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.
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.
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 ♥
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.
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 ♥
Primary vesicoureteral reflux (VUR) is the commonest congenital urological abnormalities in children, which has been associated with an increased risk of urinary tract infection (UTI) and renal scarring, also called reflux nephropathy (RN).
HELLO FRIENDS HERE CAUSES OF HEMATURIA IS HERE MANAGEMENT IN NEXT PRESENTATION ...YOU CAN SEE AND SUBSCRIBE OVER YOU TUBE ...LEARN UROLOGY IS CHANNEL NAME
FOLLOW THE YOU TUBE CHANNEL FOR FUTURE UROLOGY VIDEO
https://www.youtube.com/channel/UCINcUe475Y3c3BvXHvZ8wEw
Primary vesicoureteral reflux (VUR) is the commonest congenital urological abnormalities in children, which has been associated with an increased risk of urinary tract infection (UTI) and renal scarring, also called reflux nephropathy (RN).
HELLO FRIENDS HERE CAUSES OF HEMATURIA IS HERE MANAGEMENT IN NEXT PRESENTATION ...YOU CAN SEE AND SUBSCRIBE OVER YOU TUBE ...LEARN UROLOGY IS CHANNEL NAME
FOLLOW THE YOU TUBE CHANNEL FOR FUTURE UROLOGY VIDEO
https://www.youtube.com/channel/UCINcUe475Y3c3BvXHvZ8wEw
Vesicoureteric Reflux in Children—Current ConceptsApollo Hospitals
Urinary tract infection (UTI) is a common problem in infants and young children affecting about 2–5% of all small
children. Almost a third to half of infants who are inflicted with urinary infection are likely to have an abnormal urinary
tract, commonest of which is vesicoureteric reflux (VUR). Around 10–20% of children with VUR end with hypertension
or end stage renal disease stressing the need to diagnose and manage these children early. This article reviews
current status of clinical manifestations, diagnosis, and management of children with VUR.
Sometimes during pregnancy, there may be swelling of the kidneys called HYDRONEPHROSIS. Which can sometimes leads to complications in the mother and fetus. Contact female urology DOCTOR in Hyderabad to get best treatment, without effecting your baby’s growth.
"Understanding And Treating Major Urological Problems In Children" by Dr. Vivek Rege at HELP
This is part of the HELP Talk series at HELP,Health Education Library for People, the worlds largest free patient education library www.healthlibrary.com.
For info log on to www.healthlibrary.com.
Vesicoureteric reflux , a common condition in children which could be misdiagnosed . Early diagnosis can help prevent renal scarring and other complications
Procurement and packaging of Donor Heartsanyal1981
history of cardiac transplant, dr christian bernard, Groote schuur hospital,denise darvall, louis washansky, donor surgery, preservation solutions for harvested organs, organ transport systems
Case of chronic mesenteric ischemia, with pre-operative history and evaluation using ultasound doppler, CT angiogram and laboratory values. This followed by a detailed description of the surgical steps. A discussion then ensues over the management modalities and discussion on the outcomes using references and meta-analysis data
ICMR guidelines on antimicrobial use in Sepsis and SSI's in Indiasanyal1981
Sepsis, septic shock, sepsis induced hypotension, SIRS, common pathogens, trends of antimicrobial resistance. Emperical antibiotic therapy, Classification of surgical site infections with specifications regarding site specific pathogens and peri-operative prophylaxis
anatomy of median nerve,course in arm and struthers ligament, branches in the forearm, carpal tunnel and course in hand, high and low median nerve injuries, principles of surgical management, pronator teres syndrome, anterior interosseous nerve syndrome, open and endoscopic carpal tunnel release
gastric resection, reconstruction and post gastrectomy syndromessanyal1981
discussion regarding history of gastrectomy, types of gastrectomy, billroth I, billroth II and roux en y gastrojejunostomy........discussion of post gastrectomy syndromes
surgery, minimally invasive techniques, continuous closed ;lavage, necrosectomy, VARD, ideal time for intervention, role of antibiotics , laparoscpic surgery
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
These lecture slides, by Dr Sidra Arshad, offer a quick overview of 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 leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
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. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
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Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
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.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...
Vesicouretric reflux
1. VUR
Resident: Dr SD Sanyal
Moderator: Lt Col MS Vinod
Cl Spl Surg & Paediatric Surgeon
2. Introduction
• Vesicoureteral reflux (VUR) represents the retrograde flow
of urine from the bladder to the upper urinary tract
• Galen and da Vinci:
- First references to VUR by Western medicine
- UVJ as a mediator of unidirectional flow of urine
from the kidneys to the bladder
• Hutch(1952): Relationship between VUR and chronic
pyelonephritis in paraplegic patients
• Hodson(1959):UTI and renal scarring carried a high
likelihood of VUR in children
3. Inheritance & Genetics
• The prevalence of reflux is higher in siblings
• There is a tendency for an autosomal
dominant pattern of inheritance
• Probably many genes are involved:
- PAX2
- GDNF-RET
- UPK3
- AGTR2-ACE
4. Anti-Reflux Mechanism
• Functional integrity of the ureter:
- Antegrade peristalsis
• Anatomic composition of the UVJ:
- 5:1 ratio of tunnel length to ureteral diameter
in nonrefluxing junctions ( Paquin, 1959 )
• Functional compliance of the bladder
5.
6. Etiology
• Primary Reflux:
- fundamental deficiency in the function of the
UVJ
- bladder and ureter remain normal
- reflux occurs despite an adequately low-pressure
urine storage profile in the bladder
- length-diameter ratio is almost always less than
that described by Paquin
- inadequate tunnel length has greater implication
7. Etiology
• Secondary reflux:
- normal function of the UVJ being
overwhelmed
- bladder dysfunction : congenital, acquired, or
behavioral
- considered secondary if absence was
documented at some point before its
detection
12. Clinical features
• Features of recurrent UTI:
- Fever
- Flank pain
- probability of finding VUR in children with UTI
is 29% to 50%
• Renal failure
• Palpable renal mass
13. Diagnosis & Evaluation
• Urine microscopy & culture:
- Infant: placement of an adhesive urine collection bag
over the genitalia
- Patients who void spontaneously : clean voided
midstream catch
- Topical cleansing of the area to reduce contamination
and false-positive culture
- Repeated catheterization for the acquisition of
specimens
- SPC
14. Diagnosis & Evaluation
• Radiographic evaluation:
- Indications:
1. children younger than 5 years
2. all children with a febrile UTI
3. any male with a UTI regardless of age or
fever, unless sexually active
16. Diagnosis & Evaluation
• Other modalities:
- Uroflowmetry & urodynamic studies
- Cystoscopy & PI Cystogram
17. Sonography
• Quantitative assessment of renal dimensions :
- used to monitor renal growth
- impact of any intercurrent febrile episode on renal
growth
- need for further assessment of renal
function by scintigraphy or the need for
correction of reflux
• Degree of corticomedullary differentiation
• Imaging of perfusion abnormalities :
- Renal resistive index measurements
- Contrast-enhanced harmonic ultrasound
18. VCUG
• Provides information on :
- functional dynamics
- structural anatomy
• Parameters observed:
A. Static films
- bladder contour - presence of diverticula
- ureteroceles - grade of reflux
- configuration & blunting of calyces - bladder neck anatomy
- urethral patency
- intrarenal reflux
19. VCUG
B. Dynamic films:
- Passive/active reflux
C. Delayed or postvoid films:
- Crucial in documenting clearance of contrast
from the upper tracts
- Dilated PCS + Retained contrast = PUJO
• Contraindicated in active cystitis
- Exceptions: In children with a h/o recurrent
pyelonephritis and repeatedly negative voiding
studies in the intercurrent periods
20. DRCG
• Radiation exposure 1% of VCUG
• Little anatomic detail is afforded
• Ideal for:
- screening
- monitoring the natural history
- surgical follow-up of reflux
• Greater sensitivity in grades II to V reflux
• Grade I reflux into distal ureter poorly
detected
21. Scintigraphy
• DMSA:
- detection of reflux-associated renal damage
- acute pyelonephritic changes
- follow-up of reflux
• SPECT:
- 3D images
22. Uroflowmetry & Urodynamic study
• For establishing bladder functioning
• Lack of smoothness of the flow-velocity curve =
incomplete relaxation of the bladder outlet
during voiding
delays the natural history of reflux resolution or
even
perpetuate reflux
• Increased PVRU may be a risk factor for UTI
23. Cystoscopy
• Routine use is not mandated
• Role immediately prior to surgery for confirming:
- orifice position
- duplication
- proximity of diverticula to the orifice
- urethral patency
- endoscopic Mx(DEFLUX)
• PIC:
- to detect reflux under GA in pts with febrile UTIs
but a normal VCUG
24. Associated anomalies
1. PUJ Obstruction
- incidence of VUR associated with PUJO = 9% -
18%
- the incidence of PUJO in patients with reflux =
0.75% to 3.6%
- incidence with high-grade reflux = five times
more likely than lower grades of reflux
25. Associated anomalies
2. Ureteral duplication:
- VUR is the most common
abnormality associated
- reflux occurs most commonly
into the lower pole
26. Associated anomalies
3. Bladder diverticulae:
- outpouching of mucosa between detrusor
muscle bundles without any true muscle backing
itself
- Cause of reflux:
1. paraureteral diverticulum
2. large paraureteral diverticulum could expand
within Waldeyer's fascia and cause ureteral
obstruction/ project forward into the bladder
and obstruct the bladder outlet
27.
28. Associated anomalies
4. Renal anomalies:
- Renal agenesis: 46% association
- MCDK: 28% association
- Presence mandates VCUG
5. Megacystis-Megaureter syndrome:
- More common in males
- Differentiation from PUV
29. Associated anomalies
6. Pregnancy associated reflux:
- Women with hypertension and an element of
renal failure are particularly at risk
7. Other anomalies:
- VACTERL anomalies
- CHARGE syndrome
- Imperforate anus
30. Natural history
• Spontaneous resolution:
- At birth, the probability of spontaneous
resolution of primary reflux is inversely
proportional to the initial grade
- If a patient is encountered at a later age,
resolution from any point in time forward will
depend on the initial grade of reflux
31. Natural history
• Resolution by grade:
- Most cases of low-grade reflux (grade I and II)
will resolve : 63-85%
- Grade III reflux will resolve in approximately
50% of cases
- Higher-grade reflux (grades IV and V and
bilateral grade III) : 9-25%
32. Natural history
• Resolution with age :
- Age has greater significance than grade
- Most prevalent in neonates and young
children and will demonstrate the greatest
tendency to resolve in this group
33.
34. Management
• Principles of management:
1. Spontaneous resolution of reflux is very
common
2. High-grade reflux is less likely to resolve
spontaneously
3. Extended use of prophylactic antibiotics &
“ Watchful waiting”
4. The success rate with surgical correction is very
high
35. Medical management
• Watchful waiting
• Antibiotic prophylaxis:
- Amoxycillin < 2mths
- Co-trimoxazole > 2mths
- Alternatives: Nitrofurantoin/ Pro-biotics
• Breakthrough pyelonephritis
- indication for termination of medical mgt
36. Indications for surgery
ABSOLUTE INDICATIONS :
Breakthrough urinary tract infections
Failure of medical management
– - patient noncompliance
– - persistance of reflux with prolonged medical management.
– - progressive deterioration in renal function.
Ureteral obstruction assoc with VUR
Refluxing ureter opening into bladder diverticulum
Cystoscopic observation of golf hole orifice
RELATIVE INDICATIONS :
– Presence of massive reflux – gr IV & V
– Reflux associated with paraureteral diverticulum
– In girls whose reflux persists after they have reached the full somatic
growth potential at puberty.
– Parental preference
37. Surgical management
The principles of surgical correction :
- Exclude secondary reflux
- Adequate ureteral mobilization and protection of the
ureteral blood supply
- A generous submucosal tunnel should be fashioned
- Attention should be directed to angulation and twisting
- Bladder tissues must be handled gently
- Always consider bladder function preoperatively, as
well as in all cases of persistent or recurrent reflux
- Indications for correction of reflux are the same
regardless of whether the planned approach is open,
endoscopic, or laparoscopic.
38. Surgical modalities
• Endoscopic management
• Ureteric reimplantation
open
laparoscopic
SUCCESS RATE > 90% for all open surgical
procedures
39. Classification
According to approach :
• Intravesical
• Extravesical
• Combined
According to the position of the sub mucosal
tunnel in relation to the original hiatus :
• Suprahiatal
• Infrahiatal
40. Cohen’s Transtrigonal
• Intravesical, infrahiatal procedure
• Simple, safe and most commonly used
• Avoids complications of neo-hiatus formation
• Good for small capacity bladder
• Success > 95%
Problem :
• Difficult retrograde catheterization of ureters.
45. Endoscopic management
ADVANTAGES
• OPD based treatment
• less morbidity, no mortality
• No surgical scar
• Success rate almost equivalent to open surgery for primary
reflux.
DISADVANTAGES
• Cost
• Lower success rate compared to surgery for high grade reflux
49. Follow up
• Discharged on uro-prophylaxis
• Monitoring of pt’s
- BP
- renal function
- urine analysis
• Follow up USG and urine c/s after 1 mth
• VCUG after 3 mnths
• Discontinuation of uroprophylaxis on resolution
of reflux
• DMSA after 1 yr