MEGAURETER

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MEGAURETERS :

MEGAURETERS Presenter Dr.Md.Monowarul Islam

Particulars of patient:

Particulars of patient Name:Master Naihan Age:2yr 8 months Sex:Male Address: Hatirpul, Dhaka

Presentation:

Presentation Irregular fever since 1year of age Passage of cloudy urine

History of present illness:

History of present illness Patient’s father states that when baby was 1 year of his age he developed fever that was mild to moderate in intensity associated with passage of cloudy urine. As per prescription of local practitioner they administered some drugs then fever subsided. Four months later baby again developed fever then they visited urology OPD of BSMMU, subsequent investigation revealed he has been suffering from UTI. His urinary stream was good though out and there is no history of increased frequency, dribbling of urine, straining at micturition, but bed wetting one/two times at night.

History of past illness:

History of past illness PMH: None Chronic Illness: None Previous operation/accident: None

Drug history:

Drug history Previous treatment: Some medication they had administered as per advice of his physician but they can’t mention the details Current medication: None Regular medication: None Drug Allergy: none known

Family history:

Family history None of his family member has suffered from similar illness

Obstritical history:

Obstritical history Mode of delivery: LUCS Gestational period: Full term Liquor amni: normal

General Physical Examination:

General Physical Examination Appearance: Normal Temparature: Normal Pulse: BP: Respiration: Quite Oedema: Absent Dehydration:Absent

Abdomen and Ext. Genitalia Examination:

Abdomen and Ext. Genitalia Examination Suprapubic region: Normal Liver, Spleen, Kidneys: Not palpable Prepuce: Intact that open ups on retraction EUM: Normal Hernial orifices: Intact Testis: Both normal

Salient Features:

Salient Features Master Naihan, 2Y8M-old-baby boy developed two episodes of fever since one year of his age. Fever was mild to moderate in intensity associated with passage of cloudy urine. subsequent investigation revealed fever was due to UTI. His urinary stream was good though out and there is no history of increased frequency, dribbling of urine, straining at micturition, but bed wetting one/two times at night. General physical examination as well as examination of abdomen & genitourinary system reveals normal findings.

Investigation:

Investigation

Diagnosis:

Diagnosis Primary refluxing megaureter(Lt)

Treatment:

Treatment Tapering of lower ureter and reimplantation by extravesical approach( Lich Grigor tecnique)

Juxtavesical ureter:

Juxtavesical ureter

Tapering on progress:

Tapering on progress

After Detrusorotomy:

After Detrusorotomy

After reimplantation:

After reimplantation

MEGAURETERS :

MEGAURETERS Megaureter is simply a descriptive term that indicates a dilated ureter The term Megaloureter was introduced by Caulk to describe a dilated ureter.

PowerPoint Presentation:

A normal ureteral diameter is rarely greater than 5 mm (Cussen, 1971), Ureters wider than 7 to 8 mm can all be considered megaureters (Hellström et al, 1985).

PowerPoint Presentation:

Primary idiopathic cause intrinsic to the ureter Secondary outlet obstruction, neurogenic dysfunction, polyuria, or infection).

PowerPoint Presentation:

Thus a megaureter may be Obstructed, Refluxing, Both refluxing and obstructed, or Unobstructed and not refluxing

Relevant Anatomy :

Relevant Anatomy Abdominal ureter- From the renal pelvis to the iliac vessels. Pelvic ureter- iliac vessels to the bladder The UVJ may be divided into 3 sections: the terminal portion (juxtavesical ureter), the intramural portion, and the submucosal portion (under the bladder mucosa).

Pathophysiology Primary obstructed megaureter- :

Pathophysiology Primary obstructed megaureter- adynamic juxtavesical segment of the ureter that fails to effectively propagate urine flow.

Secondary obstructed megaureter:

Secondary obstructed megaureter ureteral dilatation is the result of a functional ureteral obstruction associated with elevated bladder pressures PUV Neurogenic bladder

Primary refluxing megaureter:

Primary refluxing megaureter is associated with severe VUR

Secondary refluxing megaureter:

Secondary refluxing megaureter secondary to PUV or NGB when elevated bladder pressures cause decompensation of the UVJ.

Primary refluxing obstructed megaureter:

Primary refluxing obstructed megaureter occurs in the presence of an incompetent VUJ that allows reflux through an adynamic distal segment.

Primary nonrefluxing/nonobstructed:

Primary nonrefluxing/nonobstructed diagnosis of exclusion when no evidence of obstruction or reflux can be demonstrated

Secondary nonrefluxing/nonobstructed megaureter:

Secondary nonrefluxing/nonobstructed megaureter occurs secondary to diabetes insipidus, in which high urinary flow rates may overwhelm the maximum transport capacity of the ureter by peristalsis as the result of ureteral atony due to a gram-negative UTI.

The megaureter-megacystis syndrome:

The megaureter-megacystis syndrome is an extreme form of the primary refluxing megaureters in which massive reflux prevents effective bladder emptying because urine is passed back and forth between the ureters and bladder.

Figure 1. Two-dimensional images of megacystis in 6 cases of prune belly syndrome at different gestational ages. On the left, the fetuses do not show oligoamnios. On the right, the amniotic fluid is clearly diminished. Note compression of the abdominal and thoracic organs by the megacystic bladder. :

Figure 1. Two-dimensional images of megacystis in 6 cases of prune belly syndrome at different gestational ages. On the left, the fetuses do not show oligoamnios. On the right, the amniotic fluid is clearly diminished. Note compression of the abdominal and thoracic organs by the megacystic bladder.

Etioogy :

Etioogy fetal urethral obstruction (obstructive megacystis) meconium in the urinary bladder (congenital rectovesical fistula) urethral atresia posterior urethral valve non-obstructive megacystis intestinal neuronal dysplasia vesical myopathy megacystis-microcolon-intestinal hypoperistalsis syndrome (MMIHS) trisomy 18

prune belly syndrome:

prune belly syndrome ALOO BUKHARA

Neurogenic bladder:

Neurogenic bladder Detrusor activity (normal, overactive, areflexic , impaired contractility ) Detrusor compliance (normal, decreased , increased) Smooth sphincter activity (synergic, dyssynergic ) Striated sphincter activity (synergic, dyssynergic, bradykinetic , impaired voluntary control, fixed tone ) Sensation (normal, absent, impaired )

VUDS:

VUDS VUDS is an important aid in diagnosing neuropathic voiding dysfunction, as well as other conditions that may cause elevated storage pressures. In cases where vesicoureteral reflux occurs, the volume and pressure at which it starts can be documented.

Guarding reflex:

Guarding reflex

DESD:

DESD

DSD+DESD:

DSD+DESD

PBNO+DESD:

PBNO+DESD

Indications :

Indications Increasing hydroureteronephrosis Decrease in renal function of involved kidney Development of UTI or recurrent pain

Surgical Therapy :

Surgical Therapy Most megaureters will require tapering. excising the distal redundant ureter (Hendren technique) plication (Kalicinski technique, Starr technique) Occasionally, nephroureterectomy may be necessary.

Preoperative Details :

Preoperative Details Assessment of differential function of each of the renal moieties Detection of the presence of anatomical or functional obstruction or VUR Evaluation of bladder function

Intraoperative Details :

Intraoperative Details submucosal tunnel with a length-to-ureteral diameter ratio of 5:1 to create an adequate valve mechanism to prevent VUR

Complications :

Complications The most common technical complications are ureteral obstruction (2-5%), persistent reflux(approximately 10%)., diverticula formation.

Future and Controversies :

Future and Controversies Antibiotic prophylaxis for all children with VUR remains controversial, although it is recommended in children younger than one year with a history of febrile UTI or grade III reflux or higher. Robotic-assisted ureteral reimplantation has gained popularity and will continue to evolve with time, although open ureteral reimplantation currently remains the criterion standard for surgical management of VUR.

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