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PAEDIATRICS UROLOGY UNIT 


Field of Pediatric Urology cover diagnosis and treatment and follow-up of all urologic diseases likely to develop in post-natal lives and kidney and bladder problems diagnosed while the baby is in the womb of their mothers. 

Pediatric Urology Unit has been established within the body of Urology Clinic for diagnosis and treatment of all pediatric urological diseases in 0-16 age groups in Kent Hospital. This unit offers service under the responsibility of assistant professor having European Pediatric Urology Specialty Certificate. "Laparoscopic and endoscopic" methods known as closed operation in treatment of infant and pediatric diseases are implemented with success and in this way, while minimizing post-operative pain and hospitalization stay time of infants, cosmetic image of operation place is obtained.

 Pediatric Urologic Diseases

Undescended Testis
Most frequently seen in male children, this incident infers to absence of one or two testis in scrotum. (colloquially bag). Testis mostly remains within inguinal duct, however, in some incidents, it may remain within abdomen. In rare cases there may be no testicles having occurred. This case is encountered in approximately 3 % of new born male infants and some portion of these may go into bag automatically until 1 year of age. 1 % of male infants with 1 year of age has undescended testis and after this period, bag undescended incidence is not seen much and in this case, treatment will be required. Incidence of undescended testis in premature male infants is approximately 10 times more than normal babies. Sperm reproduction functions of testis may be impaired due to temperature irregularities in undescended testis. Untreated children will severely experience infertility problems when they reach reproductive age. Since the effect in testis causing infertility exhibits itself after 6th month, treatments of undescended testis infants should be carried out following 6th month. After the infant is 6 months old age, it is not very significant to wait for testis to automatically go into bag and this case bears risk in terms of infertility. Risk of developing testis cancer of undescended testis rather than infertility is much more likely. Since especially lowering testis inside abdomen into bag, this case will enable early diagnosis in case of development of cancer, this is of high importance. Hormonal or surgical treatment can be planned based on the age of infant and the area where testis is found in the treatment. Inguinal hernia is often accompanied with undescended testis and both cases can be corrected during surgical operation. Approaches of specialist physicians in Pediatric Urology as surgical method is "laparoscopic" surgery known as "bladeless method". In this way, treatment can be performed without pain and on a daily case.

Hypospadias (half-hypospadias)
It is a congenital disease of the penis. It is in a form of foreskin deficiency and opening bottom part of penis of urinary meatus. This prevent proper urination of the infant and in some cases, it may contain severe penis curvature and bands causing deformation. In the treatment, urinary meatus is brought to end part of penis and if any, bands causing curvature is eliminated. Hypospadias surgery requires fairly significant experience it may cause very serious complications when performed by inexperienced surgeons. Since foreskin may be used for extending shorter urinary tract, circumcision will under no circumstances be applied in such types of infants and when this is noticed in infants, a urologic specialist should be consulted and its treatment in the most appropriate age should be envisaged. The most appropriate age for operation is the period when the infant completes its 6th month.

Inguinal Hernia (Hydrocele, Cord Cyst, Varicocele)
Some disorders characterized by swelling in groin areas of the infants and children are most frequency encountered. After separating diagnosis of these problems is conducted by pediatric urology, appropriate treatment should be performed. Infant hernias do not occur as a result of strain such as in adults. They occur depending on remaining open of abdominal peritoneum protrusion within inguinal duct required to be closed after birth. Intra-abdominal organs depending on increase of intra-abdominal pressure when the baby or child weep (mostly intestinal) penetrate into this clearance and causes hernia. Strangulation of the bowel by way of squeezing causes gangrene and since it may pose vital threat, it should be surgically corrected as soon as possible.

In cases where the opening is narrow, if it creates a fluid-filled swelling in bag and in the vicinity of testis by penetrating from only intra-abdominal fluid, this is called as "hydrocele". Since there is a change of spontaneous improvement in hydrocele, it may be waited for without being operated until 1 year of age. Hydroceles not vanishing or growing following one year of age should be operated. In case top and bottom closure of duct is in question and fluid is trapped in the middle, cord cyst may be mentioned and the treatment is as in hydrocele.

 Varicosele  is a condition where it is subject to varicose veins.  This incident very frequently encountered in young adults however likely to be seen in children early in their adolescence period is of utmost importance since it may case infertility. Disease generally holding left testis may cause complaint of pain.

Childhood Renal Calculus Disease
In our country where renal calculus disease is frequently used, infants may be affected from this disease not as frequently as adults. Renal calculus diseases in the infants have some differences when compared with that of adults. These differences;

Renal calculus of the infants may not generally cause very severe pains as in that of adults. These infants often complain about mild abdominal pains. Symptoms in the infants with renal calculus are generally bleeding in urine and/or urinary tract infections and related complaints.

Congenital anatomic anomalies in kidney, urinary tract or bladder in children with renal calculus are quite frequent. These anatomic disorders forming renal calculus and this renal calculus in these children should be duly treated.
Surplus of materials forming renal calculus in urine or blood of the infants with renal calculus or deficiency of materials preventing renal calculus formation are generally frequently encountered. While there is no such cause in adults, new renal calculus formations should be inhibited by way of correcting imbalances in the infants.

Extracorporeal Shock Wave Lithotripsy (ESWL) (renal calculus crushing) and closed operations (endoscopic and percutaneous) are applied in treatment of renal calculus disease in the infants. Through these methods, open renal calculus operations become to be fairly rarely applicable in the infants. Analyses and protective treatment practices should be conducted for avoiding reformation of renal calculus in the infant after eliminating renal calculus with the operation.

Urinary Incontinence in Children
The age of the infants gaining their night urinary control is generally around 2.5-3 ages. However, it may be acceptable that this period can be extended until 5 years. A behaviour therapy and follow-up medication should be generally required for night wetting in children older than 5 years. The children with wetting while only sleeping in form of urinary incontinence do not cause any severe problems. Such type of discomfort is a classical enuresis nocturnal problem that we frequently encounter in society and parent or siblings of the child in question. This problem can be prevented in high extent by way o rewarding and conditioning treatments such as alarm devices or increasing bladder capacity and medications reducing nocturnal urinary generation. However, while awake, urinary incontinence is a totally different situation and it may point out to an underlying bladder dysfunction. If especially the child undergoes any urinary tract infection, this case may be symptom of several diseases causing kidney damage or congenital anatomic disorder. The biggest mistake performed by non-specialist or in the public is to confuse such type of case with enuresis nocturnal. Such a portrait expected to heal sooner may cause very severe, permanent kidney and bladder damages. These children should be examined by a specialist in pediatric urology at all times.

Vesicoureteral Reflux (urine return from bladder to kidney)
Vesicoureteral reflux refers to return of urine from bladder to kidney duct again and to inside kidney. This case can be a symptom of recurrent urinary canal and kidney infections. In particular, recurrent infections of kidney may lead to permanent kidney damage and, in severe cases to kidney failure. Vesicoureteral reflux should be definitely investigated in infants and children having undergone urinary canal infection and inexplicable fevers. The biggest mistake made by families and some physicians is to administer blinding anti-biotic therapy by linking fever case to sore throat inflammation. Whether either presence of urine complaint or not, frequently fevered children should be investigated in terms of urinary canal infection and if necessary, vesicoureteral reflux should be evaluated. Incidence of children identified with vesicoureteral reflux is higher in sibling/s of these children. Protective treatment is initiated to the children with diagnosis of vesicoureteral reflux and this automatically heals without any need of reflex surgery in vast majority of these children. However, surgical treatment should be applied to reflex causing urinary canal inflammation despite protective treatment and having not healed automatically despite waiting for sufficient time or creating kidney failure. In our time, opened and closed operations are used in reflux treatment as operation method.  Closed operations with newer techniques (endoscopic and laparoscopic) are more comfortable and painless applications when compared with opened surgery. Since vesicoureteral reflux operations may lead very severe complications developed up to failure of kidney, this should be applied by specialist persons in infant urology. 

Ureteropelvic Stenosis (ureterovesical stenosis, hydronephrosis)
These are incidents occurred depending on available congenital narrow space of urinary canal connecting kidney to bladder in any level or compression of a vein. This may occur in single one or both two kidneys and swelling and expansion may occur as a result of insufficiency of urine transition from this narrow space. If this case is not detected and treated, it may lead to failures of kidney or kidneys. In some children, this may cause urinary canal and kidney inflammation or renal calculus formation. In our time, vast majority of these children receive diagnosis conducted during pregnancy and required measures and treatments are initiated just after the baby is born since this problem is know before the baby is born. In this way, risk of kidney failure is substantially reduced. Majority of incidents constitutes ureterovesical stenosis where a narrow area is found just at the exit of kidney. Vast majority of these infants or children should be monitored without subjecting to operation and expansion in kidney automatically remedies in most of the incidents and it sustains without causing any damage to kidney. However, severe stenosis of renal function deteriorates and is operated and stenosis is remedied. Operation will be necessary in approximately 20 % of children with congenital hydronephrosis. These children should be closely followed up for intervening without delay by way of early diagnosis of deterioration likely to occur in kidney functions. Opened or closed methods can be applied as surgery option. Closed methods are laparoscopic or percutaneous applications and are methods that are more comfortable and requiring less hospitalization stay time.

Puv
This refers to presence of congenital partition in urinary canal of bladder exit and obstructing urine flow.

Neurogenic Bladder (Spina Bifida)
This is a case where spine cannot be fully closed for forming a duct and opening is created in the level of waist most frequently. (spina-bifida meningocele, meningomyelocele). Most of the children have urination and urine incontinence problems depending on damage on nerves working bladder. Kidney damage is frequently seen accordingly in the children not followed up and treated by pediatric urology. After closing this opening by brain surgery with operations, urination and defecation problems of these children should be monitored by pediatric urology. Especially applications reducing this pressure should be used for preventing deterioration of kidneys in the children where bladder pressure gets very high. These applications can be accompanied with periodic catheter applications and medications reducing bladder pressure. In the children where such approaches are not sufficient, surgeries expanding bladder by using intestines and peritoneum are duly applied. Surgeries where ducts facilitating fitting catheter or preventing urine escape may be added to such surgeries based on the situation of the child. These types of surgeries require advanced degree of experience and specialization in pediatric urology.

Urinary Tract Infection in Children
Since urinary infection in children may indicate very severe kidney and bladder disorders, this is more important than that of adults. Inflammation in these types of children is actually a case caused by underlying disease. The most common ones of these can be listed as bladder dysfunction, vesicoureteral reflux, urinary tract stricture, renal calculus disease.  Treating urethritis in such cases is not a solution. What is important here to diagnose and treat the underlying real disease.

Urinary tract infection in children is usually insidious. Light abdominal pain, frequent thamuria and urinary incontinence can be an indicator of infection. Detecting blood in urine is a frequently encountered finding. Accompany with fever is of utmost importance and this means that inflammation retains kidney. The child should be evaluated by pediatric specialist or pediatric urology in these findings and required tests should be conducted.

Childhood Tumours Urinary System Tumours (Kidney and Testis tumours)
As not so frequent in adults, kidney and testis tumours can be seen in children. Palpable mass in the abdomen of infants and children should be investigated in terms kidney tumour (Wilm's tumour, neuroblastoma). Bleeding in the urine, however, may be a sign of kidney tumours. Presence of swelling in a male infant or child with no problem in his testis before and palpable testicular stiffness must be evaluated in terms of testicular tumours. Early treatment by a specialist physician skilled means full recovery of the child from these diseases.

Gender Uncertainty (Intersex)
Uncertainty in external genitalia of new-born infant, namely, failure to discriminate male-female genders or bearing symptoms belonging to opposite sex is called "intersex". Cause of such type of disorders can be listed as chromosome disorders, deficiency or abundance of some hormones and exposure to use of unfavourable medications during pregnancy. 

Such patients should be evaluated as soon as possible by a team consisting of neonatal specialist, endocrinologist pediatric urologist, pediatric psychiatrist and geneticist. As a result of this evaluation, to which gender the child is closer should be identified and it should be decided with which gender the child is to be maintained. Following this decision, a number of treatment and surgeries correcting gender of the infant or child should be applied. Such treatments should be completed prior to formation of gender identity of the child. Otherwise, the child will be subject to inevitable side effects.