Embryology Duplex pelvis and ureter Hypospadias Circumcision

1. Congenital Surgical
diseases of urinary tract

2. DEVELOPMENT OF URINARY TRACT

3. KIDNEY AND URETER

4. • Paramesonephron
• Mesonephron
• Metanephron- future kidney
Metanephric tissue will form nephron except
collecting duct.

6. • Ureteric bud – develops from mesonephric duct
forms-
collecting part of kidney
ureter

8. BLADDER AND URETHRA

9. Urinary bladder
Embryology
• Epithelium is of two types
• Endodermal – Cranial part of vesicourethral canal
• Mesodermal – Mesonephric duct
• Trigone is mesodermal in origin and the rest is
endodermal

11. Urethra development
Primitive
UGS
Vesicourethr
al canal
Urinary
Bladder
Primitive
Urethra
Definitive
UGS
Pelvic part of
UGS
Phallic part

12. • Female urethra formed by – Primitive urethra
- Some part of UGS
• Male Urethra
- Prostatic urethra - develop same as female
urethra
- Membranous urethra - From the Pelvic part of
urogenital sinus
- Penile urethra – Phallic part of UGS

15. Development

16. ANOMALIES OF PELVIS
AND URETER

17. DUPLEX RENAL PELVIS AND
URETER
• Congenital condition in which ureteric bud splits or
arises twice ,resulting in two ureters draining
single kidney.

18. DUPLEX RENAL PELVIS AND
URETER
• Most common (1 in 150 births)
• Unilateral duplication >Bilateral duplication (6:1)
• Common on left side
• Female > Male

19. Types
Incomplete Complete
(partial)
Ureteric bud bifurcates after
its initial development

20. Complete
Two buds
normal
Correct site in
trigone of
bladder
low
Ends in laterally
placed orifice
VUR

22. Weigert meyer Law
• In complete type,upper ureter ends distally and
medially to normal ureteric orifice.
• Whereas, lower ureter end proximally and lateral to
normal ureteric orifice.

24. Clinical features
• In adults - usually asymptomatic
• In children – presents with Vesicoureteric reflux
resulting in infection , stone
formation and hydronephrosis

25. Investigations
• IVU - diagnostic
• Cystoscopy- double ureteric orifice on the same
side
• DTPA scan – Function

27. Treatment
• Ureteric meatotomy (if narrowing of orifice)
• Treatment of complications(UTI, hydronephrosis)
• Heminephrectomy +removal of corresponding
ureter

28. ECTOPIC URETER
• Ureter rather than terminating at the urinary
bladder, terminates at different site.
• Associated with duplicated renal collecting system.
• 10% bilateral
• Female> male (7:1)

29. In females
opens either into urethra or into the vagina
leading to incontinence.
In males
opens above the external urethral sphincter.

30. Other sites-
• apex of the trigone
• posterior urethra
• seminal vesicle or
• ejaculatory duct
• can be associated with renal dysplasia ,
frequent UTI, and urinary incontinence.

32. Treatment
• Partial nephrectomy – severely diseased or atrophic
• Reimplantation – refluxing ureter
• In females- hydronephrotic and chronically infected
kidney – best to excise

33. URETEROCOELE
• Cystic enlargement of the intramural ureter
• probably due to atresia of the ureteric orifice
• Female>Male (4:1)
• 10% are bilateral.

35. • Ureters with ureterocoele drains the upper
pole frequently
• Associated with dysplastic or non functional
renal tissue

36. Clinical features
• In children – present with infection
• If large - obstruct the bladder neck or contralateral
orifice
• In adults – typically presents with stones in lower
ureter

37. Investigations
• Urography – Classical sign
– cobra head

38. • Cystoscopy – A bulging transluscent
swelling involving ureteric orifice which
fills with and empties of urine with
ureteric peristalsis.

40. Treatment
Simple
Surgical excision and
reimplantation of
ureter
Advanced
Nephrectomy

41. CONGENITAL MEGAURETER
• Uncommon condition
• Common in males
• Ureteric dilatation with or without obstruction
• May be bilateral and associated with other congenital
abnormalities

42. • . Cause – aperistalsis of distal ureter
dilatation
(cutoff value for megaureter >6 or 7mm)
• Most cases of megaureter with obstruction present in
childhood with severe infections.
• Renal stones can easily form in the dilated systems.

43. Investigation
Cystoscopy- ureteric orifice appears normal
ureteric catheter passes easily

44. • Whitaker test
Saline or contrast injected through a percutaneous
needle or nephrostomy tube at a rate of 10ml/min.
Catheter in bladder to monitor intravesical pressure.
<15cm H2O - normal
>22cm H2O - obstruction

46. Management
Refashioning lower end of affected ureter
Tunnelled reimplantation done to prevent reflux

47. ANOMALIES OF URINARY
BLADDER

48. DIVERTICULA OF THE BLADDER
Two types :
1. Congenital diverticula are the result of a
developmental defect.
2. Acquired

49. CONGENITAL BLADDER
DIVERTICULA
• Represents unobliterated vesical end of
urachus.
• Situated midline anterosuperiorly.
• Mouth of diverticulum situated above and to the
outer side of one ureteric orifice.
• Rare type and common in boys.

50. ❖ Normal intravesical pressure during voiding =35–50
cmH2O
❖Hypertrophic bladder(due to obstruction) = 150
cmH2O may be reached
Saccule formation
Diverticulum
ACQUIRED BLADDER DIVERTICULA

52. Symptoms
• Usually asymptomatic.
• Poor emptying of bladder
As diverticula do not contain
a defined functional muscularis propria
• Diagnosed incidentally.

53. • Investigations
Urine culture and sensitivity
Cystoscopy and cystogram
Intravenous urogram
Ultrasound abdomen
CT scan abdomen

55. Complications of bladder
diverticula
• Recurrent infection
• Bladder stone formation
• Obstructive uropathy
• Malignant transformation (<5%)

56. Management
• Removal of diverticula through open surgery
• Suprapubic transverse extraperitoneal approach
• Combined intravesical and extravesical
diverticulectomy

57. BLADDER EXTROPHY
• Incomplete development of infraumbilical part of
anterior abdominal wall and anterior wall of
bladder.
• Common in males (4:1)

58. Clinical Features
• Penis – Broad and short
• Urine dribbling
• Undescended testis
• B/L inguinal hernia may be present
• Separation of pubic bone (Pubic diastesis)
• In females – Bifid Clitoris

59. Other features
• Often associated with spina bifida
• Protusion of red mucus membrane of posterior
bladder wall
• Umbilicus is absent
• In males, epispadias commonly present with
rudimentary prostate and seminal vesicle.

62. Management
• Bladder is closed in first year of life after osteotomy.
• Later reconstruction of bladder neck and sphincter
is required.
• But now one stage reconstruction is done
• Urinary diversion may also be done

63. Complications
• Stricture
-B/L hydronephrosis
-Infection
• Hyperchloremic acidosis
• Increased risk of tumor formation

64. ANOMALIES OF URETHRA
• Posterior urethral valve
• Hypospadias
• Epispadias
• Urethral diverticulum

65. POSTERIOR URETHRAL VALVE
• 1/5000-8000 Live male births
• Valve are Membranous with small slit in them.
• It lies just distal to verumontanum.
• Act as unidirectional valves- causing obstruction
to antegrade urinary flow but catheter can be
passed retrogradely.

66. Clinical Features
• UTI
• Uremia
• Renal failure
If valves are incomplete ,Child is asymptomatic and
diagnosed late.

67. Diagnosis
• Should be detected and treated as early as possible.
• Antenatal Ultrasound - B/L Hydronephrosis
- Distended bladder
• Voiding cystogram
- Dilatation of urethra above the valves

68. Normal

69. Management
• Initially – Catheterisation
• Definitive – Endoscopic destruction of valves

70. HYPOSPADIAS
• External meatus opens on the underside of the
penis any where proximal to the normal site.
• Most common congenital abnormality of urethra.
• 1/200-300 Male live births

71. Types of hypospadias
• Glanular
• Coronal
• Penile
• Peno-scrotal
• perineal hypospadias

72. Characteristic Features
1.Ventrally placed meatus
• Downward directed stream of
urine
• Sperm deposition incorrect →
Infertility
2.Ventral curvature of penis
(Chordee)
3.Dorsal hood of prepuce

73. Surgery
Indication
1. To improve sexual
function
2. To correct urinary
stream
3. Cosmetic reason
• Completed by 18
months
Orthoplasty
Substitution
urethroplasty
Meatoplasty
scrotoplasty

74. Surgery
• Chordee correction - Netbit Procedure
• Urethroplasty
• MAGPI - For coronal hypospadias
• Tubularized Incised Plate urethroplasty - For distal
Hypospadias
• Preputial flap repair - For proximal hypospadias

75. EPISPADIAS
• Very rare
• Urethral opening is on the dorsum of the penis
• A/w Upward Curvature of penis
• Coexist with Bladder Extrophy

77. URETHRAL DIVERTICULUM
• Outpouching of urethra
• Two types - Anterior / Posterior
• Etiology - Partial duplication of urethra

78. Anterior Diverticulum
• Saccular outpouching arising from the ventral
surface of anterior urethra
Clinical presentation
• Straining at micturition
• Swelling of penis during micturition
• Followed by dribbling of urine and disappearance of
the swelling

82. Management
• Minor cases - Endoscopic Incision of the flap of
the urethral mucosa between the two lumens
• Severe cases – excision of the diverticulum and
primary repair of the urethra

83. PENIS

84. ANATOMY
3Tubular
structure
2 corpus
cavernosum
1 Corpus
Spongiosum

86. PHIMOSIS
• At birth foreskin is normally adherent to glans penis
• Adhesions disappear around 2 years but may persist
till 6 years

87. • PHIMOSIS in children -
scarring of prepuce causing
inability to retract
foreskin resulting in :
- Ballooning of the
foreskin during micturition
- Balanoposthitis
- Urinary obstruction
(sometimes)

88. • Phimosis in adults – Occurs as a result of
- Balanitis
- Posthitis
- Balanitis xerotica obliterans

89. • Treatment
Non retractile
foreskin
Mildly scarred
foreskin
All other
No Treatment
is necessary
Preputioplasty Circumcision

90. CIRCUMCISION
• Indications
• Anaesthesia
• Procedure
• Complication
• Contraindications

91. Indications
1. Religious reasons
2. True phimosis
3. Balanitis Xerotica Obliterans
4. Recurrent balanoposthitis
5. Inability to retract foreskin during intercourse
Recently , evidence showed circumcision is protective
against spread of HIV.

92. • Position - Supine position
Anesthesia - G/A in children and L/A or S/A in
adults

93. Procedure
1. Cleaning and draping.
2. Anesthesia is given.

94. CIRCUMCISION IN INFANTS

96. CIRCUMCISION IN ADULTS
• Dorsal slit over skin upto corona and then
circumferentially and ventrally and later skin is cut
with inner layer.
• Frenular artery is transfixed and ligated ventrally.
• Skin is apposed to cut end of corona.
• Postoperatively, antibiotics and analgesics are
given.

98. Cutting the dorsal slit

99. Cutting the circumference of
foreskin

100. Trimming the inner layer of
foreskin

102. Complications
1. Reactionary hemorrhage
2. Infection
3. Stricture urethra
4. Chordee
5. Rarely priapism
◆ BENEFIT - reduces incidence of PENILE
CARCINOMA

103. Contraindications
1. Epispadias and hypospadias
2. Hemostatic abnormalities
3. Acute penile infection

104. REFERENCES
• BAILEY & LOVE’S SHORT PRACTICE OF SURGERY
(27TH EDITION)
• GOOGLE IMAGES
• ONLINE JOURNALS

105. THANK YOU