Pediatric Urology

1- Hypospadias

Hypospadias is the condition where the urethral meatus is lower than it should be on the penis. The foreskin is not fully developed in patients.

There are many hormonal and genetic causes. It is known that the incidence increases in cases such as smoking during pregnancy, gestational hypertension, and low birth weight.

It occurs in approximately one in 300-500 births. Although it can be seen with more than 200 syndromes, it is mostly seen as an isolated disease. The most common concomitant pathology is unilateral or bilateral undescended testis.

A. Hypospadias Surgery Turkey

The treatment for hypospadias is surgery. Although the surgery can be performed at any age, the most appropriate time frame is between 6-24 months. If not treated;

• Cosmetic problems,
• Difficult urinating,
• Infertility (If the urethral meatus is too low or there are concomitant conditions such as undescended testicles).

2- Undescended Testicle

During the development of the testicles in the mother's womb, they are first in the posterior abdominal wall and descend into the scrotum during the last 3 months of pregnancy and immediately after birth.

Undescended testis is classified as palpable (can be felt on physical exemination) or nonpalpable (cannot be felt on physical exemination). 80% of undescended testicles can be felt on palpation.

If the testicle is not in the scrotum in a baby, the main causes of this condition are:

• The testicles may not have completed the normal descent process,
• The testis may not have developed at embriological age,
• The testis may be located at a different point from the normal descent path.

Retractile Testicle: In some children, the testicles sometimes descend into the scrotum and sometimes go up. This is due to the overactive cramester reflex. The approach for these patients is different from the undescended testis. The distinction should be made by a specialist with physical exemination. Annual follow-up is recommended for retractile testicles due to they can transform into real undescended testicles.

Why should it be treated? How is the diagnosis and treatment?

Cryptorchidism or undescended testis is one of the most common birth defects of male newborns. Its incidence varies with age. 

Undescended testis may predispose to testicular cancer and infertility. The earlier the treatment for an undescended testicle, the lower the risks.

Physical examination by a specialist is the first and most important step for the diagnosis of undescended testis. Conditions such as family history, previous surgery history should be questioned. If necessary, radiological imaging is used.

Undescended Testicle Surgery Turkey

The main treatment for undescended testicle is surgery. The recommended time for surgery is between 6 months and 12 months. Treatment is recommended for at least 18 months. Hormone therapy; It is not preferred because of the low chance of success (20%) compared to surgical methods and its side effects.

3- Vesicoureteral Reflux (VUR)

Urine flowing from the kidneys to the bladder in a healthy person; In this disease, the ureter escapes upwards due to the insufficiency of the muscle structure at the end of the opening to the bladder.

The frequency of VUR in the normal population is 1%. This rate is 30% in children with recurrent urinary tract infections. In newborns with kidney enlargement (hydronephrosis) detected in ultrasonography in the womb; While the frequency of VUR is 15% in those with no abnormality in postnatal ultrasonography, this rate is around 35% in those with any abnormality.

While the probability of having VUR in siblings of children with VUR is 35%; 100% VUR is detected in identical twins.

The most common sign of vesicoureteral reflux is a previous febrile urinary tract infection. Imaging methods are mandatory for the diagnosis of VUR.

The methods that can be used in standard imaging are Ultrasonography (USG),Voiding Cystourethrography (VCUG) and Renal Scintigraphy. Voiding Cystourethrography (VCUG): It is the most important test to be performed in the diagnosis of VUR. Contrast material is injected into the bladder through a catheter. With the images taken at intervals, it is evaluated whether there is an upward escape or not. If there is VUR, it is graded between 1-5 according to its severity.

The Importance of Vesicoureteral Reflux

VUR; It is a disorder that can have serious consequences such as kidney damage, hypertension, kidney failure and growth retardation.

Treatment of Vesicoureteral Reflux

Non-Surgical (Conservative) Treatment: The main goal is to prevent febrile urinary tract infections. Because most patients with low-grade VUR recover spontaneously.

Antibiotic Prophylaxis: It is the long-term administration of low doses of antibiotics to prevent urinary tract infection.

Urination Training: The child should be encouraged to go to the toilet and urinate regularly at home and at school. The child must sit on the toilet in the appropriate position so that the child completely empties the bladder and bowels. Fluid intake is evenly spread throughout the day. Children with constipation problems must be treated.

Circumcision has a protective effect as it reduces infections

Vesicoureteral Reflux Surgery Turkey: Reconstructive operation should be considered for VUR with persistent urinary tract infection despite antibiotic prophylaxis, increased areas of renal loss in high-grade reflux, or girls who have reached puberty.

Endoscopic Technique: It is the process of injecting a filling material near the ureter orifice (the hole entering bladder) with a cystoscope. It is a daily procedure, it can be applied in a short time. The success rate is up to 85% in repetitive applications.

Open Surgery (Ureteroneocyctostomy Turkey): It is an important option in patients with a history of unsuccessful injections, in patients with high-grade VUR, and in cases where VUR is associated with other anatomical disorders. There are many surgical techniques reported and success rates are around 98%.

4- Ureteropelvic Junction Stenosis (UPJS)

Ureteropelvic Junction Stenosis (UPJS) is a congenital anomaly of the ureter and is a functional impairment of the urinary passage from the kidney to the ureter. Urine transport is impaired due to UPJS and an enlargement of the kidney pool (hydronephrosis) occurs due to the urine accumulating in the kidney. This stenosis can lead to a decrease in kidney function over time and even to kidney failure.

Frequency of UPJS  is approximately 1/750-1500. It is usually in boys (3 times more) and often on the left side. It is the most common cause of enlargement of the kidney pool (Antenatal Hydronephrosis) seen in the fetal age.It is usually a congenital pathology. Apart from this, vascular abnormalities, previous surgeries or infections may also be the cause.

The diagnosis is usually made by ultrasonography performed in the fetal age. Some cases are diagnosed by imaging techniques performed for pain, urinary tract infection or other reasons. Ultrasonography is the first preferred imaging method in the diagnosis of UPJS. In patients diagnosed with UPJS; Kidney Scintigraphy (DTPA or MAG-3) is the most important examination to determine the severity of this condition and to decide on surgery or follow-up.

Who is candidate for surgery 

• Grade 3-4 Hydronephrosis,
• Patients with impaired kidney function,
• Bleeding, stones or infection in the urine,
• Stenosis causing active complaint in the patient (pain),
• Hypertension.

Ureteropelvic Junction Stenosis (UPJS) Treatment, Laparsocopic Pyelopasty Turkey

The treatment of Ureteropelvic Junction Stenosis is surgery. The stenosis is treated with a surgery called "pyeloplasty". This method can be done by open or laparoscopic method. Laparoscopic surgery has advantages such as less bleeding, less post-operative pain, and less hospital stay.

In addition, the "Endopyelotomy" operation, which is performed endoscopically in some selected patients and therefore does not require any incision in the body, is another surgical technique in UPJS.

5- Circumcision

Circumcision; It is the process of surgically cutting and removing the piece of skin surrounding the tip of the penis (foreskin). Circumcision practiced by experienced people has many benefits. In the hands of inexperienced people, it brings many risks such as infection and bleeding.

Benefits of Circumcision

• It reduces urinary tract infection,
• It reduces the risk of transmission of some sexually transmitted diseases,
• It has been shown to reduce the risk of penile cancer.

Best Time for Circumcision?

• Although circumcision can be performed at any age, the first 2 years, when the risk of psychological trauma and infection is less, is expressed as the most appropriate time.
• It has been shown that some psychological negativities may occur if circumcision is performed between the ages of 2-6, when children's sexual awareness begins to develop. If circumcision is to be performed in this age range, general anesthesia would be more appropriate instead of local anesthesia.

Which Anesthesia Technique is Preferred?

In the neonatal period, circumcision can be performed with local anesthesia. In older children, circumcision is recommended to be performed under general anesthesia to avoid surgical stress.

Circumcision Techniques

Many surgical methods have been defined for circumcision and all these techniques have common stages. It should not be forgotten that no matter what technique is used, it is the most important condition for the circumcision procedure to be done by experienced people.

6- Urination Disorders and Bedwetting

Involuntary leakage of urine during sleep is called enuresis. It is not considered abnormal for children under the age of 5 to wet the bed at night. Primary enuresis is defined as persistent nocturnal urinary incontinence of the child for no longer than 6 months without being dry. Enuresis that occurs after a dry period longer than 6 months is defined as secondary.

The frequency of enuresis decreases with age. About 15% of 5-year-old children have bedwetting problems at night. Its incidence decreases by about 15% each year, and its incidence in adolescence is approximately 1%.

Voiding Disorders and Causes of Bedwetting

• Genetic predisposition is an important reason.
• If there is a disorder in the rhythm of the release of the hormone called ADH, which ensures water retention in the body, nighttime urine production increases, which can cause nighttime urinary incontinence.
• Children with deep sleep and waking problems have the problem of not being able to perceive the bladder fullness or not being able to wake up even though it is perceived.
• Children with involuntary contractions of the bladder may also experience urinary incontinence at night.
• Psychological problems are seen in approximately 5-10% of these patients.
• Organic causes such as urinary tract infection and Diabetes Mellitus are seen in approximately 2-3% of patients.

Voiding Disorders and Wetting Treatment

First of all, the family and the child should be given detailed information about the situation and their participation in the treatment process should be ensured.

It is important for children to restrict their fluid intake about 2 hours before bedtime. Before going to sleep, it is necessary to make the child go to the toilet and urinate. Fluid intake should be spread throughout the day; If the patient has constipation problem, it should be resolved.

Urination habits should be regulated, the child should go to the toilet every 2-3 hours at school and at home and urinate regularly.

The nights that the child wets and does not wet the bed should be noted, and a voiding diary should be created.

• The administration of analogues of the hormone "Desmopressin" to reduce the production of nocturnal urine is a common method. Its effect starts in a short time, it is easy to use. The most obvious disadvantage is that wetting problems can continue after the drug is discontinued.
• Alarm therapy is a treatment method recommended especially for children with deep sleep and waking problems. When the child leaks urine, the alarm sounds and the child, who wakes up with the alarm, contracts the bladder sphincter muscle as a conditional reflex and holds his urine. It is a long-term treatment method. It should not be forgotten that the child should be taken to the toilet every time the alarm goes off. 6-8 weeks of application is recommended to evaluate its effectiveness. For children who benefit, the treatment period is extended.

7- Hydrocele and Hernia

Hydrocele is the name given to excess fluid accumulation between the two membranes surrounding the testis. It is divided into two types.

In Cominican Hydrocele, the relationship between the two membranes surrounding the testis and the membrane in the abdominal cavity continues. The fluid in the abdomen fills around the testis through this opening and causes this pathology, which is also called water hernia among the people.

Non-Communican Hydrocele occurs in advanced ages and the swelling is not related to the peritoneum. Usually the only symptom is painless swelling. If necessary, ultrasonography can be performed to understand whether there is a bowel in the swelling.

The treatment of hydrocele is surgical, but it is recommended to wait for 1 year as the possibility of spontaneous recovery is high in the first 12 months. However, in case of additional pathology, early surgery can be performed.

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Note: Page contents are for informational purposes only and a doctor's application is required for your diagnosis and treatment.