|Year : 2021 | Volume
| Issue : 1 | Page : 37-42
Spectrum of postoperative genitourinary (GU) cases in pediatric patients
Shoheli Alam, Nazrul Islam, Fatema Tul Jannat, K. M. Didarul Islam, Noor Mahammad, Umme Habiba Dilshad Munmun
Paediatric Surgery Department, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
|Date of Submission||07-Sep-2021|
|Date of Acceptance||23-Sep-2021|
|Date of Web Publication||29-Dec-2021|
Mr. Shoheli Alam
Paediatric Surgery Department, Bangabandhu Sheikh Mujib Medical University, Dhaka
Source of Support: None, Conflict of Interest: None
Background: Genitourinary (GU) disorders may be congenital or acquired. Congenital cases are most often undiagnosed. This study was carried out to find the types of congenital, acquired GU cases and redo surgery from neonate to early adult life and the age of diagnosis of congenital anomalies. Materials and Methods: This retrospective study was carried out from January’2016 to December’2018 in the inpatients of the Paediatric Surgery Department of Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh. All admitted patients having congenital or acquired GU cases and postoperative complications of these systems required redo surgery were included. The data were reviewed for patient demographics, frequency, and distribution pattern of admitted GU cases and types of redo surgery. Result: A total of 1329 patients were operated in the Paediatric Surgery Department of BSMMU, Dhaka, Bangladesh over a 3 years’ period. Among them, 508 patients (38.2%) were GU cases. The age ranged from 2 days to 18 years (mean age: 5.68 ± 3.77) at diagnosis. The male: female ratio was 5.7:1. Out of the total 508 patients, 432(85%) were boys while only 75 (15%) were girls. Among the 508 GU cases, 355 (69.9%) were congenital cases, 56(11%) were acquired cases, and redo cases were 97(19.1%). In this study, 43.7% of children who had congenital GU anomalies were >5 to 12 years old, and the neonatal age group was in 2.3% of cases. Among the congenital GU anomalies, hypospadias was more common in 141(27.8%) cases. 41(8.1%) had urogenital tumors. Wilm’s tumor was in 18 (3.5%) of children, 9 (1.8%) patients had urethral stricture, 6(1.2%) patients had urolithiasis. In case of redo surgery, urethrocutaneous fistula was found in 42(8.3%) patients. Conclusion: GU cases are more common than the other systemic cases in pediatric surgical patients. Among the GU cases, congenital anomalies are more than the acquired cases in our institution. But most of the congenital anomalies were diagnosed at a later age.
Keywords: genitourinary, pediatrics, postoperative, spectrum
|How to cite this article:|
Alam S, Islam N, Jannat FT, Islam KM, Mahammad N, Munmun UH. Spectrum of postoperative genitourinary (GU) cases in pediatric patients. Paediatr Nephrol J Bangladesh 2021;6:37-42
|How to cite this URL:|
Alam S, Islam N, Jannat FT, Islam KM, Mahammad N, Munmun UH. Spectrum of postoperative genitourinary (GU) cases in pediatric patients. Paediatr Nephrol J Bangladesh [serial online] 2021 [cited 2022 Aug 18];6:37-42. Available from: http://www.pnjb-online.org/text.asp?2021/6/1/37/334120
| Introduction|| |
Genitourinary (GU) disorders are disorders that affecting the urinary and genital tracts. .GU disorders may be congenital or acquired. Congenital disorders occur usually due to abnormal development of the fetus during pregnancy. Acquired types develop over time and these occur due to stones, tumors, or injury.
Congenital anomalies of the kidney and urinary tract (CAKUT) present with varying degrees of severity, are part of a genetic syndrome, or are associated with morphological changes in other parts of the body. More than 500 syndromes have been described in the defects of the kidney and other organ systems.
Forty percent of pediatric end-stage renal disease (ESRD) are due to CAKUT and this causes a significant proportion of adult nephropathy. It includes structural and functional malformations of the renal system, such as in the kidney (e.g., hypoplasia and dysplasia), collecting system (e.g., hydronephrosis and megaureter), bladder (e.g., ureterocele and vesicoureteral reflux [VUR]), or urethra (e.g., posterior urethral valves).
Recommended treatment for CAKUT is conservative management. Surgery is reserved for those who have persisting clinical symptoms or declining renal function. Management options include observation with or without continuous antibiotic prophylaxis (CAP) and surgical correction via endoscopic, open, or laparoscopic/robotic approaches.
Therefore, it is essential to have basic information on these anomalies. Incidence or prevalence of congenital anomalies are also important for primary health services planning.
This study was carried out to find the types of congenital, acquired GU cases and redo surgery from neonate to early adult life and the age of diagnosis of congenital anomalies.
| Materials and Methods|| |
This retrospective study was carried out from January 2016 to December 2018 in the admitted patients of the Paediatric Surgery Department of Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh.
All admitted children having congenital or acquired GU disorders along with these patients having complications after primary surgery required redo surgery were included.
We excluded those GU cases where surgical corrections were done on daycare basis in our institution. Daycare surgical patients in our institution were not admitted to our surgical ward and treated as outdoor patients.
Redo cases were not only the outcome of our institutional primary surgery of this system. It also included those whose primary surgery was done in other institutes.
Most (75%) patients were diagnosed in our Paediatric Surgery outdoor clinic of BSMMU. Few (25%) of them required additional investigations after admission
A total of 1329 patients were operated in the Paediatric Surgery Department of BSMMU, Dhaka, Bangladesh over a 3 years’ period. Among them, 508 patients (38.2%) were GU cases. The age ranged from 2 days to 18 years (mean age: 5.68 ± 3.77) at diagnosis. The male: female ratio was 5.7:1. Out of the total 508 patients, 432(85%) were boys while only 75 (15%) were girls.
Urethral stricture usually developed after trauma, hypospadias surgery, epispadias surgery, after valve fulguration, after surgery for anorectal malformation (ARM), and Hirschsprung’s disease were included.
Routine investigations usually were complete blood count (CBC), serum creatinine, urine R/M/E (routine and microscopic examination), and C/S (culture and sensitivity), and ultrasonogram of KUB (kidney, ureter, and bladder) region.
Special investigations were MCU (micturating cystogram for VUR, VUJO), IVU (intravenous urogram for stone in KUB region, hydronephrosis, duplex kidney, and ectopic ureter), MCU and RGU (retrograde urethrogram) for stricture urethra, CT (computed tomography) urogram also for accurate delineation of tumor, hydronephrosis, and duplex system.
DTPA (diethylenetriamine pentaacetic acid) scan was done for assessing the functional status of kidneys.
DMSA (dimercaptosuccinic acid) scan was done to assess the renal scarring.
A urodynamic study was done for the diagnosis of neurogenic bladder.
The diagnostic cystoscopic examination was also required for the diagnosis of PUV (posterior urethral valve) to know the size, shape, and caliber (stenotic or not) of ureteric orifice and bladder wall change and bladder diverticulum.
Data were analyzed by the SPSS software. The data were reviewed for patient demographics, frequency, and distribution pattern of inpatient GU cases and type of redo surgery.
| Results|| |
A total of 1329 patients were operated in the Pediatric Surgery Department of BSMMU, Dhaka, Bangladesh over a 3 years period. Among them, 508 patients (38.2%) were GU cases. The age ranged from 2 days to 18 years (mean age: 5.68 ± 3.77) at diagnosis. The male:female ratio was 5.7:1 [Table 1].
Out of the total 508 patients in our study group, 432(85%) were boys, while only 75 (15%) of them were girls [Figure 1].
|Figure 1: Pie chart of genitourinary operated cases according to gender (n = 508)|
Click here to view
Among the 508 GU operated cases, 355(69.9%) were congenital cases, 56(11%) were acquired cases, and redo cases were 97(19.1%) [Figure 2].
In our study, 43.7% of children who had congenital GU anomalies were in >5 years to 12 years old at diagnosis, and neonatal age group were in 2.3% of cases [Figure 3].
|Figure 3: Distribution of age in congenital genitourinary cases at diagnosis (n = 355)|
Click here to view
Hypospadias was in 27.8% of cases. Other congenital anomalies like pelviureteric junction obstruction (PUJO) was in 11.8% of cases, vesicoureteric junction obstruction (VUJO) was in 2.4% cases, nonpalpable undescended testes (UDT) were in 3.1% cases, ambiguous genitalia were in 1.4% cases, aphallia was in 0.4% case, vaginal atresia was in 0.6% cases. Ureterocele was in 1.6% of cases, epispadias totalis was in 1.6% of cases, and exstrophy-epispadias complex (EEC) was in 1.2% of cases [Table 2].
In this study, 8.1% was found GU tumors. Wilm’s tumor was in 18 (3.5%) children.
9(1.8%) patients had urethral stricture; 6(1.2%) patients had urolithiasis [Table 3].
In the case of redo surgery, urethra cutaneous fistula was found in 42(8.3%) patients [Table 4].
| Discussion|| |
Surgery of children has been practiced from time immemorial. It is the evolution of an oak tree from an acorn, growing from humble beginnings to a well-recognized surgical specialty.
Pediatric urology is a pediatric specialty for the diagnosis and treatment of congenital and acquired genitourinary tract diseases. This is rapidly changing due to the technological development that has been emerging in recent years.
CAKUT includes various entities of structural malformations that result from defects in their morphogenesis. Clinical research and genetic studies on the origins of CAKUT are quickly evolving, with significant growth of high-quality research.
In our study, GU cases (congenital, acquired, and redo) were operated in 508(38.2%) patients out of 1329 pediatric surgical cases. Stephen et al. showed that the GU cases were in 257(14.9%) patients out of 1726 pediatric surgical cases. So, in our study GU cases were more common than the other study in Pediatric patients.
In our study, 1329 patients were operated, where congenital GU cases were 355 (69.9%). Bhat et al. showed apparent GU congenital anomalies were diagnosed in 799, with an incidence 39.1 per 1000 newborns. Basavanthappa et al. found that musculoskeletal malformations were the commonest malformation and accounted for 27.5% of all the malformations in a hospital of South India. This was followed by cutaneous 19.16%, GU 15.83%, gastrointestinal 12.5%, neurological 10%, and cardiac malformations 5.83%. Congenital UG cases in our study were more than in the other studies.
In our study in congenital cases, hypospadias patient was in 27.8% of patients and PUJO was in11.8%patients, PUV was in 4.3%patients, EEC was in 1.2% patients, undescended testes (nonpalpable) were in 0.7% patients. In acquired cases, Wilm’s tumor was in 3.5% of patients, urolithiasis (kidney, ureter, bladder) was in 1.2% of patients and in redo cases, UC fistula was in 8.3%patients. Stephen et al. showed that in congenital cases inguinal hernia in 9.6%patients, hypospadias in 0.6%patients, PUV in 0.6% patients, undescended testes in 1.2% patients, and EEC in 0.5%patients. In acquired cases, paraphimosis in 0.6%patients, bladder stone in 0.3%patients, and UC fistula in 0.3% cases.
The pattern and distribution GU cases of our study were also different from the study of Stephen et al. The cause of differences in pattern and distribution of cases of our study from Stephen's study is that in our institution some GU cases like hernia, hydrocele, palpable undescended testes were done on daycare basis. No established emergency facility persists in our setting.
In our study, 85% were boys while only 15% of them were girls. Pal et al. showed 62% males and 38% females were affected in their study. Both studies showed that male was predominant.
In this study, age ranged from 2 days to 18 years, and mean age was 5.68 ± 3.77 years. Male and female ratio was 5.7:1. The study of Abahuji et al.  showed their age range and mean of age was almost the same as the present study. But the male and female ratio was 2.2:1.
In our study, 43.7% of children with congenital GU anomalies were in >5 years to 12 years old and the neonatal age group was in 2.3% of cases. Radha et.al. showed in their study that 41% of children belong to the 1–5 years age group and neonatal patients were in 12% of cases.
Delay in diagnosis of GU cases in our institute because of some congenital anomalies like hypospadias, usually practicing in delay surgery at least when the child is school-going age. Moreover, in our country, there is no routine screening of the newborn for surgical causes of congenital anomalies.
In our study, Hypospadias was present in 27.8% of cases. Other congenital anomalies like PUJO in 11.8% of cases, VUJO in 2.4% cases nonpalpable UDT in 3.1% cases, Ambiguous genitalia in 1.4% cases, aphallia in 0.4% case and vaginal atresia in 0.6% cases. Srivastava et al. showed hypospadias in 16.4% cases, PUJO in7.3% cases, UDT in 7.3% cases, ambiguous genitalia in 3.6% cases, aphallia and vaginal atresia in 1.8% of cases. In our study, hypospadias was more common than the other congenital anomalies which was similar to Srivastava’s study.
In our study PUV in 4.3% cases, ureterocele in 1.6% cases, epispadias totalis in 1.6% of cases, and EEC in 1.2% cases. Lioyd et al. showed in their study EEC in 6.3% cases, epispadias totalis in 33% cases, PUV in 16.7% cases. In our study, PUV, ureterocele, epispadias totalis, and EEC were less than Lioyd’s study.
Tumors of the kidney, adrenal, ovary, testis, and bladder represent a large part of the adult urologic practice but are relatively infrequent in children. In our study, 8.1% of urogenital tumors were found, and Wilm’s tumor (3.5%) was the most common. Vendana et al. showed in their study that the average incidence of urogenital tumors was 0.89%. Wilm’s tumor was also most common (32.1%). Though Wilm’s tumor was a common urogenital tumor in both studies, but in percentage, it was less in our study than in Vendana’s study.
In our study 9 (1.8%) patients had urethral stricture out of 508 urogenital cases over the three years periods. Urethral stricture developed after trauma, hypospadias surgery, epispadias surgery, after valve fulguration, after surgery for anorectal malformation (ARM), and Hirschprung’s disease, were included. Koushik et al. found that 23(0.12%) children had urethral stricture out of 19,250 admitted patients from Januaryn2005 to May 2016. They included the cases of urethral stricture developed after trauma, surgery for ARM, and unspecified urethritis. After hypospadias, repair was not included in this study. The causes of urethral stricture were not similar in both studies.
Urolithiasis is uncommon in children. The discovery of urolithiasis in children required a systemic and thorough etiological investigation in search of metabolic disease, hereditary anomaly, or associated uropathy. Besides medical care, urological care is also essential.
In our 3 years study, 6 patients had urolithiasis. Bouthour et al. showed in their study that 45 patients had urolithiasis over the period of 18 years. Incidence of urolithiasis was almost similar in both studies, though the length of the study was varied.
In our study, urethro-cutaneous (UC) fistulas, failed urethroplasty, urethral stricture, urethral diverticulum, cripple hypospadias were noticed after urethroplasty which required redo surgery. Mouriqu et al. noticed the same complications after urethroplasty.
UC (3.16%) fistula in our study was a common complication after urethroplasty. Lu et al. showed similar results where urethral fistula was the most common complication reported in the regions of North America, Europe, and China in a total of 113 studied and selected cases. But the percentage of UC fistula varied from our study. They showed 5.1% of UC fistula developed in the North America region, 7.6% were in the Europe region and 9.4% were in the China region.
| Conclusion|| |
GU cases are more common than the other systemic cases in pediatric surgical patients. Among the GU cases, congenital anomalies are more than the acquired diseases in our institution. But most of the congenital anomalies were diagnosed at a later age in our institution.
So, for early diagnosis of congenital anomalies of the genitourinary system should be ensured by proper neonatal examination. The community, primary health care staff, promotion of a lay-support organization, training of nurses and doctors should be institutionalized.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4]