12th July 2018 Presenter Ravindar Anbarasan Paediatric Urology Fellow 3540 boy RDS NICU admission Oxygen at birth then stable Urine output 3 mlkg 26 weeks Mild unilateral HN ID: 1009759
Download Presentation The PPT/PDF document "Case 1 Nephro -Urology Study Day" is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
1. Case 1Nephro-Urology Study Day 12th July 2018PresenterRavindar AnbarasanPaediatric Urology Fellow
2. 35/40 boyRDS - NICU admissionOxygen at birth, then stableUrine output 3 ml/kg26 weeks - Mild unilateral HN resolved on further scansD2 Creatinine 102 and 126D2 USS KUB - Bilateral HUN (R > L)
3. What is your next step?Read Regional guidelines as not sure what to doInsert a urethral catheterDischarge and book a Renal USS in 6 weeksCommence on prophylactic antibiotics, discharge and refer to urology
4. Advice over telephone...Indwelling Urinary catheter and free bladder drainageLook for post-obstructive diuresisliaison with nephrology (Dr Nagra), bloodsProphylactic TMP
5. MCUG(Day 7)no PUVGrade 5 VUR (Right)Grade 4 VUR (Left)
6. PLAN No active urology intervention - follow up USS 8/52 Nephrology follow up for VUR with renal impairment Due to significant bilateral reflux - at risk of incomplete bladder emptying (due to re-filling) - urinary stasis and UTI. TMP prophylaxis 2mg /kg. If breakthrough infection - low threshold for offering circumcision +/- STING.
7. USS 8/52Normal bladder6mm right ureter behind bladderLk normal - 5.6cmRK smaller - 3.9 cmsome cortical thinningAPD 7 mmdilated ureter throughout its lengthurothelial thickening
8. No breakthrough UTI “Does he need any Intervention ??”
9. What management option would you choose?Conservative management, serial USS, monitoring of renal functionConservative management with antibiotic prophylaxisCircumcisionBilateral STINGCircumcision + STING
10. Cystoscopy and endoscopic correction of bilateral vesicoureteric reflux(5 months age)
11. Mum and dad preferred to defer circumcision Small scarred RK, reduced functioncompensatory functional enlargement LKLast clinic in July 2018 – Doing well, No UTIs, ongoing nephrology care
12. Case 2Nephro-Urology Study Day 12th July 2018PresenterRavindar AnbarasanPaediatric Urology Fellow
13. 38/40, girl, maternal drug abuseFoster care – awaiting adoptionTransfer to nephrology for urosepsis and AKI
14. on IV ceftriaxoneUrine culture: enterococcus - resistant to ceftriaxone sensitive to amoxicillinChanged to PO amoxicillin urinary retentionDifficult catheterisation by Urology Specialist Nurse - large volume in bladder polyuric post catheterisationseveral days of IV fluid support
15. What are the possible Differentials?UreterocoeleNeuropathic bladderUrogenital sinus anomalyPre-sacral massRhabdomyosarcomaAll of the aboveSome of the above
16. U&E’s normalisewhat is your next step?
17. USS on arrivalBilateral HUNthick walled bladder
18. X-ray & USS Spine
19. What next ??
20. MCUG Markedly trabeculated bladder Grade 4 bilateral VUR Normal AP imaging of the urethraWhat’s Going On?What Next ?
21. EUA cystovaginoscopynormal perineum, urethra, vagina, anusCystoscopy normal urethra, bladder neck orthotopic bilateral UO but very gaping trabeculated bladder with diverticulae catheter related cystitis cystica
22. Functional BOO !!
23. How to facilitate urinary tract decompression?Clean intermittent catheterisationInsertion of suprapubic catheterVesicostomyUreterostomyBilateral percutaneous nephrostomy
24. Clean Intermittent Catheterisation ?Issues...Drainage needed for long termDifficulty in catheterisation Foster care
25. laparoscopy assisted left loop ureterostomy
26. MRI Spinetiny speck of intrathecal high signal – may represent a tiny filum lipomaOtherwise, normal intraspinal appearances conus terminates at L1 Posterior elements intact
27. Case 3Nephro-Urology Study Day 12th July 2018PresenterRavindar AnbarasanPaediatric Urology Fellow
28. 20:45 hoursMale babyRespiratory distressAbdominal distension at birthResuscitated by aspiration of 250 ml straw coloured fluid from abdomen
29. Antenatal historyAntenatal scan showing echogenic bowelCounselled by paediatric surgeonNormal liquor at 30 weeksSibling - chromosome 7 deletion and cardiac anomalies
30. 00:20 hours
31. What are your thoughts about gender at this stage?MALEFEMALEDSD
32. AXR
33. 02:30 AMNext most appropriate investigation ?USSAscitic fluid biochemistryKaryotypeContrast studyLaparoscopy
34.
35. Fluid creatinine 445Ascitic Fluid biochemistry
36. Possible Diagnosis ?Posterior Urethral ValvesCongenital Adrenal HyperplasiaCloacal anomalyBilateral Vesicoureteric reflux
37. Reassessment 8AM500 ml in the next 6 – 8 hours via left percutaneous drainIncreasing abdominal distensionNo passage of urine or meconiumLaparotomy
38. Laparotomy
39. Classic Persistent Cloaca
40. Posterior Cloaca Variant
41. THANK YOU