'PURE' (Pediatric Urology Ramachandra Education)
Currently most pregnant women undergo one or two ultrasound scans during their pregnancy. When the fetus is scanned, kidneys and the urinary tracts are analyzed, In addition the volume of liquor (amniotic fluid) also helps to suspect kidney problems. Of late stretching of the kidney (Hydronephrosis) is detected very frequently.
Kidney Stretching (Hydronephrosis)
During scanning of 100-200 pregnant ladies, one fetus is found to have this abnormality. This usually happens because of a blockage in the urinary tract. Before proceeding further it is essential to describe the normal arrangement of the kidneys.
In human body there are two kidneys, one on either side of belly. From each kidney urine drains out via a tube called ‘ureter’ into a common urinary bladder. The bladder is located in the lower most part of belly. Once enough urine accumulates, it empties via a tube called ‘urethra’. Whenever there is a block in any of these tubes, kidney stretching results.
Single Kidney Stretching (Unilateral Hydronephrosis)
When only one kidney (right or left) stretches, blockage is suspected only on that side. When kidneys only stretch, the blockage is suspected at a higher location (PUJ obstruction). When the pipe draining the kidney also stretches, blockage is suspected at a lower location (VUJ obstruction).
Newborns with this problem need to be scanned on the third day after birth. In general very mild stretching is likely to settle spontaneously. Huge stretching requires surgery urgently to prevent loss of kidney function (renal failure). Children with moderate stretching need close monitoring with repeat scans and further tests. It is essential to consult a pediatric urologist to determine what tests are required and when a surgery could be avoided. Also it is essential to prevent urinary infection by taking a small dose of antibiotic once at night.
Both Kidneys Stretching (Bilateral Hydronephrosis)
When both kidneys stretch, they can be blocked separately. But usually they are blocked as urine exits the bladder in the ‘urethra’. In boys a valve like blockage can result in stretching of both kidneys (posterior urethral valve – PUV). Immediate endoscopic intervention after birth is essential to prevent urine infection and kidney failure.
Consultation before birth (Antenatal Counseling)
When there is a fetal kidney problem, there could be a lot of anxiety among parents. Consulting a paediatric urologist can relieve the anxieties and also provide answer to many questions. It will help to plan the type of delivery, place of delivery (where the treatment is available to the baby after birth), the type of tests required after birth. Also it helps to find out more about what is expected in the long run (prognosis) and whether the problem can occur again in future children (familial incidence).
This section discusses about blockage caused by PUJ obstruction. In this condition there is a blockage of urine at the junction of kidney and the pipe draining (ureter) - pelvi ureteric junction (PUJ). Because of this the kidney stretches. Often it affects one side alone although it can involve both kidneys.
What are the symptoms of hydronephrosis?
How is hydronephrosis diagnosed?
How can hydronephrosis be treated?
What does a pyeloplasty involve?
Under general anaesthesia, a small cut is made in the kidney region. The blocked portion is removed and reconnected. A small tube called stent may be kept to protect the sutures. It may be kept fully inside (needs removal under a second anaesthesia) or partly out (bedside removal after 7 days). The hospital stay is between 4-8 days. Children recover very well and it is not very painful as medicines will be given to take care of it. They can have normal feeds within 24 hours of operation.
For older children it can be performed laparoscopically (key hole surgery) to avoid a scar. Laparoscopic pyeloplasty has a very good success rate.
What is the outlook for children with hydronephrosis?
Posterior urethral valves (PUV) is a condition found only in boys. PUV occurs in one in every 8000 boys born. It affects the urethra (the tube which runs from the bladder to the outside). In boys with PUV, the urethra has a blockage in it near the bladder. This makes it difficult for them to pass urine. As the bladder pushes hard to get the urine out, it causes pressure which may result in urine being pushed back from the bladder into the ureters and kidneys (reflux). This causes the kidneys and bladder to swell. This also may lead to kidney damage.
What are the symptoms of PUV?
There are various symptoms associated with PUV, but they may not affect every child in the same way. The degree of blockage affects the severity of the symptoms. These boys can have
How is it diagnosed?
PUV can be diagnosed by a routine ultrasound scan during pregnancy if the bladder, ureters or kidneys are swollen. It can also be diagnosed in a newborn baby if the bladder is swollen and urine dribbles constantly. If the blockage is not severe the condition can remain undetected until the child has symptoms as above.
How can PUV be treated?
There are several options for treatment, depending on how severely the symptoms are affecting your child:
What is the outlook for children with PUV?
The outlook depends on how much damage has already occurred in the kidneys. Your doctors will be able to give you a better idea once they have all of your son’s test and blood results. It is essential to keep up with the follow up appointments as they need long term monitoring; some time for years together.
Dr. Ramesh Babu, MS, MCh, FRCS, Paediatric Surgeon, Paediatric Laparoscopic Surgeon and Paediatric Urologist Chennai. For further information contact: email@example.com; Mobile 9840359062