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1. Dr. Ali M Ahmad MBBCh, MS, MD, MRCS-Ed, EBPS Associate Pediatric Surgery; KAAUH_ PNU 2. Stones in the right ureter 3. Urethra calculus 4. Bladder stone 5. PUV: Trabeculated bladder indicating long-standing outflow obstruction 6. Large Ureterocele: Filling defect at the bladder base 7. DMSA: Ectopic left pelvic kidney 8. DMSA: horseshoe kidney 9. Horseshoe kidney (a) DMSA: functioning renal tissue (b) CT angiogram: kidney + nephrostomy tube 10. PUJ Rt : (b) MAG3 Delayed isotope with poor drainage after micturition (c) rising excretion curve in Rt kidney indicating poor drainage 11. MRI ‘crossing vessel’ causing PUJ Rt Kidney a) T2- marked hydronephrosis b) T1-after gadolinium: main Rt renal artery but also an accessory Rt RA ‘crossing’ the distended renal pelvis 12. The balance between functional & anatomical factors in the aetiology of VUR 13. VUR 2ry to spina bifida @ NB: Bladder Trabeculated 14. MCU Rt VUR, fine trabeculation and probable sphincter– detrusor dyssynergia. Good response to antibiotic prophylaxis, anticholinergic and voiding regimen 15. DMSA: left renal scarring with patchy cortical damage 16. • Grade I: to ureter only • Grade II: to upper tract (pelvic calyces), no dilatation • Grade III: mild to moderate dilatation • Grade IV: moderate dilatation, loss of angles of fornices, papillary impressions in calyces still present • Grade V: gross dilatation and tortuosity, and the impressions of papillae no longer visible. 17. Cohen cross-trigonal reimplantation 1. Intravesical mobilisation of ureter 2. Creation of submucosal tunnel 3. Ureter reimplanted across the width of the trigone 18. Lich–Gregoir Extravesical reimplantation Unsuitable for dilated ureters 1. Refluxing ureter exposed and mobilised extravesical 2. Detrusor muscle incised + Bladder mucosa exposed 3. Detrusor closed around distal ureter 19. Dynamic Renography (MAG3 and DTPA) • Type 1. Normal uptake with prompt washout. • Type 2. Rising uptake curve; no response to diuretic (obstruction). • Type 3a. Initially rising curve, that falls rapidly in response to diuretic (non- obstructive dilatation). • Type 3b. Initially rising curve which neither falls promptly nor continues to rise. 20. Aetiology of pelviureteric junction obstruction 1.Intrinsic stenosis 2.Ureteric folds 3.Extrinsic obstruction by crossing lower pole vessels. 21. Anderson–Hynes dismembered pyeloplasty. The procedure of choice in children 22. Surgical approach to kidney 1. Anterior subcostal incision, extraperitoneal exposure 2. Posterior lumbotomy 3. Supra-12’ loin incision. 23. Ureterocele Delay in canalisation of the upper ureteric bud at around the time it makes contact with the upper pole metanephric blastema results in cystic dilatation subsequently resulting in the formation of a duplex Ureterocele 24. Ureterocoeles: (c) Single-system orthotropic Ureterocele. (d) Duplex ectopic Ureterocele. (e) Caecoureterocoele. Large ureterocoele extending distally downward from the deficient trigone towards the perineum in a plane between the urethra anteriorly and the vagina posteriorly 25. Ureterocele surgery (a) Normal lower pole, non-functioning upper pole managed by upper pole heminephrectomy, excision of the proximal ureter via the same incision, and aspiration of the residual upper pole ureteric stump (‘simplified approach’) 26. Ureterocoele surgery: (b) Functioning upper pole, dilated lower pole – management by pyelopyelostomy. Excision of proximal upper pole ureter and aspiration of ureteric stump 27. Ureterocoele surgery: c) Functioning upper pole, non-dilated lower pole – management by excision of ureterocoele and reimplantation of conjoined duplex ureters. 28. Ureterocoele surgery: (d) Heminephroureterectomy with excision of ureterocoele (often necessitating lower pole ureteric reimplantation) 29. MCUG: PUV Grossly dilated posterior urethra, bladder neck, small Trabeculated bladder 30. Cold knife and cutting resectoscope loop & Position of the cutting loop prior to ablation of the valve membrane 31. PUV Follow-up protocol 32. PU polyp prolapsing from its point of origin into the membranous and bulbar urethra. 33. Autosomal recessive polycystic renal disease. Diffuse bilateral renal enlargements 34. Autosomal dominant PKD. Discrete cysts of varying size interspersed between areas of normal renal parenchyma 35. Au dominant PKD: Multiple large hypoechoic cysts 36. Multicystic dysplastic kidney: Kidney replaced by collection of cysts of varying size. Ureteric atresia. 37. Multilocular renal cyst 38. Simple renal cyst – rare in childhood 39. Pyelolithotomy: Open removal of a calculus from the renal pelvis 40. A. Surgical exposure of calyceal neck by dissection at the renal hilum B. Nephrolithotomy C. High pressure saline irrigation. 41. Percutaneous Nephrolithotomy (PCNL) 42. Ureteroscopy and laser lithotripsy 43. Endoscopic fragmentation of bladder calculus by lithoclast 44. Childhood urinary incontinence 45. Organic causes of childhood urinary incontinence • Urinary infection (Intermittent leakage) • Neuropathic (Continuous/intermittent leakage) • Bladder outflow obstruction (Intermittent leakage) • Structural (Continuous leakage) Exstrophy/epispadias Ureteric ectopia (girls) Congenital short urethra (girls) Urovaginal confluence (girls) 46. Labial adhesions: Retrograde filling of vagina during voiding {Cured by separation of the labial adhesions} Dripping of urine 47. Bifid clitoris with wide urethral meatus {invariably associated with sphincter weakness incontinence. Urinary incontinence: Female epispadias: 48. Functional diurnal enuresis 49. Neuropathic Bladder: Sacral agenesis – characteristic wasting of the buttocks 50. (a) Bladder opened Laterally and incised down to the trigone (b) Segment of ileum + its mesentery are sutured on to the bladder Clam ileocystoplasty 51. a)Segment of sigmoid colon isolated on its mesentery b)Reconfigured as a pouch Sigmoid pouch cystoplasty 52. Ureterocystoplasty 53. Complications of enterocystoplasty 54. Inflatable Periurethral constrictor 55. Pippi Salle procedure Urethral lengthening procedure 56. Bladder Exstrophy 57. Bladder Exstrophy: Female 58. Cloacal Exstrophy Two Hemibladders Exomphalos Midline Bowel Field 59. Male primary epispadias: (a) Glanular (b) penile; (c) penopubic 60. Female epispadias: Clitoris is separated on either side 61. a. Primary closure of a newborn male exstrophy b. Separation of the bladder plate c. Closure of bladder with ureteric catheters d. After abdominal wall closure with plaster cast 62. Ureteric catheters are removed after 10 days urethral stent after 2–3 weeks 63. The Kelly operation (I) Penile corpora and urethral plate are dissected and the bladder is held to the left, the base of the corpus is separated from the pubis and moves medially, the pelvic floor has been released and the pudendal pedicle is seen (arrowed). (II) From below the penis, the urethra has now been detached, tubularised and brought between the mobile corpora; muscle is being wrapped around it 64. Male cloacal exstrophy, closed at 3 months Osteotomies enable the bladder plates and hemiphalli to be brought together in the midline. In addition, End colostomy and umbilicoplasty. 65. Causes of penile Chorde 66. (Baskin) Correction of intrinsic chordee by plication on the dorsal aspect of the corpora 67. (Snodgrass) tubularised incised plate repair 68. Two stage repair 69. Two stage repair 70. MAGPI: Urethral repositioning 71. (Mathieu) perimeatal -based flap 72. Pedicle flap repair 73. Megameatus intact prepuce 74. Buccal mucosa graft 75. Pathological phimosis due to Balanitis xerotica obliterans 76. Balanitis xerotica obliterans extensive glanular involvement and meatal stenosis. 77. Right ectopic testis 78. Testicular microcalcification Incidental finding by US, Multiple small echogenic foci of calcification, no need any intervention 79. a. Communicating hydrocoele b. Hydrocoele of the cord c. Non-communicating hydrocoele 80. Varicocoele treatment Options (1) Surgical ligation of individual veins, inguinal approach (2) Surgical ligation of veins and artery, high approach (3) Laparoscopic clipping, all vessels or selective ‘artery sparing’ (4) Embolisation 81. A.Rt Testis Torsion: tender, swollen and elevated position B.OR: good return of perfusion following detorsion 82. 46XY DSD (male pseudohermaphroditism) Defects of testosterone production Defects of testosterone metabolism Defects of receptor sensitivity Abnormalities of MIS activity 83. Sever Lt Renal injury @ Minor Trauma Due to pre pre-existing PUJ obstruction 84. Grading of renal trauma I: Renal contusion II: laceration but not extending into collecting system III: laceration involving collecting system, perirenal haematoma and extravasation IV: Extensive laceration / avulsion injury V: Shattered kidney and/or avulsion of vascular pedicle. 85. a) Optical urethrotomy b) End-to-end anastomosis c) Buccal mucosagraft Post-traumatic urethral stricture treatment options:
