This document discusses perinatal hydronephrosis (ANH), which refers to dilation of the renal pelvis detected on prenatal ultrasound in 1-3% of pregnancies. ANH is most commonly used to define this condition but measurements and definitions vary. Ultrasound remains the main imaging modality used, while MRI can provide additional detail. Factors like gestational age, bladder filling, and grading systems impact ANH assessment and prediction of postnatal outcomes. Counseling involves discussing differential diagnoses, natural histories, and management plans. Fetal intervention is rarely needed but may be considered to improve pulmonary and renal development in cases of late oligohydramnios or poor fetal urine markers.
Antenatally detected hydronephrosis is one of the most common abnormalities detected on prenatal ultrasound. It can identify urinary tract obstructions and reflux before complications develop. The degree of hydronephrosis seen on prenatal ultrasound provides prognostic information, with mild cases often resolving and severe cases more likely to require postnatal intervention. Evaluation after birth depends on the severity and laterality of the hydronephrosis seen prenatally, with more severe or bilateral cases warranting earlier and more extensive testing like dynamic renal scintigraphy to assess kidney function and guide management.
This document discusses antenatal hydronephrosis. Some key points:
- The prevalence of antenatally detected hydronephrosis ranges from 0.6-5.4% and is bilateral in 17-54% of cases. 41-88% resolves at birth or infancy, while 4-15% require intervention.
- Factors like gestational age, hydration status, and bladder distention affect measurements of the renal pelvis anteroposterior diameter (APD), which is used to diagnose and grade hydronephrosis. Threshold APD values increase with gestational age.
- Additional evaluation including assessment for lower urinary tract obstruction, renal dysplasia
This document summarizes antenatal diagnosis of kidney diseases. It discusses the incidence and types of congenital renal diseases detected prenatally. Diagnostic tools mentioned include fetal ultrasound, amniocentesis, and genetic testing. Key stages of kidney development are outlined. Features of various kidney anomalies detectable by ultrasound are described, such as bilateral renal agenesis, unilateral renal agenesis, cystic kidney diseases, antenatal hydronephrosis, and bladder anomalies. Associations with other structural abnormalities and recommendations for further evaluation are provided for different conditions.
1. Antenatal hydronephrosis is a common prenatal finding that requires postnatal evaluation to identify potential kidney abnormalities.
2. Most cases of antenatal hydronephrosis are transient and resolve without intervention, while others may indicate issues like urinary tract obstruction that require treatment.
3. Postnatal evaluation includes ultrasound, voiding cystourethrogram, diuretic renography and other tests to determine the severity and cause of hydronephrosis and assess kidney function.
This document summarizes key points about vesicoureteral reflux (VUR):
- VUR is retrograde flow of urine from the bladder to the upper urinary tract and is more common in females under 5 years old. It can be primary due to UVJ deficiency or secondary to bladder issues.
- VUR is graded I-V based on VCUG findings. Low grade (I-III) often resolves spontaneously while high grade (IV-V) is less likely to without intervention. Treatment involves watchful waiting with antibiotics or surgical correction.
- Surgical correction aims to lengthen the UVJ tunnel to satisfy a 5:1 ratio using various techniques. Endoscopic injection
Hello Guys,
This presentation talks about diagnosis and management of Antenatally detected hydronephrosis. We have discussed evidence based fetal hydronephrosis management including - antenatal followup schedule, fetal interventions, postnatal screening and follow up proforma, MCU, Functional renal scans, prophylactic antibiotics and available surgical management options.
The document discusses chronic pelvic pain, including its physiology, causes, diagnosis, and treatment challenges. It notes that the definitive cause is often not determined, and that non-gynecological sources like urinary and gastrointestinal issues are more common than previously believed. A thorough history and multidisciplinary approach are important to properly assess and manage chronic pelvic pain of unknown origin.
Antenatally detected hydronephrosis is one of the most common abnormalities detected on prenatal ultrasound. It can identify urinary tract obstructions and reflux before complications develop. The degree of hydronephrosis seen on prenatal ultrasound provides prognostic information, with mild cases often resolving and severe cases more likely to require postnatal intervention. Evaluation after birth depends on the severity and laterality of the hydronephrosis seen prenatally, with more severe or bilateral cases warranting earlier and more extensive testing like dynamic renal scintigraphy to assess kidney function and guide management.
This document discusses antenatal hydronephrosis. Some key points:
- The prevalence of antenatally detected hydronephrosis ranges from 0.6-5.4% and is bilateral in 17-54% of cases. 41-88% resolves at birth or infancy, while 4-15% require intervention.
- Factors like gestational age, hydration status, and bladder distention affect measurements of the renal pelvis anteroposterior diameter (APD), which is used to diagnose and grade hydronephrosis. Threshold APD values increase with gestational age.
- Additional evaluation including assessment for lower urinary tract obstruction, renal dysplasia
This document summarizes antenatal diagnosis of kidney diseases. It discusses the incidence and types of congenital renal diseases detected prenatally. Diagnostic tools mentioned include fetal ultrasound, amniocentesis, and genetic testing. Key stages of kidney development are outlined. Features of various kidney anomalies detectable by ultrasound are described, such as bilateral renal agenesis, unilateral renal agenesis, cystic kidney diseases, antenatal hydronephrosis, and bladder anomalies. Associations with other structural abnormalities and recommendations for further evaluation are provided for different conditions.
1. Antenatal hydronephrosis is a common prenatal finding that requires postnatal evaluation to identify potential kidney abnormalities.
2. Most cases of antenatal hydronephrosis are transient and resolve without intervention, while others may indicate issues like urinary tract obstruction that require treatment.
3. Postnatal evaluation includes ultrasound, voiding cystourethrogram, diuretic renography and other tests to determine the severity and cause of hydronephrosis and assess kidney function.
This document summarizes key points about vesicoureteral reflux (VUR):
- VUR is retrograde flow of urine from the bladder to the upper urinary tract and is more common in females under 5 years old. It can be primary due to UVJ deficiency or secondary to bladder issues.
- VUR is graded I-V based on VCUG findings. Low grade (I-III) often resolves spontaneously while high grade (IV-V) is less likely to without intervention. Treatment involves watchful waiting with antibiotics or surgical correction.
- Surgical correction aims to lengthen the UVJ tunnel to satisfy a 5:1 ratio using various techniques. Endoscopic injection
Hello Guys,
This presentation talks about diagnosis and management of Antenatally detected hydronephrosis. We have discussed evidence based fetal hydronephrosis management including - antenatal followup schedule, fetal interventions, postnatal screening and follow up proforma, MCU, Functional renal scans, prophylactic antibiotics and available surgical management options.
The document discusses chronic pelvic pain, including its physiology, causes, diagnosis, and treatment challenges. It notes that the definitive cause is often not determined, and that non-gynecological sources like urinary and gastrointestinal issues are more common than previously believed. A thorough history and multidisciplinary approach are important to properly assess and manage chronic pelvic pain of unknown origin.
The document discusses various ureteral anomalies in children, including ureteroceles and megaureters. It covers the demographics, diagnosis, and treatment options for these conditions. Treatment goals are preservation of renal function, elimination of infection/obstruction, and maintenance of continence, with minimization of surgical morbidity. Options discussed include observation, endoscopic versus open surgical procedures, and complete reconstruction depending on factors like severity of reflux and hydronephrosis. Outcomes of different surgical techniques are compared based on studies.
Undescended testis, or cryptorchidism, refers to the absence of one or both testes from the normal scrotal position. It occurs in 1-4% of full-term and 1-45% of preterm newborn boys. The specific cause is often unknown, but risk factors include prematurity and maternal estrogen exposure. Diagnosis involves examination to locate any undescended testes. Early surgical treatment before age 18 months is recommended to preserve fertility and reduce cancer risks. Options include inguinal or abdominal orchidopexy. Long term risks include reduced sperm counts and increased testicular cancer risk.
Management of Infants Diagnosed with Antenatal Hydronephrosis and Determining...asclepiuspdfs
Antenatal hydronephrosis (ANH) is the most common pathology in the fetal period. The cause of ANH ranges from intrauterine transient hydronephrosis to clinically severe congenital anomalies of the kidney and urinary tract. Coexistence with oligohydramnios, ectopic kidney, and extrarenal anomalies in the prenatal period supports the existence of important pathology. Ultrasonography should be performed on all babies with ANH in the postnatal period, and the follow-up of the patients should be done according to the anteroposterior renal pelvic diameter and the grading recommended by the Society for Fetal Urology. Surgical intervention is vital according to some criteria in patients with progressive hydronephrosis and vesicoureteral reflux.
This document provides guidance on the management of adnexal torsion. It discusses the definition, epidemiology, diagnosis and treatment. For diagnosis, ultrasound with Doppler is the preferred imaging method. Findings suggestive of torsion include decreased or absent blood flow and increased ovarian volume. For treatment, laparoscopy is preferred and conservative management including detorsion with or without cystectomy is recommended, even in cases of discolored ovaries, as ovarian function can be preserved. Delaying cystectomy may avoid further trauma. The goal is to preserve ovarian tissue when possible.
Assessment of infertility using hystero laparoscopyNiranjan Chavan
This study assessed infertility using hystero-laparoscopy in 504 patients over 3 years. Key findings include:
Tubal factors were the leading cause of infertility (35%). Hysteroscopy found endometrial polyps in 5% and adhesions in 4%. Laparoscopy found endometriosis in 20% and thickened tubes in 13%. Hystero-laparoscopy allowed diagnosis of factors missed by other tests and endoscopic management such as adhesiolysis, myomectomy, or polycystic ovarian drilling. The study concluded hystero-laparoscopy is a feasible one-time approach for infertility assessment and treatment.
Pediatric kidney transplantation has improved significantly over the past decade. Living donors provide better outcomes than deceased donors, with steady improvements in short and long-term graft survival rates. Around 33% of pediatric transplant patients require urologic surgery like augmentation or catheterizable channels before transplantation. Careful medical evaluation of both recipients and living donors is essential to maximize outcomes. Post-transplant care involves immunosuppression, infection prophylaxis, and management of potential urologic complications.
- A newborn boy presented with a large, firm left flank mass found on physical examination. An ultrasound revealed a solid renal mass.
- The most likely diagnosis is congenital mesoblastic nephroma (CMN), a rare renal tumor that typically presents in infants less than 3 months old as a painless abdominal or flank mass.
- CMN is usually benign and curable with surgical excision alone, though cellular variants and incomplete resection can cause more aggressive behavior.
This document discusses various causes and investigations for infertility. The major causes include ovarian, tubal, uterine, cervical and peritoneal factors. Ovarian factors account for 30-40% of cases and include anovulation, luteal phase defects, and follicular issues. Tubal factors cause 25-35% of infertility through infections, adhesions or blockages. Investigations to diagnose ovulation include basal body temperature, cervical mucus analysis, hormone levels, ultrasound and laparoscopy. Tubal patency is assessed using hysterosalpingography, laparoscopy and dye tests. Uterine abnormalities are investigated with ultrasound and hysteroscopy. Cervical factors are analyzed with post-co
Globally, over 600,000 new cases and 300,000 deaths were estimated for cervical cancer in 2020 .
Third most common gynecological cancer in Palestine.
Palestine has a higher age-standardized mortality rate than other countries in the region
This document discusses renal transplantation in children. It provides an overview of the indications, contraindications, pretransplant evaluation and preparation of both the recipient and donor. Surgical techniques and perioperative management are described, including vascular access, ureteral anastomosis techniques, and postoperative monitoring in the intensive care unit with a focus on graft perfusion and fluid management. Goals for hospital discharge are also mentioned.
Guía ISUOG sobre ecografía en embarazo gemelarTony Terrones
This document provides guidelines from the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) on the role of ultrasound in twin pregnancies. It recommends that twin pregnancies be dated using the larger crown-rump length between 11-13 weeks of gestation. It also recommends determining chorionicity and amnionicity before 14 weeks using membrane thickness and placental mass number. Uncomplicated dichorionic twins should have scans at 11-14 weeks, 20-22 weeks, and every 4 weeks thereafter, while uncomplicated monochorionic twins should have scans every 2 weeks after 16 weeks to monitor for twin-to-twin transfusion syndrome and other complications.
1. Tubal disease is a common cause of female infertility, affecting approximately 25% of cases. The fallopian tubes are responsible for egg pickup and early embryo transport.
2. Tubal disease can be caused by infections, pelvic inflammatory disease, prior surgeries, ectopic pregnancies, or other pelvic conditions. It may involve tubal blockages, narrowing, or abnormalities that prevent egg fertilization.
3. The presence of a hydrosalpinx, where fluid accumulates in a blocked fallopian tube, can reduce IVF success rates by around 50% by negatively impacting endometrial receptivity and embryo implantation. Surgical removal of hydrosalpin
1. Pediatric laparoscopy can impact the cardiovascular, pulmonary, and renal systems due to increased abdominal pressure from insufflation and positioning effects. Close monitoring is important, especially in patients with preexisting conditions.
2. Initial trocar insertion poses a risk of visceral or vascular injury. Direct visualization techniques like the Hasson method or optical trocars may reduce risks compared to blind insertion. Careful attention to anatomy and technique is important to prevent complications.
3. Potential complications include access injuries, gas embolism, pain, and port site hernias. Injuries are most common during initial access and prompt recognition and treatment is important to manage risks.
This document discusses the history and future of prenatal diagnosis from the 1970s to present day. It covers the evolution of prenatal screening techniques from early ultrasound to assess fetal structures, to the introduction of biochemical markers in maternal serum. Today, first trimester screening using ultrasound markers like nuchal translucency along with serum markers can assess risk for conditions like Down syndrome. Non-invasive prenatal testing (NIPT) using cell-free DNA in maternal blood has further improved prenatal screening accuracy. The document outlines the multidisciplinary team involved in prenatal diagnosis and management of high-risk pregnancies. It envisions the role of emerging techniques like NIPT for detecting more genetic conditions.
Prenatal diagnosis detects fetal abnormalities before birth through non-invasive and invasive techniques. Non-invasive techniques include ultrasound, fetal echocardiography, and magnetic resonance imaging to visualize the fetus. Maternal serum screening analyzes markers in the mother's blood to assess risk of fetal conditions like Down syndrome. Invasive techniques obtain fetal tissue through procedures like amniocentesis for cytogenetic or molecular testing to diagnose genetic disorders. Prenatal diagnosis aims to provide risk information to families for informed decision making during pregnancy.
This document summarizes antepartum fetal surveillance and aneuploidy screening. It discusses:
1) The importance and benefits of antepartum fetal surveillance in predicting risks like perinatal death and detecting conditions like fetal growth restriction.
2) The various methods used in aneuploidy screening including ultrasound measurements, maternal serum markers, cell-free DNA testing, and invasive diagnostic tests.
3) The guidelines and best practices for aneuploidy screening including integrating first and second trimester screens and contingent screening models based on risk levels.
This document discusses prenatal screening methods for detecting congenital abnormalities and genetic disorders. It covers:
1. Various prenatal screening tests for neural tube defects like spina bifida and aneuploidies like Down syndrome including maternal serum screening, ultrasound, and amniocentesis.
2. Risk factors, prevention, and screening candidates for neural tube defects which can be reduced by folic acid supplementation.
3. First trimester screening includes measuring nuchal translucency and maternal serum markers like hCG and PAPP-A levels to detect aneuploidies.
The document discusses various ureteral anomalies in children, including ureteroceles and megaureters. It covers the demographics, diagnosis, and treatment options for these conditions. Treatment goals are preservation of renal function, elimination of infection/obstruction, and maintenance of continence, with minimization of surgical morbidity. Options discussed include observation, endoscopic versus open surgical procedures, and complete reconstruction depending on factors like severity of reflux and hydronephrosis. Outcomes of different surgical techniques are compared based on studies.
Undescended testis, or cryptorchidism, refers to the absence of one or both testes from the normal scrotal position. It occurs in 1-4% of full-term and 1-45% of preterm newborn boys. The specific cause is often unknown, but risk factors include prematurity and maternal estrogen exposure. Diagnosis involves examination to locate any undescended testes. Early surgical treatment before age 18 months is recommended to preserve fertility and reduce cancer risks. Options include inguinal or abdominal orchidopexy. Long term risks include reduced sperm counts and increased testicular cancer risk.
Management of Infants Diagnosed with Antenatal Hydronephrosis and Determining...asclepiuspdfs
Antenatal hydronephrosis (ANH) is the most common pathology in the fetal period. The cause of ANH ranges from intrauterine transient hydronephrosis to clinically severe congenital anomalies of the kidney and urinary tract. Coexistence with oligohydramnios, ectopic kidney, and extrarenal anomalies in the prenatal period supports the existence of important pathology. Ultrasonography should be performed on all babies with ANH in the postnatal period, and the follow-up of the patients should be done according to the anteroposterior renal pelvic diameter and the grading recommended by the Society for Fetal Urology. Surgical intervention is vital according to some criteria in patients with progressive hydronephrosis and vesicoureteral reflux.
This document provides guidance on the management of adnexal torsion. It discusses the definition, epidemiology, diagnosis and treatment. For diagnosis, ultrasound with Doppler is the preferred imaging method. Findings suggestive of torsion include decreased or absent blood flow and increased ovarian volume. For treatment, laparoscopy is preferred and conservative management including detorsion with or without cystectomy is recommended, even in cases of discolored ovaries, as ovarian function can be preserved. Delaying cystectomy may avoid further trauma. The goal is to preserve ovarian tissue when possible.
Assessment of infertility using hystero laparoscopyNiranjan Chavan
This study assessed infertility using hystero-laparoscopy in 504 patients over 3 years. Key findings include:
Tubal factors were the leading cause of infertility (35%). Hysteroscopy found endometrial polyps in 5% and adhesions in 4%. Laparoscopy found endometriosis in 20% and thickened tubes in 13%. Hystero-laparoscopy allowed diagnosis of factors missed by other tests and endoscopic management such as adhesiolysis, myomectomy, or polycystic ovarian drilling. The study concluded hystero-laparoscopy is a feasible one-time approach for infertility assessment and treatment.
Pediatric kidney transplantation has improved significantly over the past decade. Living donors provide better outcomes than deceased donors, with steady improvements in short and long-term graft survival rates. Around 33% of pediatric transplant patients require urologic surgery like augmentation or catheterizable channels before transplantation. Careful medical evaluation of both recipients and living donors is essential to maximize outcomes. Post-transplant care involves immunosuppression, infection prophylaxis, and management of potential urologic complications.
- A newborn boy presented with a large, firm left flank mass found on physical examination. An ultrasound revealed a solid renal mass.
- The most likely diagnosis is congenital mesoblastic nephroma (CMN), a rare renal tumor that typically presents in infants less than 3 months old as a painless abdominal or flank mass.
- CMN is usually benign and curable with surgical excision alone, though cellular variants and incomplete resection can cause more aggressive behavior.
This document discusses various causes and investigations for infertility. The major causes include ovarian, tubal, uterine, cervical and peritoneal factors. Ovarian factors account for 30-40% of cases and include anovulation, luteal phase defects, and follicular issues. Tubal factors cause 25-35% of infertility through infections, adhesions or blockages. Investigations to diagnose ovulation include basal body temperature, cervical mucus analysis, hormone levels, ultrasound and laparoscopy. Tubal patency is assessed using hysterosalpingography, laparoscopy and dye tests. Uterine abnormalities are investigated with ultrasound and hysteroscopy. Cervical factors are analyzed with post-co
Globally, over 600,000 new cases and 300,000 deaths were estimated for cervical cancer in 2020 .
Third most common gynecological cancer in Palestine.
Palestine has a higher age-standardized mortality rate than other countries in the region
This document discusses renal transplantation in children. It provides an overview of the indications, contraindications, pretransplant evaluation and preparation of both the recipient and donor. Surgical techniques and perioperative management are described, including vascular access, ureteral anastomosis techniques, and postoperative monitoring in the intensive care unit with a focus on graft perfusion and fluid management. Goals for hospital discharge are also mentioned.
Guía ISUOG sobre ecografía en embarazo gemelarTony Terrones
This document provides guidelines from the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) on the role of ultrasound in twin pregnancies. It recommends that twin pregnancies be dated using the larger crown-rump length between 11-13 weeks of gestation. It also recommends determining chorionicity and amnionicity before 14 weeks using membrane thickness and placental mass number. Uncomplicated dichorionic twins should have scans at 11-14 weeks, 20-22 weeks, and every 4 weeks thereafter, while uncomplicated monochorionic twins should have scans every 2 weeks after 16 weeks to monitor for twin-to-twin transfusion syndrome and other complications.
1. Tubal disease is a common cause of female infertility, affecting approximately 25% of cases. The fallopian tubes are responsible for egg pickup and early embryo transport.
2. Tubal disease can be caused by infections, pelvic inflammatory disease, prior surgeries, ectopic pregnancies, or other pelvic conditions. It may involve tubal blockages, narrowing, or abnormalities that prevent egg fertilization.
3. The presence of a hydrosalpinx, where fluid accumulates in a blocked fallopian tube, can reduce IVF success rates by around 50% by negatively impacting endometrial receptivity and embryo implantation. Surgical removal of hydrosalpin
1. Pediatric laparoscopy can impact the cardiovascular, pulmonary, and renal systems due to increased abdominal pressure from insufflation and positioning effects. Close monitoring is important, especially in patients with preexisting conditions.
2. Initial trocar insertion poses a risk of visceral or vascular injury. Direct visualization techniques like the Hasson method or optical trocars may reduce risks compared to blind insertion. Careful attention to anatomy and technique is important to prevent complications.
3. Potential complications include access injuries, gas embolism, pain, and port site hernias. Injuries are most common during initial access and prompt recognition and treatment is important to manage risks.
This document discusses the history and future of prenatal diagnosis from the 1970s to present day. It covers the evolution of prenatal screening techniques from early ultrasound to assess fetal structures, to the introduction of biochemical markers in maternal serum. Today, first trimester screening using ultrasound markers like nuchal translucency along with serum markers can assess risk for conditions like Down syndrome. Non-invasive prenatal testing (NIPT) using cell-free DNA in maternal blood has further improved prenatal screening accuracy. The document outlines the multidisciplinary team involved in prenatal diagnosis and management of high-risk pregnancies. It envisions the role of emerging techniques like NIPT for detecting more genetic conditions.
Prenatal diagnosis detects fetal abnormalities before birth through non-invasive and invasive techniques. Non-invasive techniques include ultrasound, fetal echocardiography, and magnetic resonance imaging to visualize the fetus. Maternal serum screening analyzes markers in the mother's blood to assess risk of fetal conditions like Down syndrome. Invasive techniques obtain fetal tissue through procedures like amniocentesis for cytogenetic or molecular testing to diagnose genetic disorders. Prenatal diagnosis aims to provide risk information to families for informed decision making during pregnancy.
This document summarizes antepartum fetal surveillance and aneuploidy screening. It discusses:
1) The importance and benefits of antepartum fetal surveillance in predicting risks like perinatal death and detecting conditions like fetal growth restriction.
2) The various methods used in aneuploidy screening including ultrasound measurements, maternal serum markers, cell-free DNA testing, and invasive diagnostic tests.
3) The guidelines and best practices for aneuploidy screening including integrating first and second trimester screens and contingent screening models based on risk levels.
This document discusses prenatal screening methods for detecting congenital abnormalities and genetic disorders. It covers:
1. Various prenatal screening tests for neural tube defects like spina bifida and aneuploidies like Down syndrome including maternal serum screening, ultrasound, and amniocentesis.
2. Risk factors, prevention, and screening candidates for neural tube defects which can be reduced by folic acid supplementation.
3. First trimester screening includes measuring nuchal translucency and maternal serum markers like hCG and PAPP-A levels to detect aneuploidies.
This document discusses various soft markers that can be detected on ultrasound during the second trimester to screen for fetal aneuploidies like Down syndrome. It describes markers like thickened nuchal fold, mild ventriculomegaly, echogenic bowel, mild pyelectasis, single umbilical artery, echogenic intracardiac focus, choroid plexus cysts, and enlarged cisterna magna. For each marker, it discusses the association with aneuploidy and provides recommendations from medical organizations on evaluation and need for further testing.
This document discusses antenatal hydronephrosis and its management. It begins by stating that fetal urinary tract dilation is the second most common prenatal anomaly detected. Antenatal hydronephrosis is diagnosed based on measurements of the anterior-posterior renal pelvic diameter. While most cases are transient and physiological, it can also indicate congenital anomalies of the kidney and urinary tract. Prenatal imaging using ultrasound is important to identify and monitor any urinary tract anomalies. Postnatal evaluation and management seeks to identify infants with clinically significant congenital anomalies of the kidney and urinary tract that may require treatment or surgery.
Bisrat Edit Approach to Hydronephrosis in children.pptxBedrumohammed2
This document discusses the approach to hydronephrosis in children. It covers antenatal hydronephrosis, postnatal evaluation and management, common causes like ureteropelvic junction obstruction, vesicoureteral reflux, and posterior urethral valves. Grading systems, diagnostic tests, and treatment options are presented for each condition. The goal is to recognize and treat any congenital anomalies that could impact renal function or cause urinary tract infections.
This document provides information on the FIGO classification system for abnormal uterine bleeding (AUB). It discusses the definition of AUB and introduces the two FIGO classification systems: System 1 which categorizes AUB based on bleeding patterns, and System 2 which categorizes AUB into nine etiological categories called PALM-COEIN. For each category, the document provides details on evaluation and management. The goal of the FIGO classification systems is to standardize terminology and guide clinical practice for AUB.
This document discusses organ transplantation and pregnancy. It begins by introducing that organ transplantation is life-saving but can restore fertility, and that successful pregnancies have occurred in transplant recipients. It then summarizes key details on pregnancies in recipients of kidney, liver, pancreas/kidney, heart/lung, and intestine transplants. Important considerations for transplant recipients planning pregnancy include optimal timing, vaccination, contraception, preconception counseling, and close monitoring during high-risk pregnancies. Factors that can influence pregnancy outcomes are also outlined.
1 prof james bently cervical cancer screening 2014Tariq Mohammed
This document discusses options for cervical cancer screening including visual inspection with acetic acid (VIA), cervical cytology, HPV testing, and combinations of tests. It reviews the strengths and limitations of different screening methods and highlights priorities for efficient, low-cost screening in low-resource settings. Optimal screening may involve initial HPV testing at age 35 with reflex cytology for positives and cytology follow-up of negatives before longer rescreening intervals.
1 prof james bently cervical cancer screening 2014Tariq Mohammed
This document discusses options for cervical cancer screening including visual inspection with acetic acid (VIA), cervical cytology, HPV testing, and combinations of tests. It reviews the strengths and limitations of different screening methods and highlights priorities for efficient, low-cost screening in low-resource settings. Optimal screening may involve initial HPV testing at age 35 with reflex cytology for positives and cytology follow-up of negatives before longer interval rescreening.
Vesicoureteral reflux (VUR) is retrograde flow of urine from the bladder to the upper urinary tract. It can be primary due to deficiencies in the ureterovesical junction or secondary due to bladder dysfunction. Diagnosis involves urine tests, ultrasound, VCUG, DMSA scan and urodynamic studies. Most low-grade reflux resolves spontaneously while high-grade reflux is less likely to resolve. Management includes antibiotics and watchful waiting or surgical correction via open or endoscopic techniques like injection of bulking agents. The goal is to prevent urinary tract infections and renal damage.
This document provides an overview of prenatal screening and diagnosis of neural tube defects and Down syndrome. It discusses the incidence, risk factors, screening tests, and diagnostic evaluation for neural tube defects including ultrasound, maternal serum AFP testing, amniocentesis, and fetal MRI. Prenatal screening tests for aneuploidies like Down syndrome are also covered, including first trimester ultrasound, maternal serum markers, and integrated screening. Prevention through folic acid supplementation and pregnancy management options are summarized.
The document provides information on fetal imaging techniques including sonography. It discusses:
1. How sonography is used in prenatal care to evaluate fetal anatomy and detect abnormalities in the first and second trimesters.
2. How digital ultrasound produces real-time images of the fetus, amniotic fluid, and placenta using sound wave reflections.
3. Guidelines that ultrasound exposure should be limited to medical purposes and that current evidence does not demonstrate adverse effects in humans from diagnostic ultrasound.
4. Evaluation of fetal anatomy including the brain, spine, heart, face and neck during the second and third trimesters and common abnormalities that can be detected through ultrasound.
This document provides an overview of prenatal diagnosis. It discusses how major congenital abnormalities are identified in 2-3% of pregnancies and are a leading cause of infant death. Prenatal diagnosis aims to identify fetal malformations, disruptions, and genetic syndromes to improve counseling. Structural abnormalities can develop through malformation, deformation, or disruption. Neural tube defects are among the most common birth defects. Maternal serum screening for alpha-fetoprotein is an established screening test for neural tube defects. Advances in screening include first trimester screening using nuchal translucency and serum markers, as well as cell-free DNA screening. Sonographic screening can identify soft markers and structural abnormalities. Pregnancies at
1. The document discusses the evaluation and management of pelvic masses. It covers demographic factors, differential diagnosis, general evaluation including medical history, physical exam, imaging and labs.
2. Common adnexal masses include functional cysts, dermoid cysts, endometriomas and leiomyomas. Management depends on age, size, symptoms and surgical findings.
3. Benign ovarian tumors are more common than malignant. Common benign types are serous cyst adenomas, mucinous cyst adenomas and dermoid cysts. Their features, diagnosis and treatment are outlined.
This document discusses various management options for uterine bleeding and prolapse in women. It describes conservative treatments that can help avoid hysterectomy such as medical management using hormones, the Mirena IUD, and minimally invasive procedures. It also discusses the importance of considering conservative therapies and not assuming the uterus is vestigial after childbearing. Surgical options for fibroids like myomectomy and embolization are presented. Conservative surgeries for prolapse in young patients like cervicopexy and sling procedures are also mentioned.
This document summarizes renal cell carcinoma (RCC), including its incidence, risk factors, pathology, subtypes, clinical presentation, and prognosis. RCC accounts for 2-3% of adult cancers and is the most lethal urologic cancer. Clear cell RCC is the most common subtype, accounting for 70-80% of cases. Other subtypes include papillary RCC, chromophobe RCC, collecting duct carcinoma, and unclassified RCC. Tumor size, grade, stage, and histologic subtype are important prognostic factors. Over 60% of RCCs are now detected incidentally with improved imaging techniques.
This document provides guidelines for treating non-muscle-invasive bladder cancer. It discusses diagnosing and staging Ta, T1, and Tis tumors using techniques like white-light and blue-light cystoscopy. For cTa low-grade tumors, the guidelines recommend TURBT followed by a single dose of immediate intravesical chemotherapy. For cTa high-grade tumors, options include TURBT followed by observation, mitomycin C, or BCG. For cT1 tumors, the guidelines recommend complete TURBT along with a second TURBT for high-risk cases, followed by adjuvant intravesical therapy.
This document discusses management strategies for localized prostate cancer, including active surveillance and radical prostatectomy. It notes that active surveillance involves delayed treatment if cancer progresses, allowing patients to avoid or delay unnecessary treatment. However, criteria for patient selection and treatment triggers require further definition and validation. Radical prostatectomy remains the gold standard for treating localized prostate cancer as it offers the possibility of cure while minimizing damage to surrounding tissues when performed skillfully. Innovations have led to improved preservation of urinary continence and erectile function with this procedure.
The document discusses therapeutic principles for treating germ cell tumors (GCTs), including:
1) An aggressive treatment approach is recommended to cure patients and avoid unnecessary death or side effects, including rapid diagnosis, staging, and expedient chemotherapy and surgery.
2) Chemotherapy is often administered even if patients have low blood counts or kidney issues, and all residual disease is surgically removed after chemotherapy.
3) Treatment is most successful at high-volume centers, where surgeons have extensive experience performing complex procedures like retroperitoneal lymph node dissection (RPLND).
Study designs & amp; trials presentation1 2Praveen Ganji
This document defines and describes different types of clinical research studies and trials. It discusses meta-analyses, systematic reviews, randomized controlled trials, cohort studies, case-control studies, cross-sectional studies, case reports, editorials, animal research, laboratory research, and clinical trial phases. For each type of study, it provides brief explanations of their purpose and advantages and disadvantages. It also defines key statistical concepts like p-values and standard deviation.
The document describes a Gleason grade grouping system used to classify prostate cancer based on biopsy results. It assigns prostate cancers a grade from 1 to 5 based on their Gleason scores, with lower grades indicating less aggressive cancers and higher grades indicating more aggressive cancers likely to spread.
Metabolic evaluation of urinary lithiasis 2Praveen Ganji
This document discusses the metabolic evaluation of urinary lithiasis (kidney stones). It outlines the diagnostic evaluation process, including use of stone analysis and imaging to determine stone composition. An abbreviated protocol is described for low-risk first-time stone formers, while a more extensive evaluation is recommended for recurrent stone formers and those at high risk of recurrence. The economics of metabolic evaluation are discussed, noting the high costs of stone treatment but also the costs of testing. Finally, different classifications of nephrolithiasis based on underlying metabolic abnormalities are presented along with diagnostic criteria.
This document provides information on pheochromocytoma, including:
1) It describes the history, epidemiology, clinical features, differential diagnosis, and "10% tumor rule" characteristics.
2) Biochemical testing using urine or plasma tests for metanephrines is described as the primary diagnostic method. Localization uses CT, MRI, or MIBG scans.
3) Extensive pre, intra, and postoperative management is outlined to prevent hemodynamic instability, including alpha-blockade, IV fluids, and monitoring. The goal of treatment is surgical removal which is often curative.
This document discusses various minimally invasive and endoscopic procedures for treating benign prostatic hyperplasia (BPH), including bipolar transurethral resection of the prostate (B-TURP), transurethral vaporization of the prostate (TUVP), transurethral microwave therapy (TUMT), transurethral needle ablation (TUNA), transurethral incision of the prostate (TUIP), and various laser treatments such as photoselective vaporization of the prostate (PVP) and holmium laser enucleation of the prostate (HoLEP). Many of the procedures provide improvements in urinary symptoms comparable to traditional TURP but with benefits such as less
The document discusses different procedures for inguinal lymph node dissection, including standard, modified, and radical dissection. It describes key aspects of modified inguinal lymphadenectomy such as a shorter skin incision and preservation of structures like the saphenous vein. Complications of inguinal node dissection are also outlined, ranging from minor issues like lymphocele and wound infection to major complications including debilitating lymphedema, flap necrosis, and blood clots. The document provides details on surgical techniques, postoperative care, and risks associated with dissection of lymph nodes in the groin area.
This document discusses renal nuclear scans using MAG3 or DTPA to evaluate kidney function. MAG3 is now preferred over DTPA as it is both filtered and secreted by the kidneys, making it more useful for evaluating impaired kidney function. A renal nuclear scan has three parts: images of the kidneys, graphical curves representing tracer movement, and numerical values of GFR, transit time and split function. The images show perfusion and excretion phases. The curves plot tracer levels in the aorta, left kidney and right kidney over time. Renal scans using tubular agents like MAG3 can be done up to creatinine levels of 7 mg/dl. Three diuretic protocols - F+20,
Pheochromocytoma is a rare tumor of the adrenal medulla that secretes excess catecholamines. It was first described in 1886 and successful surgical treatment was reported in 1926. It typically presents with headaches, sweating, and palpitations. Biochemical testing of urine or plasma is used to diagnose, and imaging such as CT, MRI, or MIBG scans are used to localize the tumor. Preoperative management focuses on alpha-blockade to prevent hypertension during tumor manipulation. Surgery is usually curative though long term monitoring is needed due to risk of recurrence.
This document provides an overview of adrenal incidentalomas. It defines incidentalomas as unsuspected adrenal masses greater than 1 cm found on imaging for unrelated reasons. Nearly 20% may require surgery. Evaluation involves imaging to characterize the mass and metabolic testing to check for hormone hypersecretion. Computed tomography and MRI are used to identify lipid-rich adenomas. Biopsy has limited utility due to risk and inability to differentiate adenoma from carcinoma. Masses larger than 4 cm or those that grow over 1 cm may require resection. Metabolic testing evaluates for cortisol, catecholamine, aldosterone, and sex steroid hypersecretion, though sex hormone testing is not routinely recommended.
This document provides an overview of urodynamic studies (UDS), which are used to evaluate bladder storage and voiding functions. It describes various UDS techniques including uroflowmetry, post-void residual measurement, cystometry, and pressure-flow studies. Cystometry involves bladder filling while measuring pressures, and is used to assess capacity, compliance, and for detecting detrusor overactivity. Pressure-flow studies performed during voiding provide information about bladder contractility and outflow obstruction. Together these invasive UDS techniques provide valuable information to characterize lower urinary tract dysfunction.
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• Building trust with communities online and offline
• Equipping health professionals to address questions, concerns and health misinformation
• Assessing risk and mitigating harm from adverse health narratives in communities, health workforce and health system
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptxHolistified Wellness
We’re talking about Vedic Meditation, a form of meditation that has been around for at least 5,000 years. Back then, the people who lived in the Indus Valley, now known as India and Pakistan, practised meditation as a fundamental part of daily life. This knowledge that has given us yoga and Ayurveda, was known as Veda, hence the name Vedic. And though there are some written records, the practice has been passed down verbally from generation to generation.
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
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These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
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2. Fetal Imaging
• The increased use of maternal-fetal ultrasound
has led to the development of the field of
perinatal urology.
3. ANH
• Antenatal hydronephrosis (ANH)
• identified in 1% to 3% of all pregnancies
• one of the most common birth defects
detected.
4. • Ultrasonography continues to be the mainstay
of fetal imaging.
• With experience, this modality provides
intricate detail and diagnostic capability that is
similar to that of ultrasonography in the
neonate.
5. • Fetal magnetic resonance imaging (MRI)
• a valuable adjunct
• when further delineation of anatomic detail is
believed to be necessary to optimize diagnosis
and/or management strategy
6. • Use of complementary computed tomography
is controversial
• the additive information may not outweigh the
added risk of fetal and maternal radiation
exposure.
8. • ANH:
• Defined as an anteroposterior diameter (APD)
of the renal pelvis greater than 5 mm.
• But the consensus on the definition of ANH is
lacking.
• With the rapid improvement of ultrasound
technology, the incidence of detection of renal
anomalies may be changing.
9. • In a single institutional study,
Study Period
Incidence of
Urinary tract
abnormlaities
1989-1993 0.3%
1999-2003 0.76%
10. • A large prospective study of 11,986 Swedish
women conducted between 1978 and 1983
identified renal anomalies in 0.28% of fetuses.
• Over two thirds of the anomalies were
hydronephrosis (0.18%)
11. • A British prospective screening study of 6292
pregnant women at 28 weeks’ gestation
demonstrated
• hydronephrosis in 1.40% of patients,
• with postnatal confirmation in 0.65%
15. • Hydronephrosis, or dilation of the renal pelvis,
is the most common urologic abnormality
found on ultrasound evaluation.
16. • Numerous grading systems have been developed
• however, there is no consensus on the best and most
consistent method of reporting ANH.
• Measurement of the APD has been used widely
• but there have been no formal studies to determine the
interobserver and intraobserver reproducibility of ANH
measurement.
17.
18. Disadvantages of
use of APD
• APD fails to describe
• pelvic configuration,
• calyceal dilation &
• laterality of findings,
which should be
included.
• APD can be affected by
• gestational age,
• hydration status of the
mother
• bladder hypertonicity &
• degree of bladder distention
19. • Because the dimensions of the renal pelvis
may normally increase with gestational age,
most investigators have adjusted threshold
APD values for early and later gestational age.
20. • Unfortunately, a simple threshold APD value
that separates normal from abnormal does not
exist
• even severe cases of ANH have the potential to
resolve without incident
• whereas mild degrees of ANH have the
potential to progress
21. • Varying the minimal APD threshold can
significantly alter the specificity and sensitivity
of APD as a measure of ANH and postnatal
pathology.
• To date there is no consensus on the optimal
APD threshold for determining the need for
postnatal follow-up.
22. • An APD cutoff of 15 mm for determining
obstruction yielded a postnatal sensitivity of
73% and specificity of 82%.
Late Gestational age APD
cutoff
Abnormality detection
10mm 23%
7mm 68%
23. ANH categories by APD
• There is near-total agreement that APD greater
than 15 mm represents severe or significant
hydronephrosis.
• A lower threshold of 4 to 5 mm is an
appropriate value for considering APD to be
abnormal
24.
25. Alternative
Measurements
• 3D volume measurements of the renal pelvis.
• Hydronephrosis index to correct for bladder
distention for a more precise evaluation.
• Society for Fetal Urology (SFU) ultrasound
grading system of ANH.
27. • MRI may also prove useful in prenatal
evaluation
• Advantage: high anatomic detail without
ionizing radiation exposure.
• High cost and limited data currently confound
the optimal use of this modality in the context of
ANH.
28. Diagnostic Accuracy
• The ability to determine definitive postnatal
pathology based on antenatal findings is
difficult.
29. • In a systematic review of the ANH literature, Lee and
colleagues in 2006 attempted to determine the risk of
a pathologic diagnosis for patients with varying
severity of ANH .
• The review included 1308 patients who were identified
with ANH and sufficient postnatal radiographic follow-
up.
30. Other category includes
prune-belly syndrome,
VATER (vertebral, anal, tracheo-esophageal and renal anomalies) syndrome,
solitary kidney,
renal mass, and
Unclassified causes.
31. • The degree of ANH was defined by APD
identified in a particular trimester.
• Approximately 36% of the patients had a
postnatal pathologic diagnosis.
• The overall risk for any pathologic process
increased with increasing degree of ANH.
32. • However, the risk of vesicoureteral reflux
(VUR) remained consistent regardless of the
degree of ANH
• ANH is not an appropriate indicator for VUR.
33. • Earlier literature suggests that obstruction
location can be determined prenatally in 88%
of cases.
• but many researchers have reported a high
false-positive rate (9% to 22%) .
34. • The majority of false-positive findings in these
studies involved nonobstructive causes of
hydronephrosis, such as
• high-grade reflux,
• large nonobstructed extrarenal pelves, or
• transient hydronephrosis.
35. • Early and accurate diagnosis of posterior urethral
valves is critical but difficult.
• The hallmark signs of an in utero diagnosis of posterior
urethral valves have been described
• Oligohydramnios,
• dilated posterior urethra,
• thickened bladder
• hydroureteronephrosis
• increased renal echogenicity.
36. • Regardless, there are very few studies that have
prospectively examined the clinical urologic
implications of these findings alone or in combination.
• In one series of 22 fetuses, the false positive rate was
as high as 58% .
• In a population-based series the sensitivity in
detecting valves was as low as 23%.
37. • Regardless of the degree or severity of the
finding, after any antenatal detection of a
urinary tract anomaly a thorough fetal survey
must be conducted.
38. • Amniocentesis and karyotype should be
considered if intervention or a major anomaly
is suspected,
• because the incidence of concurrent
chromosomal anomalies is relatively high in
fetuses with concomitant urologic anomalies.
40. • Up to 3% of all pregnancies involve fetal urinary
tract anomalies.
• vast majority associated with hydronephrosis.
• Less than 5% of all detected anomalies have
severe enough obstruction that might warrant
antenatal intervention.
41. • The primary role for the perinatal urologist is
to provide education and counseling for
prospective parents in an objective manner.
42. • The counseling urologist should
(1) provide reassurance and dispel misconceptions,
(2) provide a reasonable differential diagnosis
(3) supply information regarding the natural history of the
disease,
(4) give antenatal recommendations &
(5) provide a postnatal management plan.
43. • The need for continued antenatal evaluation is
debatable and unclear
• particularly with mid- and late-trimester mild and
moderate hydronephrosis.
• More regular follow-up is reasonable
• In severe unilateral or bilateral hydronephrosis,.
• If there is a suspicion of bladder outlet obstruction.
44. • Normal fetal growth parameters,
• amniotic fluid volume,
• renal appearance (echogenicity, degree of
hydronephrosis, cystic changes) &
• extrarenal fluid collections
should be monitored closely.
46. • Overall, the need to consider in utero intervention for
obstruction is uncommon.
• However, in the specific cases in which it should be
considered, the rationale for antenatal treatment of
hydronephrosis is to maximize development of
• pulmonary and
• renal function.
47. • These two aspects of fetal development are
closely linked because
• urine comprises more than 90% of amniotic fluid
volume by the 16th week of gestation and
• oligohydramnios during the 2nd trimester is
often associated with a lethal postnatal
outcome secondary to pulmonary hypoplasia
48. • Before prenatal surgical intervention for
obstructive uropathy, it is critical to assess the
risk-benefit ratio.
• The time of onset of oligohydramnios has been
shown to be an important determinant of
outcome.
49. • In fetuses in which adequate amniotic fluid was
documented at up to 30 weeks’ gestation in
association with a urologic abnormality,
• pulmonary outcomes were satisfactory and
• postnatal clinical problems were related to renal disease.
• Therefore, in the setting of late-onset oligohydramnios
there appears to be limited usefulness of urinary tract
decompression or early delivery for pulmonary
reasons.
50. • It is also unclear whether early delivery to
permit earlier postnatal urinary decompression
is beneficial.
• If early delivery is considered, maternal
corticosteroid administration for pulmonary
development should be considered.
51. • The most widely accepted indicator of
salvageable renal function is analysis of fetal
urine.
53. Use of fetal urine β2 microglobulin
• An indicator of tubular damage.
• In normal postnatal kidneys, >99.9% of β2 microglobulin
is reabsorbed and metabolized in the proximal tubules.
• In postnatal renal disease with damage to this area, β2
microglobulin is excreted in the urine.
• Including this parameter, poor renal outcome has been
predicted with a specificity of 83% and sensitivity of 80%
54. • Findings on antenatal ultrasound have also
been examined with regard to prediction of
long-term postnatal renal function.
55. • In a systematic review of 13 articles encompassing 251
women,
• oligohydramnios and
• appearance of the renal cortex (increased echogenicity
or cystic changes) at the diagnosis of lower urinary tract
obstruction
were the best factors to predict poor renal function
(defined as creatinine >1.2 mg/dL).
• In this particular study, gestational age at diagnosis
(<24 weeks) was not predictive of renal function.
57. • The ability to diagnose severe prenatal hydronephrosis
and advances in fetal intervention have helped
develop prenatal surgery for obstructive uropathy.
• Harrison and colleagues (1982) described the initial
report of fetal surgery in a 21-week-old fetus with
bilateral hydroureteronephrosis secondary to
posterior urethral valves.
58. • More recently, with improved technology
• the initial method of decompression with open surgery
has largely been replaced by in utero shunt placement.
• The shunt is placed under ultrasound guidance using a
Seldinger technique through a trocar.
• Current practice uses the Rodeck shunt, which lies flat
against the abdomen to minimize shunt dislodgment
59.
60. Complications of Shunting
1. Shunt dislodgment
2. Bowel herniation.
3. Amnioinfusion may be needed to improve visualization for
shunt placement
• this may lead to excessive fetal movement.
4. Occasionally the fetus needs to be paralyzed for accurate
placement.
5. Very large bladders may cause the shunt to be placed too
high in the abdomen, resulting in dislodgment from the
bladder after it decompresses.
61. 6. Induction of premature labor,
7. Perforation of fetal bowel and bladder,
8. fetal loss,
9. fetal and/or maternal hemorrhage and
infection.
62. Fetal Cystoscopy
• Fetoscopic methods for direct intervention to provide
prolonged bladder drainage have also been explored.
Advantage over vesicoamniotic shunting:
improved drainage and
restoring normal cycling of the bladder.
63. Drawbacks of Fetal Cystoscopy
• There are no studies to determine if this method of
decompression is adequate in the face of significant
prenatal bladder dysfunction.
• Furthermore, fetoscopic intervention also introduces
the additional potential for iatrogenic injury to the
urethra, bladder neck, or external urethral sphincter.
65. • To date, the reported long-term outcomes of
antenatal intervention for severe obstructive
uropathy (e.g., posterior urethral valves,
prune-belly syndrome, urethral atresia) are
mixed
66. Long-term outcomes of
in-utero vesicoamniotic shunting
Acceptable renal
function
45%
Mild impairment
22%
Renal failure
33%
67. Best Renal Outcome
with shunting
0
20
40
60
prune-belly syndrome
PUV
Urethral atresia
57%
43%
25%
68. PLUTO trial
• European-based multicenter randomized clinical trial
• PLUTO (Percutaneous Shunting for Lower Urinary
Tract Obstruction)
• Aim:
To evaluate the safety and effectiveness of vesicoamniotic
shunting as compared with conservative management in
singleton pregnancies with ultrasound evidence of lower
urinary tract obstruction
69. Results of PLUTO trial
CATEGORY NUMBER
Vesicoamniotic shunt patients 16
Controls 15
Total 31 cases
71. • All postnatal deaths were from pulmonary hypoplasia.
• Although underpowered, the study demonstrated a
nonsignificant increase in survival in the vesicoamniotic
shunt group.
• Consistent with the results of the systematic review of
existing prenatal intervention data, there was minimal
likelihood of surviving with longterm normal renal
function.
72. • Overall, it appears that select in utero intervention for
the appropriate patient may reduce the risk of
neonatal mortality.
• Without doubt, more sensitive and specific markers to
better identify which fetus will benefit from in utero
shunting need to be defined.
74. • A child with a prenatal diagnosis of a urologic renal
abnormality such as ANH should be carefully evaluated
and followed by a pediatric urologist from birth.
• The vast majority of these children appear entirely
healthy and in the absence of prenatal ultrasound
findings would not have any indications for regular
urologic follow-up.
• Parental anxiety is common and should be addressed
directly with prenatal counseling and education.
76. • The presence of prenatally detected unilateral dilation
of the kidney warrants postnatal ultrasound evaluation
in a timely but nonurgent fashion (3 to 8 weeks of life).
• The most common diagnoses associated with this
finding are
1. UPJ obstruction,
2. VUR,
3. UVJ obstruction &
4. Megaureter.
77. • Normal postnatal ultrasound examination
findings indicate that obstructive uropathy is
not present;
• however, normal findings do not indicate
whether the child has VUR.
78. • It is important to keep in mind that a postnatal
ultrasound evaluation performed within the
first 48 hours of life may not yet demonstrate
hydronephrosis or may underestimate the
degree of hydronephrosis secondary to
physiologic oliguria in the newborn.
79. VCUG &
Prophylactic Antibiotics
• The current trend in management of ANH minimizes
postnatal prophylactic antibiotics and testing for VUR
• in cases of resolved ANH or
• in mild to moderate cases of persistent postnatal ANH
owing to a lack of evidence for a benefit to
screening.
80. • Severe ANH
• may be associated with an increased risk of febrile
urinary tract infection and
• possibly may indicate a higher grade of VUR.
• Infants with severe ANH should be placed on a
prophylactic antibiotic (amoxicillin, 10 to 25 mg/kg/day)
and undergo VCUG.
81. • Diuretic renography…
• with technetium-99m mercaptoacetyltriglycine
• reserved for those with persistent moderate or
severe postnatal hydronephrosis not related to
VUR.
82. • Perhaps the most challenging aspect of managing ANH
is determining if and when postnatal surgical correction
for obstruction is appropriate.
• regardless of the degree of ANH, moderate or severe
postnatal hydronephrosis with evidence of decreased
renal function should be an indication for surgical
intervention.
85. • Infants with bilateral hydroureteronephrosis
may have
1. posterior urethral valves,
2. bilateral VUR,
3. bilateral UPJ or UVJ obstruction, or a
combination of these findings.
86. • For the child with bilateral
hydroureteronephrosis suggestive of bladder
outlet obstruction,
• ultrasound evaluation and
• VCUG
should be performed promptly.
87. • In boys, the presence of posterior urethral valves is the
most important diagnosis to be ruled out.
• In girls, an obstructing ectopic ureterocele would be
the most likely cause of bladder outlet obstruction.
• In the event that an obstructive lesion is discovered, it
should be corrected promptly.
88. • For children with suspected lower urinary tract
obstruction (e.g., posterior urethral valves),
• prompt bladder decompression and
• antibiotic prophylaxis (amoxicillin 10 to 25
mg/kg/day)
should be initiated before radiographic
intervention.