly indicated for patients >5 yr, especially
if body habitus poor or if parents wish)
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| URINARY INCONTINENCE: BLADDER NECK SLING WITH SMALL INTESTINAL SUBMUCOSA (SIS)
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| Conditions associated with pediatric bladder dysfunction: spina bifida among most common, due to prevalence
of lumbosacral lesions; associated with small poorly compliant areflexive bladder; management goal upper
tract preservation, even at expense of continence
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| When to consider continence procedures: when social consequences become important (around school age)
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| Evaluations: video urodynamics, VCUG, renal US, and urinary history
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| Treatment: maximize medical management; start clean intermittent catheterization (ascertain that child can empty
bladder); evaluate bladder compliance; increase urethral resistance if intrinsic sphincter deficiency present; consider
surgery if medical management fails
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| Surgical procedures: no data on which one (if any) best; can be classified as bladder neck suspension (coaptive), tubularization
(tapering), or flap valve procedures; injection of bulking agents; bladder neck closure “last-ditch effort” in
pediatric population”, for all, success rates 70% to 80% (except for bulking agents [“abysmal”])
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| Bladder neck sling materials: nonsynthetic ones include rectus fascia, fascia lata, myofascial wraps, and SIS; results
with all good (small series); study of 58 patients receiving rectus fascia sling (all patients also underwent bladder
augmentation), continence 88% at 4 yr of follow-up; study of 36 patients undergoing bladder neck sling with SIS
(some also underwent bladder neck tapering), continence rates 70% and 89%, respectively; girls did better than
boys; in boys, continence associated with ambulatory status or orthopedic condition; chances of incontinence 75%
in wheelchair-bound patients, compared to 40% in ambulatory patients; in one small study (N=4), combined sling-
tapering procedure provided 100% continence in nonambulatory patients
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| SIS: submucosal layer of pig intestine; acellular collagen matrix with intrinsic growth factors that can induce in vivo tissue-specific
regeneration (cytokines stimulate development of host organ attributes); SIS readily available; eliminates
need for fascia harvest; speaker and colleagues perform combined bladder suspension and sling/coaptation through 4-
cm midline lower abdominal incision, accessing space between bladder and proximal urethra from above
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| Experience with bladder neck reconstruction: 30 cases over past 7 yr, including 20 SIS slings; overall continence rate
77%; mean age of patients receiving SIS slings 7.8 yr, with mean follow-up of 3.6 yr; continence achieved in 15 of
those patients; 2 more patients became dry after undergoing bladder augmentation (one also required deflux); no
complications specifically related to sling
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| Conclusions: consider SIS sling for patients who need bladder neck reconstruction; ambulatory boys may benefit from
bladder neck tapering as well (not yet confirmed)
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Educational Objectives
| The goal of this program is to review the diagnosis and management of perinatal urologic conditions. After hearing
and assimilating this program, the listener will be able to:
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| 1. Identify candidates for ureteroureterostomy.
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| 2. Interpret prenatal ultrasonography or laboratory findings associated with hydronephrosis.
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| 3. Plan the postnatal management of a baby born with hydronephrosis or oligohydramnios.
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| 4. Explain why minimally invasive open renal surgery may be preferable to laparoscopic surgery in the pediatric
patient.
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| 5. Describe the advantages of bladder neck reconstruction for selected patients with urinary incontinence.
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Discussed on this Program
Acetaminophen (N -acetyl-P -aminophenol; APAP) [several preparations and trade names]
Amoxicillin [Amoxil, Amoxil Pediatric Drops, Trimox, Trimox Pediatric Drops]
Ketorolac tromethamine [Acular, Acular LS, Acular PF, Toradol]
Suggested Reading
Bugg CE Jr, and Joseph DB: Bladder neck cinch for pediatric neurogenic outlet deficiency. J Urol 170: 1501,
2003; Caione P, and Lais A: The endoscopic treatment of incontinence in children. Curr Urol Rep 3: 121, 2002;
Clementson Kockum C et al: Pediatric urinary tract reconstruction using intestine. Scan J Urol Nephrol 33: 53,
1999; Coplen DE et al: The magnitude of fetal renal pelvic dilatation can idenfity obstructive postnatal hydronephrosis,
and direct postnatal evaluation and management. J Urol 176: 724, 2006; Fefer S, and Ellsworth P: Prenatal
hydronephrosis. Pediatr Clin North Am 53: 429, 2006; Furness PD 3rd, et al: Injectable small intestinal submucosa:
preliminary evaluation for use in endoscopic urological surgery. J Urol 164: 1680, 2000; Han SW et al: Lamina
muscularis propria thickness of renal pelvis predicts radiological outcome of surgical correction of ureteropelvic
junction obstruction. J Urol 165: 1648, 2001; Kasprian G et al: MRI of normal and pathological fetal lung development.
Eur J Radiol 57: 261, 2006; Kirsch AJ et al: Minimally invasive treatment of vesicoureteral reflux with
endoscopic injection of dextranomer/hyaluronic acid copolymer: the Children’s Hospitals of Atlanta experience. J
Urol 170: 211, 2003; Misseri R et al: Small intestinal submucosa bladder neck slings for incontinence associated
with neuropathic bladder. J Urol 174: 1680, 2005; Perez-Brayfield M, et al: Endoscopic treatment with dextranomer/hyaluronic
acid for complex cases of vesicoureteral reflux. J Urol 172: 1614, 2004; Sherer DM: A review of
amniotic fluid dynamics and the enigma of isolated oligohydramnios. Am J Perinatol 19: 253, 2002.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue,
there is nothing to disclose.
Dr. Furness spoke at the 26th Annual Jackson Hole Urologic Conference, held January 28-February 3, 2006, at Teton
Village, WY, and sponsored by the University of Colorado School of Medicine. The Audio-Digest Foundation thanks
the speaker and the sponsor for their cooperation in the production of this program.
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