Vesicoureteric reflux , a common condition in children which could be misdiagnosed . Early diagnosis can help prevent renal scarring and other complications
Ureteropelvic junction obstruction by\ Eman Salman
It was used for student presentation in Urology course rotation
I Hope you find what is helpful for your knowledge ♥
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.
POSTERIOR URETHRAL VALVES- Pediatric Surgery
• Dear viewers,
• Greetings from “ Surgical Educator”
• Today I have uploaded one more video in Pediatric Surgery/Pediatric Urology- “ Posterior Urethral Valves”
• Posterior Urethral Valves is the congenital cause for Bladder Outlet Obstruction, resulting in abnormal development of the kidneys as well as the bladder.
• In this video, I talked about the learning outcomes, introduction, etiopathogenesis, clinical features, investigations, differential diagnosis, treatment, follow-up and prognosis of “ Posterior Urethral Valves”
• I hope you will enjoy the video for its educational value.
• You can watch all my teaching videos in the following links
• surgicaleducator.blogspot.com youtube.com/c/surgicaleducator
• Thank you for watching the video.
Presentation delivered at a paediatric clinical meeting of the Federal Medical Center, Lokoja. Nigeria
This presentation doesn't serve as a substitute for texts and/or journals.
Description of Urinary tract infections of pediatric age group, signs and symptoms, presentations, diagnosis, investigations, prognosis and management plan
Ureteropelvic junction obstruction by\ Eman Salman
It was used for student presentation in Urology course rotation
I Hope you find what is helpful for your knowledge ♥
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.
POSTERIOR URETHRAL VALVES- Pediatric Surgery
• Dear viewers,
• Greetings from “ Surgical Educator”
• Today I have uploaded one more video in Pediatric Surgery/Pediatric Urology- “ Posterior Urethral Valves”
• Posterior Urethral Valves is the congenital cause for Bladder Outlet Obstruction, resulting in abnormal development of the kidneys as well as the bladder.
• In this video, I talked about the learning outcomes, introduction, etiopathogenesis, clinical features, investigations, differential diagnosis, treatment, follow-up and prognosis of “ Posterior Urethral Valves”
• I hope you will enjoy the video for its educational value.
• You can watch all my teaching videos in the following links
• surgicaleducator.blogspot.com youtube.com/c/surgicaleducator
• Thank you for watching the video.
Presentation delivered at a paediatric clinical meeting of the Federal Medical Center, Lokoja. Nigeria
This presentation doesn't serve as a substitute for texts and/or journals.
Description of Urinary tract infections of pediatric age group, signs and symptoms, presentations, diagnosis, investigations, prognosis and management plan
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- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
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Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
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RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
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2. TABLE OF CONTENT
• Introduction
• Epidemiology
• Etiology
• International Classification of Vesicoureteral Reflux
• Pathophysiology
• Clinical features
• Complications of Reflux
• Investigation
• Treatment
• Follow-up
• Prognosis
• References
3. Introduction
Vesicoureteral reflux (VUR) is a condition in which urine flows retrograde, or
backward, from the bladder into the ureters/kidneys.
Urine normally travels in one direction (forward, or antegrade) from the
kidneys to the bladder via the ureters, with a 1-way valve at the
ureterovesical (ureteral-bladder) junction preventing backflow
The valve is formed by oblique tunneling of the distal ureter through the wall
of the bladder, creating a short length of ureter (1–2 cm) that can be
compressed as the bladder fills.
Reflux occurs if the ureter enters the bladder without sufficient tunneling
4. Epidemiology
• It has been estimated that VUR is present in more than 10% of the
population.
• Younger children are more prone to VUR because of the relative shortness
of the submucosal ureters. This susceptibility decreases with age as the
length of the ureters increases as the children grow.
• In children under the age of 1 year with a urinary tract infection, 70% will
have VUR. This number decreases to 15% by the age of 12.
• VUR is more common in males antenatally,
• in later life there is a definite female preponderance with 85% of cases
being female.
• 30 to 60% of children with VUR have renal scarring
• Female: Male ratio= 5:1
5. Etiology
In healthy individuals the ureters enter the urinary bladder obliquely
and run submucosally for some distance. This, in addition to the
ureter's muscular attachments, helps secure and support them
posteriorly. Together these features produce a valvelike effect that
occludes the ureteric opening during storage and voiding of urine. In
people with VUR, failure of this mechanism occurs, with resultant
retrograde flow of urine.
It could be primary or secondary
8. Primary Reflux
Normal mechanism has –
• oblique entry of the ureter
• submucosal –intramural length of ureter
• Ratio of tunnel length : diameter of ureter-3:1
• Ureterotrigonal longitudinal muscles
• Active ureteral peristalsis
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9. Primary Reflux
Insufficient submucosal length of the ureter relative to its diameter
causes inadequacy of the valvular mechanism. This is precipitated by a
congenital defect/lack of longitudinal muscle of the intravesical ureter
resulting in an ureterovesicular junction (UVJ) anomaly.
10. Secondary VUR
• In this category the valvular mechanism is intact and healthy to start
with but becomes overwhelmed by raised vesicular pressures
associated with obstruction, which distorts the ureterovesical
junction. The obstructions may be anatomical or functional.
• Secondary VUR can be further divided into anatomical and functional
groups.
12. International Classification of Vesicoureteral Reflux
• Grade I – reflux into non-dilated ureter
• Grade II – reflux into the renal pelvis and calyces without dilatation
• Grade III – mild/moderate dilatation of the ureter, renal pelvis and
calyces with minimal blunting of the fornices
• Grade IV – dilation of the renal pelvis and calyces with moderate
ureteral tortuosity
• Grade V – gross dilatation of the ureter, pelvis and calyces; ureteral
tortuosity; loss of papillary impressions
• Note:
13. International Classification of Vesicoureteral Reflux
The younger the age of the patient and the lower the grade at
presentation the higher the chance of spontaneous resolution. Most
(approx. 85%) of grade I & II cases of VUR will resolve spontaneously.
Approximately 50% of grade III cases and a lower percentage of higher
grades will also resolve spontaneously.
17. Vesico- ureteral reflux
• Grade III
Vesicoureteral Reflux:
urine refluxes all the
way up the ureter with
dilatation of the ureter
and calyces (part of
the kidney where urine
collects)
18. Vesico- ureteral reflux
• Grade IV
Vesicoureteral
Reflux:
urine refluxes all
the way up the
ureter with
marked
dilatation of the
ureter and
calyces
19. Vesico- ureteral reflux
• Grade V Vesicoureteral
Reflux:
massive reflux of urine
up the ureter with
marked tortuosity and
dilatation of the ureter
and calyces
21. Pathophysiology
• VUR > High pressure urine into ureters & Kidneys
• Stasis of urine because of post-voidal residual urine
• Stasis of urine good nidus for superadded infection
• Refluxed infected urine >Pyelonehritis >Renal scarring >Reflux
Uropathy >ESRD
• Reflux,UTI & Pyelonephritis scarring >Well known Triad in Pediatric
urology
22. Clinical Features
• Neonates : usually asymptomatic, non specific symptoms
• Infants : the signs and symptoms of a urinary tract infection may
include only fever and lethargy, with poor appetite and sometimes
foul-smelling urine, Young infant not thriving
• older children : dysuria and frequent urination, urine retention,
Cloudy or blood tinged urine
24. Investigations
• Prenatal screening : hydronephrosis or hydroureter on Ultrasound
• Fluoroscopic Voiding cystourethrogram (VCUG) : VCUG is the method of
choice for grading and initial workup
• Abdominal ultrasound :suggest the presence of VUR if ureteral dilatation is
present; however, in many circumstances of VUR of low to moderate
severity, the sonogram may be completely normal, thus providing
insufficient utility as a single diagnostic test in the evaluation of children
suspected of having VUR, such as those presenting with prenatal
hydronephrosis or urinary tract infection (UTI).
35. Treatment
• The goal of treatment is to minimize infections, as it is infections that
cause renal scarring and not the vesicoureteral reflux.
• Minimizing infections is primarily done by prophylactic antibiotics in
newborns and infants who are not potty trained.
• When medical management fails to prevent recurrent urinary tract
infections, or if the kidneys show progressive renal scarring then
surgical interventions may be necessary.
• Medical management is recommended in children with Grade I-III
VUR as most cases will resolve spontaneously.
36. ….
• A trial of medical treatment is indicated in patients with Grade IV VUR
especially in younger patients or those with unilateral disease.
• Of the patients with Grade V VUR only infants are trialled on a
medical approach before surgery is indicated.
• In older patients surgery is the only option.
37. Medical Treatment
• Medical treatment entails low dose antibiotic prophylaxis until resolution
of VUR occurs
• The specific antibiotics used differ with the age of the patient and include:
• Amoxicillin or ampicillin - infants younger than 6 weeks
• Trimethoprim-sulfamethoxazole (co-trimoxazole) - 6 weeks to 2 months
• After 2 months the following antibiotics are suitable:
• Nitrofurantoin {5–7 mg/kg/24hrs}
• Nalidixic acid(10 mg/kg in bid doses)
• Bactrim(2 mg/kg of TMP as a single dose at bedtime)
• Trimethoprim
• Cephalosporins
38. Medical Treatment
• Urine cultures are performed 3 monthly to exclude breakthrough
infection
• Annual radiological investigations are likewise indicated. Good
perineal hygiene, and timed and double voiding are also important
aspects of medical treatment.
• Bladder dysfunction is treated with the administration of
anticholinergics.
39. Surgical Treatment
• A surgical approach is necessary in cases where a breakthrough infection
results despite prophylaxis, or there is non-compliance with the
prophylaxis.
• if the VUR is severe (Grade IV & V),
• pyelonephritic changes or
• congenital abnormalities.
• failure of renal growth,
• formation of new scars,
• renal deterioration and
• VUR in girls approaching puberty.
40. Surgical Treatment
• There are three types of surgical procedure available for the
treatment of VUR:
• Endoscopic (STING/HIT procedures);
• Laparoscopic; and
• Open procedures (Cohen procedure, Leadbetter-Politano procedure).
41. Prognosis
• The younger the age of the patient and the lower the grade at
presentation the higher the chance of spontaneous resolution.
• Most (approx. 85%) of grade I & II cases of VUR will resolve
spontaneously.
• Approximately 50% of grade III cases and a lower percentage of
higher grades will also resolve spontaneously.
• Prognosis is good when diagnosis is made early
42. Follow-up
• The American Urological Association recommends ongoing
monitoring of children with VUR until the abnormality resolves or is
no longer clinically significant.
• The recommendations are for annual evaluation of blood pressure,
height, weight, analysis of the urine, and kidney ultrasound.
43. References
• Institute of Urology & Nephrology, London, UK, The cellular basis of
bladder instability UJUS 2009, Retrieved 4-20-2010
• Peters CA, Skoog SJ, Arant BS, Copp HL, Elder JS, Hudson RG, Khoury AE,
Lorenzo AJ, Pohl HG, Shapiro E, Snodgrass WT, Diaz M (September 2010).
"Summary of the AUA Guideline on Management of Primary Vesicoureteral
Reflux in Children.". The Journal of Urology. 184 (3): 1134–44.
doi:10.1016/j.juro.2010.05.065. PMID 20650499
• Tekgül, S; Riedmiller, H; Hoebeke, P; Kočvara, R; Nijman, RJ; Radmayr, C;
Stein, R; Dogan, HS; European Association of, Urology (September 2012).
"EAU guidelines on vesicoureteral reflux in children.". European Urology. 62
(3): 534–42. doi:10.1016/j.eururo.2012.05.059. PMID 22698573.