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In children symptoms dizziness nausea purchase mentat ds syrup 100 ml fast delivery, when there has been complete disruption of the urethra or avulsion from the bladder medicine 853 cheap mentat ds syrup 100 ml with mastercard, there is some evidence to suggest that primary realignment performed endoscopically can have good results (Herschorn et al medicine xalatan order mentat ds syrup australia. Others advocate against this because of high rates of stricture and subsequent need for further intervention (Husmann et al medicine 1700s cheap 100ml mentat ds syrup visa. In the case of endoscopic alignment medicine you can give dogs buy 100ml mentat ds syrup visa, it may simply be too difficult to identify the bladder neck and access the bladder medicine 72 generic 100ml mentat ds syrup with amex. In the attempt to do so, irrigation is infused into the pelvis, potentially complicating a simple hematoma and expanding the space between the bladder and the pelvic floor. It is also argued that prior endoscopic attempts at realignment can negatively impact the success of a delayed open repair when necessary (Culty and Boccon-Gibod, 2007; Singh et al. Therefore, in the stable patient an attempt can be made to pass a catheter endoscopically, but prolonged attempts should be avoided. Open realignment in the acute setting often requires further endoscopic treatment or open revision making the benefit of attempting this questionable (Nerli et al. In addition, once the pelvic space is violated, a hematoma, once controlled by tamponade, may no longer be contained and is free to bleed. Cystogram after resolution of hematoma with descent of bladder back into pelvis before reconstruction (C). This is despite the findings by some that the results can be quite similar to delayed repair (Husmann et al. One more clear indication for immediate repair is with an associated bladder neck injury. It has been shown to be beneficial to repair the injury up-front largely as a result of concern for resultant urinoma and infection rather than long-term benefit of the early repair (Routh and Husmann, 2007). If a catheter cannot be placed easily, a suprapubic catheter can be left in place and allowed to drain until a repair can be performed at a later date (Trachta et al. For a delayed urethral repair, we typically wait several months from the date of injury to let the scar mature. If there is a pelvic hematoma that has elevated the bladder up off the pelvic floor, common in the case of a complete urethral disruption, it will resolve over this period, allowing the bladder to descend back into the pelvis, facilitating the repair. This evolution of the scar can change a defect that appeared rather large in the acute setting into a relatively small one later on. For this reason, it is recommended to reevaluate any patient needing a delayed formal repair with imaging and cystourethroscopy closer to the date of the repair. In these cases, a suprapubic catheter was inevitably placed at the time of the initial presentation. This access helps in determining the size of the gap between bladder neck and patent urethra. This can be easily assessed by cystography and retrograde urethrography or a combination of radiologic imaging with cystoscopy from below and/or above through the suprapubic cystotomy site. In children, even with the most severe injuries, excision of the scar with primary anastomosis is typically feasible to perform without concern about tension on the anastomosis (Helmy et al. We perform this through a perineal approach with the child in the lithotomy position, making sure to prepare the lower abdomen in case the bladder needs to be mobilized from above. A midline incision is made on the perineum, and the urethra is mobilized and circumscribed. Proximal dissection is performed to the scar and, assuming a primary repair is being performed, the urethra is transected through the scar. The bladder neck can be difficult to identify depending on the extent of the scar. This is facilitated by the passage of a sound through the suprapubic site into the bladder neck. An incision through the scar onto the sound then provides a more direct entry into the bladder neck. The scar is then excised aggressively from both the distal and proximal portions of the urethra until only soft tissue with good blood supply is present. The urethra is then spatulated and the anastomosis is performed with interrupted dissolving suture over a Foley catheter. If there is tension on the anastomosis after mobilization of the urethra, more length can be obtained first by partial pubectomy and then by mobilization of the bladder from above through an abdominal incision. A similar technique can also be performed through a posterior sagittal transanorectal approach (Onofre et al. Chapter 52 If the gap is too large for excision and primary anastomosis, several options are available for reconstruction. Interposition with appendix, bowel, and ureter has also been described for larger defects. Defects less than 5 cm in length, however, are typically amenable to excision and primary anastomosis. This is the case in almost all initial repairs, however in the situation of reoperation, the defects can be longer (Aggarwal et al. Complications can include urinary retention (either caused by atony or recurrent stricture), incontinence, penile shortening, and erectile dysfunction as in adults, however the rates are lower (Trachta et al. Recurrent stricture occurs in about 10% of pediatric patients, at which point internal urethrotomy can be attempted, although failure rates are high. As expected, this is more successful with shorter (<1 cm) postoperative strictures, and a repeat urethroplasty may be necessary if it fails (Aggarwal et al. Redo urethroplasty is understandably more likely to result in recurrent stricture due in part to the more complicated original lesion (Aggarwal et al. Urinary incontinence can occur in as many as 20% of children and appears to relate to the type and extent of injury. It is more commonly associated with more proximal injuries such as those to the bladder neck or prostatic urethra (Boone et al. In the case of urethral injuries that extend up into the bladder neck, continence rates are notoriously unfavorable regardless of the timing or type of repair (Routh and Husmann, 2007). Postoperative erectile dysfunction seems to correlate with preoperative dysfunction with potential long-term recovery (Aggarwal et al. In addition, certain characteristics of the injury such as the severity of the fracture and length of the defect) can predict greater likelihood of dysfunction (Hemal et al. This can occur in up to one-half of children and appears to occur more commonly in patients treated with acute open realignment, possibly providing a rationale to avoid attempts at immediate realignment (Boone et al. Other associated findings in patients with resultant erectile dysfunction are lateral prostatic displacement at time of injury and urethral gap larger than 2. This is not always obvious, and if there is any suspicion, ancillary services such as social services can be helpful in determining the safety of the child in his or her home environment on discharge from the hospital. In addition, when abuse is suspected, it is imperative to ensure that no other harm has been done. Penile Injury In larger series, most penile injury in children happens inadvertently from a number of causes. These include circumcision, hair tourniquet strangulation, motor vehicle accidents, animal bites, zippers, and burns or scalds, with circumcision making up the majority of the injuries. Amputation of the penis can occur with circumcision and strangulation injury, such as with a hair tourniquet. Depending on the technique and the training of the practitioner, newborn circumcision has been shown to have variable rates of complication and injury (Ceylan et al. Minor injury involves the removal of excess skin, and severe injuries of partial or complete amputation of the glans penis can occur. Typically these more profound injuries occur when performed without appropriate training. Injuries are less common in the hospital and clinic settings and are more often seen when a Mogen-type device is utilized. Careful lysis of preputial adhesions can probably prevent the vast majority of these complications, even with use of a Mogen clamp (Pippi Salle et al. Hair or thread strangulation results in partial or circumferential damage with urethral injury or even penile loss. In addition, the offending hair or thread may be Urethral Disruption in Females Female urethral injury requiring intervention is rare. This happens almost exclusively in the presence of pelvic fracture and most often presents as a complete disruption below the bladder neck. The overall incidence of urethral injury in female pelvic fracture is about 5% (Black et al. Common etiologies include crush injuries, motor vehicle accidents, and falls involving pelvic fracture. As described earlier, management relies on suprapubic drainage initially with delayed repair several months after the trauma. Because the external sphincter is typically preserved, the reconstruction is performed as an excision of the scar with primary anastomosis. We perform this with the patient in the lithotomy position as we do in male patients, with the abdomen prepared in case bladder mobilization is necessary. Published continence results are favorable when the bladder neck is not involved (Hosseini et al. All of these factors can lead to late recognition and potentially greater harm (El-Bahnasawy et al. When amputation occurs, whether caused by a complication of circumcision or caused by strangulation injury, careful repair often results in a good cosmetic outcome. This is the case with or without attempt at microvascular reanastomosis of the glans penis or penile shaft. A catheter is left in place for 1 to 2 weeks when a urethral anastomosis is used in the repair of the amputation. With a hair tourniquet injury, the injury may be less severe and can be managed conservatively. Fistulae can also result from causes such as hair tourniquet strangulation or circumcision. In these cases, a multilayer closure is usually performed if the fistula does not heal with an attempt at conservative management with catheter drainage. The outcomes for repair are quite favorable with occasional resultant urethral stricture or recurrent/persistent fistula (Badawy et al. In contrast, fistula from circumcision is often in a subcoronal position and may require splitting the glans and treating the injury in the manner of a hypospadias repair (Baskin et al. Usually this occurs in toilet training boys and most of these injuries are minor, typically managed conservatively and treated as an outpatient. Burns to the genitalia are rare in children but occur more commonly than in the adult population. They are usually not isolated to the genitalia and can result in significant skin loss (Abel et al. In our practice, we typically harvest from sites expected to bear less hair in the postpubertal male. This provides more natural-looking skin that moves more freely over the underlying corporal bodies. Excessive skin removal at the time of circumcision, however, can typically be managed conservatively with dressing changes, allowing the wound to heal by secondary intention with good cosmetic outcomes (Banihani et al. In the case of animal bites, debridement and copious irrigation must accompany any treatment. If there is no obvious sign of infection, wounds can be reapproximated, usually, however, they are best left to heal by secondary intention (Gomes et al. Imaging As with suspicion for testicular torsion, often a good history or examination warrants immediate operative intervention, and no imaging is necessary. However, for a child with scrotal trauma, scrotal imaging in the form of ultrasonography can be helpful in determining whether there is a rupture of the testis. Ultrasonographic signs of rupture include discontinuity of the tunica albuginea, hematocele, and loss of Doppler signal to part of or the entire testis. Management As in adults, penetrating scrotal lacerations can be managed simply with washout and closure given that the tunica vaginalis is not violated. In children, this can often be performed in the emergency department with local anesthetic and minimal sedation if any. If there is concern about entry into the tunica vaginalis or if there is extrusion of the testicle, a more formal debridement and washout in the operating room is indicated. Management of blunt trauma to the scrotum is dependent on whether there is a concern about testicular rupture. In the case in which the tunica albuginea does not appear intact on the ultrasonography or there is an apparent hematocele, testicular rupture is suspected, and exploration is typically recommended. Some authors, however, have advocated for conservative management even when a rupture is confirmed. In a recent series, atrophy rates in this setting were less than 20% (Redmond et al. Loss of scrotal skin often can be managed by coverage with surrounding skin with an advancement flap. If needed, however, skin can be harvested from the abdomen or thigh and used as a split-thickness and meshed graft. We arrange office follow-up in most of our acute scrotal trauma patients about 6 weeks after initial presentation for an examination and ultrasonography. This allows us to ensure that any symptoms are improving and visualize the testis once the acute pathology is resolved. This is particularly true if there was no operative intervention to ensure that there is no other underlying testicular pathology masked by hematoma or testicular injury. Of all surgical cases for acute scrotum, these make up less than 5% of trips to the operating room (Pogorelic et al. Penetrating trauma to the scrotum can include superficial injury to the skin and dartos or deeper injury into the tunica vaginalis (Table 52. Testis rupture with preoperative ultrasound (A) and intraoperative images before and after repair (B and C).

It is separated carefully from the lower pole ureter alternative medicine purchase genuine mentat ds syrup, divided medicine recall mentat ds syrup 100ml with visa, and used to improve access to the upper pole moiety georges marvellous medicine safe mentat ds syrup 100ml. Any larger vessels that may be supplying the upper pole can be temporarily clamped to determine the extent of their distribution medicine checker purchase 100ml mentat ds syrup with amex. The capsule of the upper pole is bluntly stripped away medications you can crush buy genuine mentat ds syrup online, exposing the often coarse and cystic parenchyma of the upper pole medicine advertisements cheap 100ml mentat ds syrup visa. This can usually be distinguished from the smooth texture of the normal lower pole. The redundant capsule is then brought over the site of repair and sewn together with a running suture. Other advantages include enhanced visualization and increased magnification of the operative field, improved cosmesis, and avoidance of a second incision that is often needed for the distal ureterectomy of a nephroureterectomy. Laparoscopic heminephrectomy can be performed in very small infants, and the operative time has decreased as experience and skill have increased (El-Ghoneimi et al. Laparoscopic heminephroureterectomy performed transperitoneally begins similarly to the open procedure in that the pathologic ureter is grasped as a handle and dissected closely to its wall to avoid compromise of the blood supply to the normal ureter. The upper pole ureter is passed behind the vessels and used to facilitate dissection of the upper pole. After the polar element is removed with electrocautery or another energy source, one can check for collecting system leakage with intravenous injection of methylene blue (Yao and Poppas, 2000). Ureteral Clipping A recently described technique for management of nonfunctioning or poorly functioning renal moieties associated with ectopic ureter or obstructive ureteroceles involves laparoscopic clipping of the involved ureter without extirpative surgery. The utilization of this technique is still in its infancy, and we advise that caution should be used. Long-term follow-up is unavailable, and these patients should be monitored long term for potential complications such as infection and hypertension (Romao et al. Laparoscopic vascular ligation of the poorly functioning upper pole vessels has also been reported as effective (Hosseini et al. A B Outcomes Results of upper pole removal for ectopic ureters and ureteroceles are, in general, very good. In cases of ureteroceles in which lower pole reflux is present, resolution may be expected in up to 20% (Husmann et al. The overall secondary surgery rate after primary upper pole nephrectomy for ureterocele is 40% to 50% based on the literature. The difficulty in interpreting the literature rests in variable indications for secondary surgery. The most significant complication related to heminephrectomy is loss of lower pole function (Mandell et al. Clinical signs that may suggest problems include fever, increasing pain, and hematuria and may be evident in the first week after surgery. Development of a postoperative upper pole urinoma has been reported in up to 20% of laparoscopic and robotic cases but is rarely of clinical significance (Valla et al. Urinomas have been reported mostly in series in which there is no formal closure of the polar defect. Whether these urinomas are caused by injury to the lower pole or remnant upper pole is unclear. Other less common problems can include inferior vena cava laceration, duodenal perforation, need for total nephrectomy, and peritoneal tears (if the procedure is done retroperitoneally). Closure of the defect may limit the incidence of postoperative fluid collections (Mason et al. In performing a partial nephrectomy, robotic-assisted laparoscopy offers advantages over standard laparoscopy (Lee et al. The magnification is augmented, and the dexterity of the robotic instruments allows for greater precision when working around the renal pedicle and controlling the upper pole vessels, in addition to the visual advantages of a three-dimensional image. The latter may be preferable by reducing the risk for avulsing a clip during later dissection. The robotic approach to heminephrectomy has been described for both upper and lower pole heminephrectomy with successful outcomes (Wiestma et al. This technique represents the newest horizon for minimally invasive surgery because only one 22-mm multitrocar port site (recessed in the umbilicus) is used to perform the entire surgical procedure (Park et al. Lower Tract Reconstruction A definitive reconstruction at the bladder is suitable for both the ectopic ureter and ureterocele. The disadvantages, however, are the potential for injury to the bladder neck and vagina and the complexity of the procedure. If clinically significant reflux persists after other procedures, lower tract reconstruction may be necessary. Proximally, a plane is obtained between the ureterocele wall and the wall of the bladder. Then the two ureters are dissected as a unit, the upper pole ureter is tapered as needed, and both ureters are reimplanted submucosally. The detrusor muscle is plicated if it is attenuated, and it appears that it may offer insufficient backing. Once again, several technical points regarding ureterocele excision and common sheath reimplantation deserve mention. Separation of the duplicated ureters during intravesical dissection is discouraged because it can lead to injury of the common blood supply running longitudinally between the two ureters. Plication of the detrusor muscle underlying the ureterocele may be necessary to reinforce any areas of muscle deficiency. Furthermore, the distal portion of the ureterocele may extend below the bladder neck. Extreme care must be taken in this part of the dissection to avoid injury to the sphincter mechanisms. If the entire ureterocele cannot be excised, it can be fulgurated carefully and closed over with two layers. Cecoureteroceles present a unique challenge in ureterocele excision and reimplantation in that the distal aspect of the ureterocele can create an obstructive flap-valve with voiding, acting like a windsock behind the urethra. Options for avoidance of this issue includes resection by gentle retraction of the ureterocele if it is not very large, closure of the opening with two layers of tissue, or fulguration of the lumen to cause collapse and closure. An alternative approach to ureterocele resection is marsupialization, in which the thin intravesical aspect is removed and the edge is sutured. No attempt is made to reinforce the back wall, based on the empirical observation that this is not always needed. Technique for excision of ectopic ureterocele and common sheath reimplantation of upper and lower pole ureters. Inset, Cutaway side view demonstrating close association of the two polar ureters with a common vascular supply. This incision is then continued around the bladder mucosal edge of the ureterocele including the orifice of the lower pole ureter. The bladder mucosal surface is also incised around the edge of the ureterocele to permit complete removal of the ureterocele. Inset, the fully mobilized distal ureterocele is retracted caudally, revealing its narrowing attachment at the bladder neck. Both are brought into the bladder through a newly formed muscular hiatus to provide adequate tunnel length for the ureteral reimplantation. The thinned-out posterior bladder wall is repaired with multiple interrupted sutures to provide adequate muscular backing for the ureters. The bladder mucosa surrounding the ureterocele defect is mobilized to permit covering of the ureters. Right, Final appearance of the ureteral tunnel after completion of the reimplantation. Although this eliminates the need to dissect out the ureterocele and avoids injury to the underlying vagina, it is our impression that this approach has inherent risks that can be avoided by a controlled and predictable surgical approach of trigonal reconstruction. A major problem with marsupialization may be uncommon, but it seems preferable to definitively correct the anatomic and functional defect as certainly as possible on the first open operation when needed. Reported results of ureterocele excision and common sheath reimplantation are very good, although persisting reflux can be an issue in 5% to 10% of patients. Although the clinical significance of this has been called into question, persisting reflux in this context must be viewed with caution. Both proximal and distal approaches may be used, and these have been described with open and laparoscopic techniques. This management technique has become increasingly used, even in nonfunctioning upper poles, as concerns for long-term problems with hypertension have not been substantiated, and the procedure can be completed through a fairly small incision, often no larger than a herniorrhaphy-type incision (Prieto et al. Operative view of robotic ureteroureterostomy for ectopic ureter presenting with incontinence. This can be done at the distal ureter via an inguinal, open approach (Huisman et al. It is critically important in this type of procedure to correctly identify the recipient lower pole ureter, and it is strongly recommended to cystoscopically place a stent into the lower pole ureter at the start of the procedure. Other options to achieve this goal are the proximal anastomotic technique of ureteroureterostomy or pyeloureterostomy (El Ghoneimi et al. Such high anastomoses may be preferable to a distal ureteroureterostomy with a dilated upper pole, because the latter may result in more urinary stasis with a distal anastomosis. Whether the "yo-yo" phenomenon is clinically significant remains uncertain, but we prefer a proximal anastomosis when there is a significant mismatch in ureteral size. A generous longitudinal pyelotomy or ureterotomy is made in the lower recipient pole to overcome such disproportion, and the anastomosis is performed in an end-to-side fashion. The distal portion of the upper pole ureter should be aspirated with a feeding tube to decompress it. If there is no reflux, the resection is taken as distally as possible and the remnant lower portion of ureter may be left open. If reflux is present in an ectopic ureter, it should be taken as close to the bladder neck as possible. If associated with a ureterocele, it may be possible to avoid resection of the ureterocele as long as it is well decompressed. Laparoscopy has also been utilized to aid with performing open ureteroureterostomy to improve ease of procedure and minimize size of incision needed for ureteroureterostomy. A babcock was then used through the small incision through which ureteroureterostomy was to be performed to grasp the ureters from the retroperitoneum and deliver them for the surgery (Grimsby et al. This technique did not increase operative time, and the success of the operation and complication rate was comparable to the traditionally performed procedures. Our preferred method of incising the ureterocele is similar to the one described by Rich et al. Making the incision as distally on the ureterocele and as close Laparoscopic Procedure Both ureteroureterostomy and pyeloureterostomy can be readily performed laparoscopically (Gonzalez, 2007; Steyaert, 2009), which is aided with robotic control (Kutikov et al. Operative times and complication rates were comparable, with slightly shorter length of hospitalization in robotic cases. In the robotic cases, cystoscopy with lower pole stenting was consistently performed, however the type of stent varied because of surgeon preference (Lee et al. This series similarly showed efficacy of the procedure, with 100% resolution of hydronephrosis postoperatively (Biles et al. Extravesical ureteroceles, however, are more likely to have persisting or new reflux and may require secondary surgery based on the presence of reflux in 70% by some series (Chowdhary et al. In the meta-analysis by Byun and Merguerian, the presence of lower pole reflux and the location of the ureterocele are similar in their impact on outcomes (Byun and Merguerian, 2006). These factors did not seem to be additive, to the bladder floor as possible lessens the chance of postoperative reflux into the ureterocele. We favor the latter instrument because it has a finer tip and allows for more precision, and the angle allows for easier manipulation. In older children, the resectoscope with the Collins hot knife may be used to make the incision. Laser incision has been reported with equivalent results (Marr and Skoog, 2002; Jankowski and Palmer, 2006; Ilic et al. The ureterocele should be incised deeply because ureteroceles may be thick walled. For the ectopic ureterocele that extends into the urethra, adequate drainage may be achieved by either a longitudinal incision that extends down from the intravesical portion into the urethral portion or by two separate punctures, one in the intravesical portion of the ureterocele and one in the urethral portion of the ureterocele. In the uninfected well child, no bladder catheter is left in place, and most children are treated as outpatients. Some authors favor puncture instead of incision, but no data are available that demonstrate a clear difference. The incision should be made inferiorly and medially to limit the risk for reflux, but the key goal is decompression. The ureterocele should be incised with the bladder partially filled, but not so much as to efface the ureterocele. Statistical differences are indicated between selected groups based on two-tailed Fisher exact testing. In some series an observational approach has been taken, and resolution has been reported in a few series with variable followup (Jesus et al. The usefulness of observing these patients is dependent on occurrence of infection and parental preferences. Ureterostomy for Ectopic Ureter the ectopic ureter in a neonate with sepsis or with massive dilation may be best managed with a temporary end ureterostomy, although drainage with either endoscopic ureteral incision and stenting or nephrostomy tube is also an option (El Ghoneimi et al. This has the advantage of permitting acute decompression to manage sepsis and permit later assessment of any function in the affected renal unit before definitive management. By performing an end ureterostomy, the ureter can decompress, and it is in position to be reimplanted if the renal unit is felt to be salvageable. No resection of redundant ureter is performed because this will shorten in time, and some length will be needed to perform the reimplantation. The stoma should be positioned at what would be the lateral end of a Pfannenstiel incision. Assessment of functional status is performed shortly before definitive surgery, usually in 4 months or after 6 months of age.

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When the native kidney is in place medications vs medicine cheap mentat ds syrup line, some advocate ligation of the proximal ureteral segment without major complications and a low rate of subsequent nephrectomies (Timsit symptoms 9 days after embryo transfer generic mentat ds syrup 100ml without a prescription, et al symptoms joint pain best 100ml mentat ds syrup. It remains unclear if this option is superior to ureteroneocystostomy but is appealing in cases with a normal treatment ulcer buy discount mentat ds syrup 100ml on-line, nonrefluxing native ureter symptoms bacterial vaginosis cheap mentat ds syrup 100ml visa, a small bladder medicine cards mentat ds syrup 100 ml sale, or a short donor ureter or when pelvic dissection is difficult because of previous surgery. Moreover, this option is available as a salvage procedure in the setting of post-transplant ureteral stenosis. Those related to the graft directly, including vascular and rejection issues, are dealt with in Chapter 88. Posterior urethral valves have been associated with an increased risk of graft dysfunction in some series (Adams et al. In nearly all series, however, obstructive uropathy is associated with a higher risk of urologic complications. Special vigilance and a lower threshold for intervention are appropriate in this population. Urine Leaks Urine leaks are typically identified in the early postoperative period with increasing fluid from the wound drains or a perinephric collection on ultrasound. At first presentation, it is critical to assess all urinary drainage tubes, particularly the indwelling bladder catheter. If the catheter is in place, it is reasonable to irrigate it and check for patency. A transplant ultrasound is performed to determine if there is hydronephrosis, although its absence does not rule out obstruction. If hydronephrosis is present, distal ureteral obstruction should be suspected and consideration for a percutaneous nephrostomy should be entertained. The indications for intervention are clinically based, and if the leak is limited, an observational approach is reasonable. We have seen leaks in the setting of very high post-transplant urine output in smaller children simply because of a small bladder catheter. If there Ureteral Stenting the role of routine ureteral stenting in pediatric transplant is highly debated, with lack of conclusive data to demonstrate its routine utility (Dharnidharka et al. There are situations in which ureteral stenting is appropriate, including a difficult implant (particularly in an abnormal bladder) or when the graft ureter appears traumatized or Chapter 51 Although pediatric urologists have different levels of involvement in this aspect of care, it is important to understand some situations that may have implications with urologic management. These include the implications of transplantation of infants or patients with prothrombotic states, which usually demands the use of anticoagulation. This has important implications in terms of bleeding risk and need for careful hemostasis during bladder surgery. The urologist must adapt and be able to address limits imposed by the length of the donor kidney, which may have to be addressed with creative use of the native ureter or bladder flaps. In addition, particular attention should be paid in cases with multiple renal arteries. Damage to an arterial branch creates a permanent area of ischemia (with subsequent scar and loss of parenchyma). Renal transplantation with venous anastomosis between donor and recipient renal vein to address prior infrarenal vein thrombosis. Note placement of allograft in an anatomic location, which demands appropriate strategies to reconstruct the lower urinary tract. By repositioning the allograft in an "upside-down" fashion, the anastomosis is successfully performed. The kidney showed minimal hydronephrosis and adequate draining on postvoid images. Without correction, anastomosis at this site may lead to poor perfusion and thrombosis of the allograft and/or lower extremity ischemia. When prominent lymphatic channels and nodes are encountered, these may be reflected and tacked to the psoas muscle rather than dividing (curved arrow). Lower pole ischemia after allograft reperfusion, likely resulting from damage to lower pole branch. This, along with extensive dissection in the area of the "golden triangle" (confined by ureter, kidney, and renal artery), increases the risk of ischemic ureteral complications, such as urine leak and strictures. Chapter 51 If the bladder wall is particularly abnormal and thick, a longer tunnel is developed and the flaps are dissected back a bit further to provide a more robust antireflux tunnel and limit the risk of obstruction, because these are typically abnormally functioning bladders. Implanting the graft ureter into an augmented bladder poses additional challenges and it is preferred to perform the ureteroneocystostomy into the detrusor. On occasion this demands an intravesical approach through the augment to reach the detrusor, which may be impossible to mobilize effectively otherwise. If there is no detrusor available, anastomosis into the bowel segment is reasonable and technically easier than into a colonic or gastric segment. It is advisable to perform a nonrefluxing ureteroneocystostomy in these settings because these patients are inevitably on intermittent catheterization and often colonized with bacteria. The goal of exploration is to identify the cause, confirm the location of the leak, and provide for repair. If the leak is bladder based, revision of the anastomosis with closure of the defect and adequate drainage is effective. However, if the leak is due to distal ureteral necrosis, some means of ureteral replacement is needed. For a short segment of necrosis, bladder mobilization and reimplantation is effective. If a long segment of ureter has been lost, native ureter, either ipsilateral or even contralateral, may be useful (if available). Infection Urinary infection is a long-term and often delayed complication that largely reflects the status of bladder function and underlying urologic causes of renal failure (Herthelius and Oborn 2007; Silva et al. The presence of hydronephrosis is often associated with pyelonephritis and worsening renal function (Chu et al. Routine assessment of bladder emptying, determining the presence of hydronephrosis, and selective use of a voiding cystourethrogram usually identify the underlying cause. Aggressive management of bladder dysfunction, which should have been identified pretransplant, is essential to preserve graft function. Reflux in the absence of infection and with normal bladder function may be observed. Detection of leak at site of uretero-ureterostomy during cystogram with retrograde flow of contrast around a stent (arrow). Note reflux into native ureter (arrowhead) up to renal pelvis as well as presence of a drain (*). Leak initially detected by increase in drain output with fluid having a high creatinine concentration. Ischemic loss of the entire renal pelvis and ureter in a cadaveric renal graft into a patient with a gastrocystoplasty. The graft was salvaged with an augment-bladder flap to the lower calyces of the graft. Reflux Vesicoureteral reflux into the transplant kidney is entirely distinct from routine reflux into an otherwise normal renal unit based upon the fact that this is a reimplanted ureter, that the risk to renal function of an episode of pyelonephritis is greater in a transplanted kidney, and that the patient is immunosuppressed (Coulthard and Keir, 2006; DeFoor et al. Routine evaluation for reflux after renal transplant has been performed in some centers, even though not all cases require surgery. Identification of this potential risk factor is useful for clinical decision making and ongoing risk assessment. The risk of subsequent episodes of allograft pyelonephritis is significant (Barrero et al. Identification of simultaneous bladder dysfunction is equally important (Casale et al. In the setting of intermittent catheterization, a lower threshold for reflux correction should be exercised because these bladders will be chronically colonized. Reflux in the absence of infection and bladder dysfunction may be observed and attempts made to improve bladder and bowel function. Close observation for possible infection or deteriorating bladder function is warranted. The role of endoscopic therapy is limited, and the few reports available suggest limited benefit, with resolution rates of 50% to 80%(Kitchensetal. There are few data regarding relative efficacy of intravesical compared with extravesical methods (Krishnan et al. A transtrigonal technique is effective if the contralateral native ureter can be avoided. If the transplant ureter was anastomosed to the ipsilateral native ureter, options are similar, yet the response to endoscopic injection Hydronephrosis and Obstruction A frequent urologic complication in pediatric renal transplant is development of hydronephrosis, and intervention for ureteral obstruction may be needed in as many as 8% of transplants (Chu et al. The presence of hydronephrosis necessitates careful evaluation and selective management to tailor appropriate treatment to the individual. The transplant kidney appears to be particularly sensitive to obstruction, and the degree of impairment does not always correlate with the grade of hydronephrosis. In most cases, obstruction is heralded by increasing renal dysfunction with a rising creatinine. More than half of obstructions in a recent series occurred within the first 100 days post-transplant (Smith et al. In the setting of normal prior bladder function, this pattern indicates ureteral obstruction until proven otherwise. Placement of an indwelling catheter may be a reasonable first step because improvement in hydronephrosis and renal function may point toward a problem with bladder function. In the setting of a rising creatinine and hydronephrosis, obstruction and rejection may be intermingled. If the hydronephrosis is mild and there are other signs of rejection, the most efficient first step is biopsy (Khater and Khauli, 2012). If there is no clinical suggestion of rejection and dilation does not improve with bladder drainage, ureteral stenting (with or without a biopsy) is a reasonable next step. Although vesicoureteral reflux is unlikely to cause progressive hydronephrosis and worsening renal function, it is reasonable to verify that reflux is not present. Diagnostic studies for obstruction in the transplant setting are not completely reliable, and given the associated risks it is warranted to have a low threshold for stenting to assess the impact on renal function. It has been in this setting, albeit rarely, that an acutely failing transplant will show subsequent improvement in function, even in the absence of rejection. The more common situation is with moderate hydronephrosis and a rising creatinine with some rejection on biopsy. If the graft is not failing rapidly, initial medical treatment of the rejection is justified, with stenting being reserved for lack of improvement. If negotiating a stent in a retrograde fashion is not successful, percutaneous drainage is justified. Subsequent antegrade studies will show the location of the obstruction, and a stent can be advanced in the same setting. Obstruction-free survival in pediatric renal transplant patients with and without a history of posterior urethral valves. In a recent analysis, neither ureteral implant method nor use of stents was a contributing factor to obstruction. Bladder abnormalities, particularly because of posterior urethral valves, however, represent a risk factor of post-transplant obstruction (Smith et al. Focal ureteral narrowing on retrograde imaging may be effectively treated with balloon dilation and stenting for 4 to 6 weeks. Long-term stenting has been used in adult series with thermolabile nitinol stents, but it is uncertain if this would be a satisfactory approach in children (Bach et al. Recognizing the risk posed to the graft resulting from obstruction, open definitive repair should not be Urologic Considerations in Pediatric Renal Transplantation 1063 delayed excessively (Smith et al. As previously mentioned, these procedures entail complex reconstruction using native ureter or bladder flaps (Kockelbergh et al. Pyeloureteral anastomosis can be an option if the native ureter remains in place and is healthy (Sandhu et al. All of the principles of reoperative reconstruction must be followed to preserve well-vascularized functional tissues. Bladder Dysfunction Bladder dysfunction may increase the risk of infections but may also create an obstructive process that impairs renal graft function (Herthelius and Oborn, 2006; Herthelius and Oborn, 2007, Nahas et al. Discriminating this from ureteral obstruction may not be simple and, on occasion, has necessitated sequential diagnostic drainage steps. If a bladder catheter can be placed easily, then continuous drainage for 1 to 2 weeks with reassessment of creatinine can usually identify bladder dysfunction as the cause of graft dysfunction if the creatinine declines. If not, then combined stent and bladder drainage followed by a re-check of the creatinine is needed. Treating bladder dysfunction involves measures to increase compliance using anticholinergics as well as instituting or enhancing an intermittent catheterization program. Bladder augmentation may also be needed, although only after aggressive medical management has been tried. When intermittent catheterization per urethra is difficult, creation of a continent stoma may be needed. As discussed in the beginning of the chapter, identification of these potential risks to graft function is best accomplished before the transplant whenever possible. Stones Nephrolithiasis in a pediatric renal transplant is uncommon, occurring in up to 5% of patients (Khositseth et al. Ultrasound image of renal allograft demonstrating hydronephrosis (H) secondary to extrinsic compression resulting from a septated fluid collection (lymphocele; L). This takes a high index of suspicion and a clear sense of which patients are at high risk for these outcomes. A multidisciplinary collaboration between pediatric nephrology, urology, and the transplant surgical team is critical to maximize patient and graft survival. Detection of an asymptomatic stone on routine surveillance should prompt attempts at removal as well as a search for an underlying predisposing factor.

Before the advent of reliable and rapid scrotal imaging medications lisinopril buy mentat ds syrup 100ml visa, immediate scrotal exploration was routine treatment varicose veins buy mentat ds syrup toronto. Radionuclide imaging carried about 90% sensitivity and specificity but was lengthy symptoms just before giving birth mentat ds syrup 100ml mastercard, was Management and Surgical Treatment Testicular torsion is a true surgical emergency because testis viability is inversely related to duration of torsion medicine 4839 purchase mentat ds syrup 100ml amex. B-Mode (left) and color Doppler ultrasonography (right) images showing hyperechoic central body of the snail and coiling of blood within the distal spermatic cord around the central echogenic "body treatment plans for substance abuse purchase mentat ds syrup online pills. The affected testis is re-examined for potential viability medicine 7253 pill best mentat ds syrup 100ml, and the largely subjective decision for orchidopexy or orchiectomy is made. A Doppler flow probe or incision of the tunica albuginea (Arda and Ozyaylali, 2001) with assessment of bleeding may document intratesticular flow after detorsion; however, the reliability of these assessments lacks validation. If the testis is to be retained, it is fixed either via dartos pouch or directly to the dartos with nonabsorbable suture. Risk factors for orchiectomy include young age, African-American race, and being on Medicaid or lacking insurance (Cost et al. This may reflect the transfer of patients, which delayed treatment by 75 minutes in the study by Bayne et al. Orchiectomy is performed by dividing the cord into segments, each of which is ligated with nonabsorbable suture. In cases of orchiectomy, prosthesis placement is usually offered after complete healing or later in puberty; however, Bush and Bagrodia (2012) demonstrated the feasibility of performing concurrent prosthetic placement and orchiectomy. The degree of torsion may provide incomplete vascular occlusion, helping to explain the variability of these data or have a multiplicative effect on the time course to testis loss (Dias et al. Orchiectomy after surgical detorsion occurs in 30% to 70% in large studies (Kaye et al. The risk of delayed atrophy after orchidopexy was less than 10%, 40%, and 75% after less than 12, 12 to 24, and more than 24 hours of pain, respectively (Visser and Heyns, 2003). Partial (<25%) testicular atrophy may occur after operative detorsion even after 4 hours after the onset of pain (Anderson and Williamson, 1986; Krarup, 1978; Sessions et al. Preoperative manual cord detorsion may relieve symptoms and allow delayed orchidopexy but may incompletely untwist the cord. The other approach is more selective of patients for surgical exploration (Caldamone et al. When findings support or raise suspicion for spermatic cord torsion, emergent scrotal exploration is indicated and should not be delayed. Surgical exploration of the testis through a hemiscrotal transverse (dartos pouch) or midline raphe incision should first address the affected side. The testis is delivered and the tunica vaginalis opened to note the color of the testis, the number of rotations, and the anatomy of the tunica vaginalis. The testis is untwisted, wrapped Prognosis Although the impact of testicular torsion on fertility is poorly understood given the inherent difficulty of long-term follow-up in these patients, the few available studies suggest that subtle abnormalities of semen quality are common. Semen density is often within the normal range but correlates with shorter duration of torsion and reduced atrophy (Anderson et al. Tense congestion of the testis (A) was relieved with incision of the tunica albuginea (marked). The tunica vaginalis flap on a vascularized pedicle is harvested (B) and used to fill the defect in the tunica albuginea (C). The hypothesis of an autoimmune phenomenon (Anderson and Williamson, 1990) was dispelled by analysis of antisperm antibodies in individuals with torsion (Anderson et al. Available animal and human data support a role for ischemia-reperfusion injury after release of testicular torsion (Kehinde et al. Additional clinical data are needed to determine long-term outcome after testicular torsion and the efficacy of any adjunctive treatment. Inhibin B levels were significantly reduced in the two torsion groups compared with the controls but not between each other. Intermittent Intravaginal Spermatic Cord Torsion Episodes of self-limited acute scrotal pain precede acute testicular torsion in 30% to 50% of patients (Stillwell and Kramer, 1986; Williamson, 1976). These episodes, single or multiple, typically begin and resolve acutely with durations of minutes to hours. Nausea and/ or vomiting or notation of scrotal swelling may or may not be present. Physical findings consistent with torsion depend on whether the testis is twisted at the time of the examination. A whirlpool sign or an abnormal boggy cord and pseudomass formation below the twisted spermatic cord may also signify intermittent torsion (Munden et al. The diagnosis requires a high index of suspicion unless the testis is noted to untwist during an examination or an ultrasound study shows absent or decreased flow before and normal to increased flow after marked improvement of symptoms. Once the condition is confirmed or highly suspected, elective bilateral orchidopexy is indicated to avert torsion and possible organ loss. Patients and parents should know that absolute confirmation of the diagnosis may not be possible and that symptoms may persist postoperatively. Transverse ultrasound image demonstrates enlarged and heterogeneous left testis and bilateral hydroceles. Extravaginal Spermatic Cord Torsion (Perinatal Testicular Torsion) Perinatal spermatic cord torsion is a term applied to infants regardless of whether the event occurred prenatally (hours, days, weeks, months), during delivery, or postpartum. Torsion of the entire cord occurs before fixation of the tunica vaginalis and dartos within the scrotum (extravaginal). This event most commonly occurs well before delivery, yielding a "vanishing" testis or a hemosiderin-containing nubbin in the scrotum or less commonly in the inguinal canal. The testis that sustains loss of blood supply close to delivery is a hard, painless testis fixed to the overlying erythematous or dark scrotal skin with or without edema. Predisposing factors such as high birth weight and/or difficult delivery are suggested (John et al. In a minority of cases, symptoms occur after a documented normal scrotal examination. Rarely, neonatal intravaginal torsion occurs or infarction occurs without torsion (John et al. Bilateral torsion was noted in 5% and 22% in two series (Baglaj and Carachi, 2007; Yerkes et al. Several series indicate that bilateral metachronous torsion may occur in boys in whom the primary event occurs prenatally or postnatally (Al-Salem, 2007; Beasley and McBride, 2005; John et al. Scrotal imaging may be obtained in cases of suspected perinatal torsion, but its usefulness and reliability are questionable. There is no consensus regarding the best treatment of perinatal testicular torsion (Snyder and Diamond, 2010). One side advocates elective exploration because of the unsalvageability in most cases, the rarity of metachronous torsion, and the increased anesthetic risk (Brandt et al. Others advocate for immediate exploration to offer possible partial or complete testicular salvage (Al-Salem, 2007; Cuervo et al. Among 110 pediatric surgeons and urologists surveyed in the United Kingdom and Ireland, few (10. If torsion is suspected after a normal postnatal scrotal examination, then prompt exploration should be performed as for intravaginal torsion. Some surgeons use a scrotal approach, whereas others advocate an inguinal approach to ligate a patent processus vaginalis and avoid the theoretic risk of trans-scrotal surgery if a tumor is found. Torsion of the Appendix Testis and Epididymis Appendage torsion is the most common cause of acute scrotum in prepubertal children. The appendix testis and appendix epididymis are vestiges of embryologic development without known function. Color Doppler ultrasonography demonstrates (A) enlarged and heterogeneous appendage and (B) absent flow despite increased flow to the epididymis and testis. The appendix testis, located at the cranial testicular pole or in the groove between the testis and epididymis, and the appendix epididymis, located along the caput, may be sessile or pedunculated. Although the sessile type may be more common (Jacob and Barteczko, 2005), the pedunculated type may be more prone to torsion (Jones, 1962). The cause of torsion is unknown but may be related to anatomy, trauma, and/or prepubertal enlargement. The peak age at occurrence is 7 to 12 years (mean 8 to 9 years) (Anderson and Giacomantonio, 1985; Lyronis et al. Symptoms vary with sudden or insidious onset of pain, which may be mild or severe and intermittent with physical activity. Similarly, physical findings depend on the severity of inflammation and duration of symptoms (Rakha et al. Early on, a "blue dot sign" (Dresner, 1973), a discoloration at the upper pole of the testis representing the ischemic appendage, may be seen through stretched scrotal skin in 0 to 52% of patients (Caldamone et al. Murphy reported a false-positive blue dot sign in a patient with testicular torsion (Murphy et al. Other early signs include a tender nodule superior to the testis with limited testicular tenderness and symmetrical cremasteric reflexes. However, with longer duration and progressive inflammation, increased swelling and tenderness, lack of distinction between testis and epididymis, and marked scrotal wall edema and erythema may make it difficult to distinguish it from testis torsion or epididymitis. Because torsion of an appendage is a self-limited process (Koff and De Ridder, 1976), surgery is rarely indicated. Treatment is aimed at reducing inflammation using ice packs and oral anti-inflammatory agents and limiting physical activity. Surgical exploration is limited to cases in which torsion of the testis is not excluded or, rarely, there is prolonged and severe pain or recurrent episodes. Epididymitis Epididymitis, infectious or noninfectious, is a broad category causing an acute scrotum. Classically, the symptoms have a more insidious onset than torsion of the cord or an appendage but may present rapidly. There is a continuum on examination from localized epididymal enlargement and tenderness to massively swollen and erythematous hemiscrotum without distinct landmarks. Efforts to reduce the inflammation include the use of ice packs, nonsteroidal anti-inflammatory agents, scrotal elevation, and rest to avoid traumatic exacerbation. In the presence of pyuria, broad-spectrum antibiotics with gram-negative coverage should be used (Siegel et al. Treatment for sexually transmitted diseases should be considered, as appropriate, in adolescents. Other clinical series have documented a low risk of urinary tract anomalies in boys with epididymitis, although infants may be at higher risk (Merlini et al. Although some findings (pyelectasis, low-grade vesicoureteral reflux) may not directly contribute to epididymitis, other findings (urethral or ureteral obstruction, ejaculatory duct or vasal anomalies) are important to detect. However, in a prepubertal child with a positive urine culture, renal ultrasonography and voiding cystourethrography are indicated. In recurrent cases, endoscopy may reveal ejaculatory duct abnormalities undetected on voiding cystourethrography (Pimpalwar et al. Recurrent epididymo-orchitis in these cases may require excision of a utricle or ejaculatory duct cyst with vasovasostomy or vasectomy. Thus, in cases in which torsion is highly suspected, emergent surgery should not be delayed by imaging studies. A "blue dot sign," discoloration at the upper pole of the testis, may be seen through stretched scrotal skin. This is a self-limiting process requiring supportive care and analgesia management. Other Causes of Acute Scrotal Pain Idiopathic scrotal edema manifests in prepubertal boys with unilateral or bilateral scrotal swelling with minimal or no pain (Klin et al. Associated findings may include local spread of erythema or edema to the inguinal or perineal region, inguinal lymphadenopathy, leukocytosis, and/or eosinophilia. Distinctive characteristics include minimal or no pain, isolated scrotal tenderness, and thickening of the scrotal wall. The "Fountain Sign," hypervascularity on color Doppler of the thickened scrotum depicted on transverse scans with both testes seen, is highly suggestive of the diagnosis. Because the process is self-limited, no treatment is needed, except perhaps for antihistamines (Geiger et al. The scrotum is involved in 2% to 38% of cases in the form of tenderness, edema, or erythema; testicular hematoma, torsion, or infarction; or cord thrombosis or epididymitis (Diana et al. The typical purpuric rash of the buttocks, perineum, and lower limbs is usually present but may not precede the scrotal findings. Urgent scrotal exploration is indicated if clinical findings suggest concomitant testicular torsion. Cystic dysplasia of the rete testis is a benign lesion of the testis that was first described in 1973 by Leissring and Oppenheimer. It may present at any age but most commonly around 6 years as acute scrotal swelling and pain (Jeyaratnam and Bakalinova, 2010; Noh et al. Rarely, an associated ureteral anomaly may lead to chronic testicular pain (McGee et al. Ipsilateral renal dysplasia, agenesis, or ureteral anomalies are present in the majority of cases and likely represent maldevelopment of the wolffian duct. Treatment is conservative enucleation, which may be associated with recurrence, or observation; reports of spontaneous regression has been reported (Gelas et al.