Program Director, David Geffen School of Medicine at UCLA
Both ureters are clearly visualized laparoscopically and protected throughout the course of dissection blood pressure 200 120 order hydrochlorothiazide without prescription. A 5-mm ultrasonic scalpel is used to completely mobilize the prostatic utricle and divide it at its confluence with the urethra blood pressure medication with food order hydrochlorothiazide discount. The urethral defect is closed by intracorporeal suturing with the use of fine absorbable sutures blood pressure 80 over 50 hydrochlorothiazide 12.5mg low cost. In our series heart attack damage purchase generic hydrochlorothiazide on-line, laparoscopic excision of the prostatic utricle was successful in all four patients, and none had any voiding difficulties. In our approach, the upper ureter is completely mobilized in the retroperitoneal cavity to the level of the iliac vessels. The patient is then repositioned supine for a Pfannenstiel incision, through which the mobilized kidney and ureter are accessed. A standard ureterocystoplasty, using the entire ureter and pelvis, is then performed. Laparoscopic Bladder Neck Reconstruction With the development of the pneumovesical approach to intravesical surgery, it is now also possible to perform a bladder neck reconstruction. The intravesical technique of bladder neck reconstruction via a pneumovesicum described here is a modified reverse Kropp procedure. The procedure has been further modified by tightening of the anterior half of the bladder neck and the proximal 1. Loss of functional bladder capacity by this procedure is minimal, and the technique provides an excellent close-up view of the bladder and its neck for performance of the reconstruction. Laparoscopically Assisted Reconstructive Surgery At the moment, the state of the art for minimally invasive reconstruction mainly involves laparoscopically assisted methods. The principle of laparoscopically assisted reconstructive surgery is to use laparoscopy to perform the parts of the operation that require upper abdominal access and to do the technically demanding reconstructive steps through an open lower abdominal incision. Figure 7-20 Two parallel incisions are placed along the posterior wall of the bladder extending from bladder neck to the interureteric ridge. The process of separating bladder muscle from mucosa has been assisted with laser, with the theoretical advantage of a limited depth of tissue destruction. Long-term results of open or laparoscopic autoaugmentation have not been consistent,128 and autoaugmentation has not achieved wide acceptance as a reconstructive technique in children. This is, however, a minimally invasive technique of bladder enlargement, and it may be considered for patients who have reasonable capacity but poor compliance and for those who do not require a large increase in bladder capacity. A urethral stent is advanced through the bladder neck, and the bladder neck is narrowed by closing the anterior rim over the stent using interrupted 5-0 Biosyn monofilament absorbable sutures. The rest of the mucosal strip is then mobilized on both sides with the aid of 3-mm scissors and hook cautery. The mucosal strip is tubularized around the stent with the use of 5-0 interrupted absorbable sutures. The mucosal edges lateral to the tubularized neourethra are then dissected free laterally so as to achieve a tension-free closure over the tubularized strip using Biosyn 5/0 interrupted stitches. The suprapubic catheter is placed via the supraumbilical port site, and the port is removed. The length of suprapubic catheter inside the bladder can be adjusted under laparoscopic guidance. The rest of the ports are removed, and the bladder defects are closed by tying the preplaced sutures. The skin wounds are further closed with a 5-0 subcuticular absorbable monofilament suture. We have done transvesicoscopic bladder neck reconstruction with urethral lengthening successfully in five patients. After the initial access to the peritoneal cavity at the umbilicus using the Hassan technique, in which a 10-mm trocar is placed, two additional trocars are placed: a 12-mm trocar along the lateral border of the left rectus muscle at the umbilical level and a 5-mm trocar along the lateral border of the right rectus muscle at the umbilical level. The appendix is separated from the cecum, leaving a small cuff of cecum with the appendix; this facilitates the stomal anastomosis and decreases the risk of stenosis. The cecal staple line is oversewn in two layers with 4-0 silk suture, using laparoscopic intracorporeal freehand suturing and knot-tying techniques. The native bladder is then identified with the aid of carbon dioxide insufflation at 12 to 14 mm Hg by way of an indwelling urethral catheter. Laparoscopic Autoaugmentation Autoaugmentation, or detrusorraphy, is a technique that involves dividing the bladder muscle and dissecting it free of the mucosa. Because this is a form of bladder augmentation that does not involve the harvesting of gastrointestinal segments and requires very little suturing, it is adaptable to minimally invasive techniques. Laparoscopic autoaugmentation has been performed in animal models123 and in children,124-126 by both a transperitoneal and an extraperitoneal approach. A 5-cm detrusor muscle trough is created along the right posterolateral aspect of the bladder, after which a small cystotomy is created at the distal end of the trough. The appendiceal-vesical anastomosis is then performed circumferentially with eight interrupted stitches using 5-0 polyglycolic acid sutures. Next, the distal 5 cm of appendix is placed in the newly prepared detrusor muscle trough, after which the detrusor muscle edges are approximated over the appendix with interrupted 4-0 polyglactin sutures, maintaining at least a 5:1 ratio of trough length to tube diameter. Care is taken to ensure absence of twisting or tension on the appendiceal mesentery. All reconstructive maneuvers are performed using laparoscopic intracorporeal freehand suturing and knot-tying techniques.
The relative function of the left kidney was virtually unchanged and the size of the left renal pelvis was also stable blood pressure medication olmetec generic hydrochlorothiazide 25mg overnight delivery. Figure 8-7 Slow drainage with urinary stasis at the pelviureteral junction does not necessarily mean obstruction blood pressure medication first line order 25 mg hydrochlorothiazide with amex. Drainage-Incomplete Duplication Drainage of the duplex kidney is by definition via two collecting systems blood pressure recommendations purchase discount hydrochlorothiazide on-line. In the case of incomplete duplex hypertension vitals cheap hydrochlorothiazide line, the two ureters may join at any level above the bladder. Urine may reflux from one moiety down the ureter and then up into the other moiety, rather than going down into the bladder; this is known as "yo-yo" reflux. It is only on dynamic radionuclide studies that this diagnosis can be made with certainty. The ureterocele may vary in size, from being so large that the inexperienced practitioner may mistake it for the bladder to being so collapsed that it is not recognizable even on a careful ultrasound examination. If one moiety drains outside the bladder, it is usually the upper moiety, and this ureter can terminate in the urethra or in the vagina in girls. Such ectopic drainage of the ureter is almost always associated with dysplasia of the upper moiety of the kidney. If both ureters drain into the bladder, the ureter draining the lower moiety is prone to reflux. This girl never had any surgery, because the size of the left renal pelvis never increased significantly, and the split function of the left kidney never fell significantly. This is an example of a dilated renal pelvis coping with the amount of urine excreted without significant resistance to outflow. A high index of suspicion when reporting on functional imaging allows the duplex kidney to be recognized easily. With incomplete duplication, the upper and lower moieties may be normal, or there may be reduced function of either element. Imaging One of the cardinal signs of a duplex system is a change in the axis of the lower moiety. This is best noted by the fact that the calyces of the lower moiety are medial to the upper group of calyces, giving the lower moiety of the kidney a longitudinal axis pointing to the shoulder on the same side. If a moiety is nonfunctional, it will not be visualized; this is important when there is a small, severely dysplastic upper Fusion Abnormalities the most common fusion abnormality is that of the horseshoe kidney with fusion of the lower poles; this is always associated with malrotation so that the pelves and ureters pass anteriorly over the fused lower poles. The two well-recognized complications are renal pelvis dilatation (with or without obstruction) and renal calculi. The left kidney is larger than the right, and therefore the mass of functioning nephrons is bigger. This is why the relative function of the left kidney is slightly higher (58%) than the accepted normal range of 55% to 45%. The right kidney is entirely normal, although it contributes only 42% to total renal function. The girl underwent a right upper pole heminephrectomy with resolution of her symptoms. At minute 8 of the acquisition, the child voided into the diaper, and there was concomitant reflux into the left upper moiety. Crossed fused renal ectopia occurs when one kidney is displaced across the midline and fused inferiorly to the other, relatively normally positioned kidney. The entire procedure is carried out on top of the gamma camera linked to a computer system with a double disposable diaper on the infant. The dynamic renogram also shows bilateral reflux coincident with an episode of micturition (images 10 and 12). The disadvantages are poor anatomic definition of the bladder and inability to study the anatomy of the urethra and, consequently, to exclude pathologies such as posterior urethral valves and syringocele. With ultrasound, it may be difficult to visualize the isthmus, as in this case where it was missed. At the end of the cystogram, if there is persisting activity within the bladder or the collecting systems, it is our practice to undertake a second cystogram, and so on until the activity in the bladder or collecting system has been cleared. In this way, reflux may well be shown on the second or third cystogram, after a negative first cystogram, and the sensitivity of the test for reflux increases. Moreover, the use of a catheter to fill the bladder creates a nonphysiologic environment for study of bladder filling and emptying. This helps to raise the suspicion of pathologies such as bladder instability (ineffective contractions of the detrusor) and lack of coordination of the detrusor and sphincter contraction, which result in a large residual in the bladder after voiding. B and C, Time-activity curves describing the variation in counts within each kidney when the counts from the kidneys have been scaled to the bladder (B) or are considered in isolation (C). The curves (especially in C) show clear increase in counts over the two kidneys, in keeping with reflux. Note that there are two episodes of reflux into the right kidney during the cystogram. B and C, Time-activity curves showing the variation in counts within each kidney when the counts from the kidneys have been scaled to the bladder (B) or are considered in isolation (C). The curves (especially in C) show clear increase in counts over the two kidneys, in keeping with bilateral reflux. Figure 8-14 A, Example of an indirect isotope cystogram in a 9-year-old girl with a history of urinary tract infection and scarred kidneys.
Because it has the clinical characteristic of swelling of the mucosa in the urogenital area arteria femoralis communis cheap 25 mg hydrochlorothiazide amex. There is a predominance of incidence in black girls arrhythmia frequently asked questions buy hydrochlorothiazide pills in toronto, and the exact cause of the problem is unknown blood pressure control generic hydrochlorothiazide 12.5 mg on line. The most evident hypothesis for urethral prolapse is poor attachment syringocele blood pressure 120 0 buy 12.5 mg hydrochlorothiazide visa, cowper Duct, and cysts the bulbourethral glands are two paired periurethral glands situated in the urogenital diaphragm and along the corpus spongiosum of the bulbomembranous and bulbospongious urethra. They were first described by Mery (1684) and chapter 34: UrethralDuplicationandOtherUrethralAnomalies 453 A B C D Figure 34-7 A 16-year-old boy presented with recurrent urinary infections and a second epispadiac meatus. However, his first urinary infection was discovered during his stay in the maternity ward as a neonate. He had a total circumcision at 12 years of age because of phimosis, and at that time a second opening on the glans was observed dorsally (A). C, During urethrocystoscopy, after insertion of a guidewire through the supplementary opening, an additional internal urethral orifice was seen on the level of the bladder neck, ventrolateral left to the orthotopic urethral opening. D, On anteroposterior plain radiographic film, the symphysis appears at least 7 mm wider than is normal for his age. Urethral prolapse can manifest similarly to a urethral polyp, a prolapsed extravesical ureterocele, a periurethral abscess, or a vaginal problem. Conservative treatment should be attempted with Sitz bathing and oral antibiotics. However, in most cases, surgical excision of the prolapse and mucosal adaptation is needed. Placement of a transurethral catheter facilitates the surgical correction and adaptation of the mucosal edges. They can be congenital or secondary to trauma, infection, or surgery (Table 34-3). In the male, strictures can occur in the posterior urethra (membranous and prostatic tract) and in the anterior urethra (fossa navicularis, penile and bulbar tract). Seventy-five percent of congenital urethral strictures are located in the pars bulbosa of the male urethra. This is the place where the proximal urethra, derived from endodermal origin, merges with the urogenital membrane. Another explanation for these strictures could be that the urogenital membrane does not retract completely. Traumatic straddle injuries most frequently lead to bulbar strictures, whereas pelvic injuries and associated ruptures of Urethral polyps Urethral polyps in girls are extremely rare and may be diagnosed as small, red, painful masses at the urethra. They are probably prolapsing urothelium that have evolved into polyps and 454 part V: InfravesicalUrineFlowImpairments the urethra cause strictures in the membranous urethra and in the prepubertal urethra close to the bladder neck. Surgical urethra strictures are most commonly hypospadias failures and may involve the (new) external meatus or the entire pendulous urethra. They are frequently associated with fistulas, diverticula, stones, hair, cosmetic defects, and residual penile curvature. Patients with congenital strictures present in either the neonatal or the postpubertal period (between 15 and 25 years). In contrast, the group of boys who present after puberty have localized irritation symptoms (urinary tract infection, epididymitis, prostatitis, hematuria) and decreased urinary flow. Documentation of urinary flow is important for initial evaluation and followup after treatment. If, after these investigations, the diagnosis is uncertain, careful low-pressure retrograde urethrography, eventually in combination with suprapubic punction, can delineate more precisely the extent of the stricture. Ultimately, endoscopic evaluation will diagnose the stricture and set the first step for treatment. The female urethra has a unique endodermal origin and can be compared with the male prostatic urethra. A normal orthotopic urethra and a hypoplastic secondary urethroanal urethra, arising from the prostatic urethra, are seen. The urethroanal urethra was surgically removed and ligated up to the level of the prostate. Symphysis Urethra Cowper duct Spongiosus tissue Cowper gland Figure 34-9 Schematic drawing of the Cowper glands and ducts and their relation to the spongiosus tissue and external sphincter. Treatment appeared easy and gained popularity because of the numerous reports of disappearance of the recurrent urinary tract infections. The normal size of the female urethra depends on the age of the child, and the reference values of Immergut and Wahman2 are still universally accepted. Although the incidence of stress incontinence or recurrence of stricture after urethrotomy appears to be low, one should be very well aware of these serious complications. Routine investigation or treatment such as urethrotomy can cause serious long-term complications and should be avoided. Urethrorrhagia idiopathica and Urethritis posterior in prepubertal and pubertal Boys Urethrorrhagia idiopathica and urethritis posterior refer to the same condition, but the former term is used more frequently in American literature. This phenomenon occurs frequently and alarms many prepubertal and pubertal boys and their parents. At the end of micturition, a few drops of blood appear at the meatus, frequently associated with a painful irritative sensation within the urethra. Sometimes, boys report gross hematuria, so a careful history and distinct examination of midstream and endstream urine are important to recognize this phenomenon. Bleeding from localized irritated mucosal changes in the bulbar urethra just distal to the external sphincter causes this condition.
Gender assignment issues at birth influence and stress parenting and the parental relationship prehypertension journal cheap hydrochlorothiazide on line. Inappropriate gender assignment can lead to significant gender identity confusion and gender role and peer relationship problems in these children for many years to come useless eaters hypertension zip purchase hydrochlorothiazide 12.5 mg without a prescription. Such self-assignment often emerges between the ages of 6 and 9 years and often after several years of gender identity and role confusion pre hypertension pathophysiology cheap hydrochlorothiazide 12.5mg fast delivery. Past stresses blood pressure medication numbness generic hydrochlorothiazide 25mg with amex, social realities, guilt feelings, and other adult concerns may create significant coping difficulties. Such children can demonstrate a gender role or behavioral spectrum from very mild to complete masculinization. The prevalence of homosexuality if these children are reared female is probably higher than in the general population. Figure 39-4 depicts some psychosexual developmental difficulties by age in children with genitourinary problems. Parent education-oral, visual, and written Patient education, appropriate for age and stage Supportive therapeutic interventions as necessary Behavioral interventions as necessary Psychopharmacologic interventions as necessary Referral to regional or national support groups as necessary Educational Interventions Family, parent, and patient educational materials can be verbal, written, pictorial, presented by video, or available on the Internet. Access to written materials is extremely helpful to parents and may be the only way to provide accurate information that parents will easily recall. Resources should include age- and stage-appropriate information that will answer general questions while providing a framework for specific questions. Although it can be quite helpful to provide written materials, children and adolescents respond best to face-to-face interactions that are private, frank, and confidential, as appropriate for age. The psychiatrist and psychologist can educate the parents about coping skills that the parents can then teach gradually to their child. Supportive therapy for self-esteem and sexual self-esteem should be directed to the child. Body image, genital image, acceptance of the genitalia, and self-genital contact may all require strong supportive, intermittent, short-term therapy as the clinical situation demands. Pharmacologic Interventions For many psychiatric problems, psychopharmacologic interventions become necessary. These levels may be well into the toxic range for cardiac function in such children. Child psychiatry involvement at the time of diagnosis, to continue longitudinally for the child and the parents 2. Evaluation of psychosocial supports and vulnerabilities chapter 39: PsychologicalandPsychiatricAspectsofGenitourinaryConditions 517 active metabolite of imipramine, has been associated with sudden death in childhood; nortriptyline has not, and it may have fewer side effects than imipramine while maintaining the same level of therapeutic effectiveness. After two or three dosage increases, the physician should determine the serum concentration. If it is low, the dose may be increased appropriately every 4 or 5 days, continuing this regimen until a therapeutic level is achieved. Adverse event reports include occasional high-flow priapism with most medications used for attention-deficit/ hyperactivity disorder except methylphenidate (Ritalin) but also with sertraline, trazodone, and a number of neuroleptics. Benzodiazepines can be valuable adjuncts for the prevention or treatment of anxiety and agitation related to procedures or perioperative situations. Diazepam (Valium) has a remarkably long half-life; lorazepam is intermediate, oxazepam is short, and midazolam (Versed) is very short. More frequent dosing of shorter-acting preparations reduces the risks of delirium, acute disinhibition ("agitation"), and drug-drug interactions and provides more frequent peak levels, commonly a therapeutic benefit in the postoperative period. It is probably wise to ask for child psychiatric consultation or intervention in children and adolescents treated with psychotropic agents. Temperament, language ability, affective vulnerability, and cognitive development interact with such medications, with unpredictable behavioral consequences. Younger children and especially infants and toddlers are quite sensitive to the simultaneous use of multiple psychotropic or psychoactive medications. Postoperative use of narcotics mixed with benzodiazepines and anticholinergic medications can, not uncommonly, lead to delirium. Treatment in such youngsters usually requires withdrawal of as many psychoactive medications as possible, as soon as possible. The risks of delirium seem to be highest in those children who are already somewhat agitated and intolerant of the restricted activity inherent in many genitourinary surgeries and who must be sedated for medical-surgical reasons. For many genitourinary conditions, sex therapy and sex counseling can be very therapeutic. Many of these children and adolescents need to learn to be verbally intimate in order to adapt to the sexual and psychosexual implications of their conditions. Similarly, verbal intimacy can be vital to the ultimate development of sexual intimacy. For the adolescent genitourinary patient, learning verbal intimacy as the initial step in sexual relationships can greatly aid normal psychosexual development and may evolve to more nearnormal sexual intimacy. When the urologist discusses with the child his sexual situation, function, and realities, openly and, preferably, alone, the child will benefit clinically and psychosexually and will learn important communication skills about intimate subjects as well. Without such an intervention, many adolescents may face a great obstacle to sexual relationships. Similarly, children and adolescents with major genitourinary conditions may have to be educated about the importance as well as the function of their own genitalia. They may require education that it is safe to touch or handle their genitalia and that masturbation is a normal activity. Males with significant penile anomalies may require education about sexual positions that permit successful and satisfying sexual intercourse. Written and pictorial materials can be very helpful, especially if the treating physician has high levels of embarrassment about frank sexual discussions. Adults who have endured congenital genitourinary anomalies may require counseling before or during marriage.
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