VESICOURETERAL REFLUX

What is vesicoureteral reflux? (VUR)

The normal urination process involves bladder contraction and urine flow out of the body through the urethra.

With vesicoureteral reflux (VUR), some urine goes back up into the ureters and possibly up to the kidneys. This process exposes the kidneys to infection.

In children, especially those in the first 6 years of life, urinary infection can cause kidney damage. The injury caused by infection to the kidney may result in scars in the kidney and loss of future growth potential or widespread scarring and loss of the normal kidney tissues. Even a small area of scarring in one kidney may be a cause of high blood pressure later in life. Untreated, severe reflux on both sides can result in kidney failure requiring dialysis or kidney transplantation.

VUR is most commonly diagnosed in infancy and childhood after the patient has a urinary tract infection (UTI). About one-third of children with a UTI are found to have VUR.

VUR can lead to infection because urine that remains in the  urinary tract provides a place for bacteria to grow. But sometimes the infection itself is the cause of VUR.

There are undetermined genetic risk factors which may affect the development of VUR. About 34% of patients who have the condition have siblings who are also affected.

Types of VUR:

Primary reflux

The most common cause for primary reflux in children is an abnormality in the section of the ureter that enters the bladder ( intravesical ureter). The intravesical ureter may not be long enough to enable the ureter to sufficiently act as a valve to prevent urine reflux, or the ureter may be inserted abnormally into the bladder.

Other causes of primary reflux include abnormalities in muscle of the bladder, abnormalities in the location of the urethral opening and abnormalities in the shape of the urethral opening. 

Secondary reflux

Secondary reflux is often caused by urinary tract infection which causes inflammation and swelling of the ureter. UTI may cause vesicoureteral reflux or vesicoureteral reflux may promote the growth of bacteria in the urinary tract, causing UTI.

Secondary reflux may also be caused by urinary tract abnormalities like narrowing of the ureter; duplicated ureters; ureterocele) and obstructions from stones or tumors. 



Evaluation

An ultrasound of the kidneys and bladder is done to 1) evaluate hydroneprosis and kidney growth and 2) detect abnormalities that cause reflux.

A renal scan is done to evaluate kidney growth and detect presence of scarring.

A voiding cystourethrogram (VCUG) is performed to determine if an abnormality in the urinary tract is causing reflux. A contrast dye is instilled into the bladder through a catheter and a series of x-rays are taken.

Grading of VUR

Grade I (least severe) to Grade V (most severe):

• Grade I results in urine reflux into the ureter only.
• Grade II results in urine reflux into the ureter and the renal pelvis, without swelling of the top of the ureter (hydronephrosis).
• Grade III results in reflux into the ureter and the renal pelvis, causing mild hydronephrosis.
• Grade IV results in moderate hydronephrosis.
• Grade V results in severe hydronephrosis and twisting of the ureter

Mild-to-moderate degrees of reflux (grades I to III) have a good chance of spontaneous resolution with age in over 80% of children. This typically occurs over the span of few years. Unfortunately, we do not know exactly when the reflux will go away for a particular child.
The chance of spontaneous resolution of high grade reflux (IV to V) is much lower.

Treatment

1) Antibiotic prophylaxis for VUR Gr II-III
2) Endoscopic treatment for VUR Gr I-IV
3) Open surgery  for VUR Gr IV-V


Follow-Up
All patients with a history of reflux will have life long monitoring. Even if the reflux resolves, there is still risk of developing kidney insufficiency, hypertension, and pregnancy-related problems.This usually involves periodic visits to the pediatrician and have the following taken: height and weight, blood pressure, and urine analysis. Kidney function can be evaluated by blood tests (creatinine and BUN) or by creatinine clearance or glomerular filtration rate. Occasional ultrasound tests will ensure that kidney growth is on target for age. Female patients should be carefully monitored during their pregnancy.

UNDESCENDED TESTIS

Undescended testicle, also called cryptorchidism, is a common condition in which one of the testicles is not located within the scrotum. During the eighth month of the mother's pregnancy, the baby's testes migrate from the abdomen, through the groin, and into the pouch that contains the testes (scrotum).

An undescended testicle may be located in the abdominal cavity, in the passageway in the groin (inguinal canal), or in an ectopic location (e.g., superficial pouch in the groin, perineum, upper thigh). This condition is usually present at birth (congenital) and is associated with sterility and an increased risk for testicular cancer if not corrected.

Undescended testicle may occur in approximately 30% of premature males and 3% of full term male infants. In 80% of cases, the undescended testicle migrates into the correct position without intervention during the first year. The condition may involve both testicles in about 10% of cases.

The cause of undescended testicle is not known. If the father or brother ad the conditionm, there is an increased risk. Other risk factors include the following:

* Low birth weight (less than 2500 g)
* Maternal exposure to estrogen during the first trimester
* Multiple birth (e.g., twin, triplet)
* Premature birth (before 37 weeks gestation)
* Small size for gestational age

Diagnosis of this condition is made through physical examination at birth to locate the testis. If one testicle is undescended, the scrotum appears unbalanced. If the undescended testis is felt (palpable) it may not have descended fully, may have descended into a location other than the scrotum (ectopic), or may move in and out of the scrotum through muscle contraction (retractile).

If the testis is non palpable, it may be located within the abdomen or may be absent (occurs in 5% of cases). A congenitally absent testicle may result from an abnormality in testicular blood vessels or testicular torsion in utero.

In humans, the scrotal location of the testicles keeps them cooler than the core body temperature which is important for the development of the testicle as well as for production of normal sperm. Studies have shown that there is an increased risk of infertility in men with a history of undescended testicles. Relocating the testicle into the scrotum may decrease the risk of fertility problems, particularly if done at an early age.

There are other advantages to a location within the scrotum. There is a cosmetic advantage. The scrotal testicle may be at less risk to injury than a testicle outside the scrotum. Finally, and perhaps as important as any other reason, a testicle that has not made it into the scrotum is not accessible to physical examination.

Undescended testicles are at increased risk for cancer. Testicular cancer may not occur until after age 40 years. Testicular carcinoma is highly curable, when detected early, and the best way to do this is monthly self-examination, which can only be done if the testicles are within the scrotum.

It is recommended that treatment of the undescended testicle be done before one year of age. There is evidence that early damage to the germ cells that produce sperm begins at this age.

There are two options for treatment. Injections of a hormone, HCG, several times per week over several weeks can produce descent in some children. However, the success rates have been reported to be as low as 10%. Also, the results of hormone treatment are less successful in children less than two years of age.

The most effective treatment is surgery, which can be performed as an outpatient. When a testis is felt in the groin area we usually explore the area through a small incision. Most undescended testes are associated with a hernia that must be repaired. After this is done, the testis is brought down into the scrotum and anchored in a space created in the scrotum (orchiopexy).

When a testis is not palpable on physical exam, its location must be determined. No x-rays are reliable in this regard. A diagnositic laparoscopy is done. A laparoscope through a small incision below the 'belly button' to look in the abdomen at the time of surgery. In those patients found to have testes very high in the abdomen, additional surgery is required to correct the problem. A number of children will be found to have very small abnormal gonads, removal of the gonad is done. Most of these children probably had torsion or twisting of the testis on its blood supply prior to birth that led to the small testis. When a boy is left with a single functioning testis it is recommended that it be anchored to minimize chances of losing it to torsion later in life.

HYPOSPADIAS

Hypospadias is a birth defect where the boy's urinary opening (urethral meatus) is not in its normal location. It may be located anywhere in the penile shaft, anywhere from tip to base. This condition is often associated with penile twisting, penile curvature/bending (chordee) and a hooded, incomplete foreskin. The degree of hypospadias depends on the location of the penis opening. This is birth defect occurring in one in one hundred to one in two hundred births (1 in 100 to 1 in 200). When we see a boy with hypospadias there is a twenty percent (20%)chance of finding this in another family member such as father or a brother.


The cause of hypospadias is not known. The condition results from abnormal development of the urethra in the embryo and not from anything the parents did or did not do during pregnancy. Hypospadias will occasionally occur in more than one male in a family.

Problems encountered are messy urination because of the direction of the urinary stream, erectile problems and impaired delivery of semen. The most devastating problem encountered is pyschological since those who have severe defects need to sit down when urinating. The ability to stand and urinate is important for boys. When the urethra opens before it reaches the glans a boy may be unable to stand and urinate with a direct stream.The youngster who has to sit down to urinate on a toilet is at a painful social disadvantage. A straight penis is necessary for satisfactory sexual function. Although this may not seem to be an important matter in childhood, this is a crucial concern later in life.

Corrective surgery usually results in a penis that looks normal and functions normally. Surgical correction of hypospadias involves straightening of any chordee and then extension of the urinary tube (urethra) out to the tip of the penis (the glans).Surgery should be performed to correct the condition as soon as is possible - certainly within the first year or two after birth.

Prostate Cancer

Prostate cancer affects the tissues of the prostate gland. It occurs when the cells of the prostate grow uncontrollably. This is the most common malignancy found in men.

Prostate cancer usually grows slowly and initially remains confined to the prostate gland, where it may not cause serious harm. There are some types of prostate cancer grow slowly and may need minimal or no treatment, while there are types which are aggressive and can spread quickly.

If prostate cancer is detected early — when it's still confined to the prostate gland then there is a 90% chance of successful treatment.

Risk factors

* Age. After age 40, the chance of having prostate cancer increases.

* Race or ethnicity. For reasons that aren't well understood, black men have a higher risk of developing prostate cancer.

* Family history. Men with a single first-degree relative—father, brother or son—with a history of prostate cancer are twice as likely to develop the disease, while those with two or more relatives are nearly four times as likely to be diagnosed. The risk is even higher if the affected family members were diagnosed at a young age, with the highest risk seen in men whose family members were diagnosed before age 60.

* Diet. A high-fat diet and obesity may increase the risk of prostate cancer. One theory is that fat increases production of the hormone testosterone, which may promote the development of prostate cancer cells.

* High testosterone levels. Because testosterone naturally stimulates the growth of the prostate gland, men who use testosterone therapy are more likely to develop prostate cancer than are men who have lower levels of testosterone.

Symptoms

Prostate cancer usually doesn't produce any noticeable symptoms in its early stages, so many cases of prostate cancer aren't detected until the cancer has spread beyond the prostate. For most men, prostate cancer is first detected during a routine screening such as a prostate-specific antigen (PSA) test or a digital rectal exam (DRE).

When signs and symptoms do occur, they depend on how advanced the cancer is and how far the cancer has spread.

Less than 5 percent of cases of prostate cancer have urinary problems as the initial symptom. When urinary signs and symptoms do occur, they can include:

* Trouble urinating
* Starting and stopping while urinating
* Decreased force in the stream of urine

Cancer in your prostate or the area around the prostate can cause:

* Blood in your urine
* Blood in your semen

Prostate cancer that has spread to the lymph nodes in your pelvis may cause:

* Swelling in your legs
* Discomfort in the pelvic area

Advanced prostate cancer that has spread to your bones can cause:

* Bone pain that doesn't go away
* Bone fractures
* Compression of the spine



Screening and Diagnosis

The first indication of a problem may come during a routine screening test, such as:

* Digital rectal exam (DRE).
During a DRE, your doctor inserts a gloved, lubricated finger into your rectum to examine your prostate. The texture, shape and size of the gland is evaluated, if abnormalities are noted, there may be a need for more tests.



* Prostate-specific antigen (PSA) test.
PSA, is a substance that's naturally produced by the prostate gland to help liquefy semen. It's normal for a small amount of PSA to enter your bloodstream. However, if a higher than normal level is found, it may be an indication of prostate infection, inflammation, enlargement or cancer. Screening with PSA and DRE can help identify cancer at an earlier stage.

* Transrectal ultrasound guided prostate biopsy.
If other tests raise concerns, a transrectal ultrasound guided prostate biopsy is perfomed to obtain a definitive diagnosis of the prostate pathology.

Who should be screened?

Both the PSA and DRE should be offered annually, beginning at age 40, to men who have at least a 10-year life expectancy. Men at high risk, such as African American men and men with a strong family history of one or more first-degree relatives diagnosed at an early age. However, all men aged 40 and above should speak with their doctors at the the time of their annual physical examinations and develop a prostate health plan.

Treatment options:

Treatment options for prostate cancer vary depending on the grade and stage of the cancer.

For low grade and early stage cancers(localized), surgery is the gold standard of treatment. Radical retropubic prostatectomy offers the highest cure rate for organ confined prostate cancers.

Other options include brachytherapy, radiation therapy, high intensity focused ultrasound (HIFU) and watchful waiting.

For moderately advanced and advanced prostate cancers, hormonal therapy plays an important role. If urinary symptoms are present, a transurethral resection of the prostate combined with the hormonal therapy is recommended.

CANCER OF THE URINARY BLADDER

Bladder cancer accounts for approximately 90% of cancers of the urinary tract (renal pelvis, ureters, bladder, urethra). The bladder is an organ located in the pelvic cavity that stores and discharges urine. Urine is produced by the kidneys, carried to the bladder by the ureters, and excreted from the bladder through the urethra.

Bladder cancer usually originates in the bladder lining, which consists of a mucous layer of surface cells called transitional epithelial cells, smooth muscle, and a fibrous layer. Tumors are categorized as low-stage (superficial) or high-stage (muscle invasive).

More than 90% of cases originate in the transitional epithelial cells (called transitional cell carcinoma; TCC). Then next most common type is squamous cell carcinoma caused by Schistosoma haematobium (parasitic organism) infection and is often times associated with a long standing urinary bladder stone. Rare types of bladder cancer include small cell carcinoma, carcinosarcoma, primary lymphoma, and sarcoma.

Incidence of bladder cancer increases with age. People over the age of 70 develop the disease 2 to 3 times more often than those aged 55–69 and 15 to 20 times more often than those aged 30–54.
Bladder cancer is 2 to 3 times more common in men. Bladder cancer is the fourth most common type of cancer in men and the eighth most common type in women.

CAUSES AND RISK FACTORS
Cancer-causing agents (carcinogens) in the urine may lead to the development of bladder cancer. Cigarettte smoking contributes to more than 50% of cases, and smoking cigars or pipes also increases the risk.

Other risk factors include the following:

• Age
• Chronic bladder inflammation (recurrent urinary tract infection, urinary stones)
• Consumption of Aristolochia fangchi (herb used in some weight-loss formulas)
• Diet high in saturated fat
• Exposure to second-hand smoke
• External beam radiation
• Family history of bladder cancer (several genetic risk factors identified)
• Gender (male)
• Infection with Schistosoma haematobium (parasite found in many developing countries)
• Personal history of bladder cancer
• Treatment with certain drugs (e.g., cyclophosfamide—used to treat cancer)

Exposure to carcinogens in the workplace also increases the risk for bladder cancer. Medical workers exposed during the preparation, storage, administration, or disposal of antineoplastic drugs (used in chemotherapy) are at increased risk. Occupational risk factors include recurrent and early exposure to hair dye, and exposure to dye containing aniline, a chemical used in medical and industrial dyes.

Workers at increased risk include the following:

• Hairdressers
• Machinists
• Printers
• Painters
• Truck drivers
• Workers in rubber, chemical, textile, metal, and leather industries

SIGNS AND SYMPTOMS

The primary symptom of bladder cancer is blood in the urine (hematuria). Hematuria may be visible to the naked eye (gross) or visible only under a microscope (microscopic) and is usually painless.
Other symptoms include frequent urination and pain upon urination (dysuria).

DIAGNOSIS

Diagnosis of bladder cancer includes urological tests and imaging tests. A complete medical history is used to identify potential risk factors (e.g., smoking, exposure to dyes).

LABORATORY TESTS

• Urinalysis (to detect microscopic hematuria)
• Urine cytology (to detect cancer cells by examining cells flushed from the bladder during urination)

IMAGING TESTS

Ultrasound

This is the initial test performed and most patients come to the urologist with an ultrasound report.

Computed Tomography

More and more frequently computed tomography (CT) without and with intravenous contrast has replaced intravenous pyelography (IVP) the evaluation of hematuria. With computer-assisted reconstruction, longitudinal views of the urinary tract can now be made, although their sensitivity in detecting small or flat tumors of the urothelium is limited.

Intravenous Pyelography

If CT is not performed, IVP is indicated in all patients with signs and symptoms suggestive of bladder cancer. Urography is not a sensitive means of detecting bladder tumors, particularly small ones. However, it is useful in examining the upper urinary tracts for associated urothelial tumors. Large tumors may appear as filling defects in the bladder on the cystogram phase of the urogram. Ureteral obstruction caused by a bladder tumor is usually a sign of muscle-invasive cancer. Additionally, of course, IVP can assess other upper tract abnormalities that may affect management decisions.

Treatment
Treatment for bladder cancer depends on the stage of the disease, the type of cancer, and the patient's age and overall health. Options include surgery, chemotherapy, radiation, and immunotherapy. In some cases, treatments are combined (e.g., surgery or radiation and chemotherapy, preoperative radiation).

Cancer of the Kidney

There are several types of cancer found in the kidneys. Renal cell carcinoma (RCCA), the most common form, accounts for approximately 85% of all cases. In RCCA, cancer (malignant) cells develop in the lining of the kidney's tubules and grow into a tumor. In most cases, a single tumor develops, although more than one tumor can develop within one or both kidneys.

Early diagnosis of kidney cancer is important. As with most types of cancer, the earlier the tumor is discovered, the better is the patient's chances for survival. Tumors discovered at an early stage often respond well to treatment. Survival rates in such cases are high. Tumors that have grown large or spread (metastasized) through the bloodstream or lymphatic system to other parts of the body are more difficult to treat and present an increased risk for mortality.

Studies have shown that certain lifestyle factors can increase the risk of developing kidney tumors. Smoking, having high blood pressure, eating a high-fat diet, and being overweight all may contribute to an increased risk of kidney cancer.

RISK FACTORS

Although we do not know all the causes of kidney cancer, the following factors can also increase the risk of developing this disease:

* long-term dialysis, a process in which a machine filters the blood of a person without functioning kidneys

* exposure to asbestos, such as occupational exposure

* exposure to cadmium, a metal that can increase the cancer-causing effect of smoking

* a family history of kidney cancer

* von Hippel-Lindau disease, a syndrome caused by a genetic mutation that leads to multiple tumors in the kidney, often at an early age

* tuberous sclerosis, a disease characterized by several bumps on the skin, seizures, mental retardation, and cysts in the kidneys, liver, and pancreas

SYMPTOMS

Kidney cancer usually shows no symptoms in the early stages. It is generally not suspected until the patient begins to experience symptoms, and at this point the tumor may have grown fairly large.

As the cancer progresses, symptoms may include some of the following:

* Abdominal mass or lump
* Blood in the urine (hematuria)
* Fever
* High blood pressure (hypertension)
* Pain in the side (flank) or lower back not associated with injury
* Persistent fatigue
* Rapid, unexplained weight loss
* Swelling (edema) in the legs and ankles

DIAGNOSIS

Blood tests :
1) CBC
3) Creatinine
3) Calcium

Imaging tests:

1)Ultrasound

2)CT Scan/MRI



STAGING



TREATMENT

Surgery is the standard treatment for RCC. There are several surgical options, depending on the stage of the disease and the overall health of the patient.

Partial Nephrectomy: Kidney-Sparing Surgery

Kidney-sparing (or nephron-sparing) surgery is the term used to describe the procedure in which a kidney tumor is removed, leaving a margin of normal kidney tissue in order to preserve the function of the remaining kidney. Studies have demonstrated that partial nephrectomy yields comparable results to complete nephrectomy in patients with small tumors (less than 4 centimeters), while maintaining functioning kidney tissue.

Radical Nephrectomy

In some situations, the entire kidney needs to be removed. Tumors that require complete nephrectomy tend to be larger in size and to have advanced locally, though sometimes they have spread to another part of the body. This procedure can be done by the open or laparoscopic approach. Because we are able to offer all possible modes of treatment, we can tailor the approach to each individual patient.

The advanced Minimally Invasive Surgery in Mindanao

The establishment of the state-of-the art center of Minimally Invasive Surgery (MIS) in Mindanao intensifies the evolution of open surgery.

The evolution of open surgery paves way to fewer invasions of human body. However, specialists can still generate quality result at a more precise manner.

The MIS employs video cameras and lens system to provide anatomic visualization using the laparoscopic/endoscopic instruments for diagnostic/ therapeutic intervention

The MIS center of DMSF Hospital has the following sections: General Surgery, Urology, Colorectal, Gastroenterology, Gyne, Orthopedic, ENT, Thoracic and Bronchoscopy.

The movers behind this revolution are trained locally and internationally.

The DMSF Hospital like any other hospitals worldwide joins in the innovation of surgical practice wherein less tissue trauma, scars and greater recovery of tissue at a more painstaking effort.

Patients can expect a more quality of alternate open surgeries at an affordable and less invasive delivery of minimally invasive surgery yet the culture of trust and utmost care is strongly practiced.

from DMSF Hospital website: http://www.dmsfhospital.com/