Urology or after pediatric surgery is a separate specialty (specialization) and pediatric patients should be followed up and treated by specialist physicians (Pediatric Urology Specialist-Pediatric Urologist). Pediatric urology Specialists, female and male patients aged 0-16, urinary system [kidney, urinary ducts (ureter), bladder] and genital system [penis, external urinary tract (urethra), egg sac (scrotum) and testicles in men, They are doctors who specialize in the diagnosis and treatment of diseases of the vagina in girls.
Diagnosis and treatment of these diseases in children require different practices and practical skills. Some diseases that concern children are not seen in adults at all, or treatment approaches may be completely different in similar diseases. Childhood, the period in which growth and development continues, is a very sensitive period. If the health problems experienced in childhood are not treated, they can continue more difficult in adulthood.
What are Pediatric Urology Diseases?
Vesicoureteral Reflux: After the urine is produced by the kidneys, it is transported to the urinary bladder (bladder) via tubes called ureters and stored. There is almost a valve mechanism between the ureter and the bladder on both sides, preventing the urine from escaping back to the kidneys. Vesicoureteral reflux is a condition in which urine escapes from the bladder to the kidneys. It is the most important cause of urinary tract infection in children.
Ureteropelvic Stenosis: Urine produced by the kidneys is first collected in a pool called the renal pelvis and then transported to the bladder by structures called ureters. The stenosis that develops at the junction of the renal pelvis and the ureters is defined as ureteropelvic junction stenosis. With the disruption of the flow of urine from the kidneys to the ureter, urine accumulates in the renal pelvis and causes enlargement called hydronephrosis. If not intervened, deterioration or complete loss of kidney functions may develop over time.
Ureterovesical Junction: The ureterovesical junction is the junction of the ureters, which carry urine from the kidney to the bladder, and the bladder. Ureterovesical junction stenosis describes the obstruction in this region. In the case of stenosis, urine cannot easily empty into the bladder; As urine accumulates in the ureter, it can cause enlargement of the ureter (megaureter) and enlargement of the kidney (hydronephrosis).
Neurogenic Bladder: When the nerves that control the functioning of the urinary bladder and the last part of the large intestine are affected, urinary bladder dysfunction occurs. Approximately 95% of children with meningomyelocele have dysfunction of the bladder and sphincter. If the bladder does not completely empty the urine in it, inflammation of the residual urine remaining inside becomes easier. The fullness of the bladder makes it difficult to pass urine from the kidneys to the bladder, causing the ureters and the collecting system in the kidney to expand and the functioning of the kidneys to deteriorate. Storing urine with high pressure or urinating with high pressure causes the urine, called vesicoureteral reflux, to flow back from the bladder to the kidneys. When urinary tract inflammation and reflux come together, the inflamed urine reaches the kidneys and causes kidney inflammation called pyelonephritis. If damage to the kidneys by reflux and inflammation is not prevented, high blood pressure or kidney failure may develop in the following years.
Hypospadias: It is the opening of the external urinary hole, which should be at the tip of the genitals in boys, somewhere on the underside of their penis. For hypospadias among the people, the expressions of prophetic circumcision or half-sunnah are used.
Epispadias: It is the opening of the urethra in the part of the penis facing the human face, from the pubis bone to the glans penis, which is the fleshy part at the tip of the penis.
Undescended Testicle (Egg): Testicular tissue first forms on the posterior abdominal wall when the baby is in the mother's womb. Then, with a number of hormonal and mechanical factors, it first moves to the inguinal region and then reaches the egg sac (scrotum). Sometimes, if these hormonal and mechanical factors that lead to the descent of the testicle develop, and if the testicle remains behind or in an abnormal position on the way it should progress, it is called an undescended testicle. The risk of infertility and testicular cancer in children with undescended testicles is higher than in the normal population, therefore treatment and follow-up are absolutely necessary.
Bladder Exstrophy: It is a congenital structural disorder. It is a disease characterized by the lack of development of the urinary bladder and the anterior abdominal wall in front of it, the appearance of the bladder when viewed from the outside, and the direct outflow of urine. The bladder cannot form its normal closed spherical shape. It is almost always associated with a penile anomaly called epispadias in boys.
Inguinal Hernia: The testicles formed in the baby's abdomen while in the mother's womb pass through the inguinal canal before birth and descend into the egg sac. During this descent, they drag the peritoneum along with them. Normally, this membrane closes and disappears after the testicles descend into the scrotum. Inguinal hernias occur when this membrane does not close and remains fully or partially open.
Hydrocele: Painless collection of fluid between the inner and outer membranes surrounding the testis.
Curvature of the Penis (Penile Curvature): It means that the penis is curved forward, backward or sideways. It becomes evident when the penis becomes hard.
Buried Penis: Although the penis is of normal size, it is seen as small when viewed from the outside, due to the fact that it is hidden by the surrounding skin.
Posterior Urethral Valve: They are thin curtain-shaped structures formed in the boy's urethra (the tube-shaped structure that extends from the bladder to the urethra that provides urination) and prevents the discharge of urine from the bladder. These structures, which prevent the discharge of urine from the bladder, may cause enlargement of the bladder, ureters and kidneys, malfunctions and kidney failure over time.
Adolescent Varicocele (Adolescent Varicocele): Varicocele can be defined as the excessive expansion of the veins carrying the dirty blood coming from the testicles and the accumulation of blood inside. In this case, the dirty blood carrying waste materials cannot be removed, and at the same time, the temperature increase caused by the accumulated blood begins to disrupt the work of the testicles. In addition to symptoms such as pain in the bags where the testicles are located, it can cause infertility as a result of regression in testicular development, atrophy (shrinkage) and deterioration of sperm values in adulthood.
Ureterocele: It is the ballooning of the part of the ureters entering the bladder into the bladder.
Urinary Incontinence: Urinary incontinence can occur at night, during the day, or both. Bedwetting at night is when a child aged 5 years and older, who should generally start nighttime urine control, wets the bed during sleep. The most important reason for the daytime urinary incontinence problem is the contraction of the muscle structure, which we call the sphincter, which controls the urine during urination.
Laparoscopy in Pediatric Urology
Laparoscopy is a surgical procedure performed with the help of instruments that are advanced into body cavities through small incisions made in the skin. Since very small incisions are made in the body in laparoscopic surgery, there are advantages such as less postoperative pain, less hospitalization time, faster recovery and earlier return to daily life. Most importantly, laparoscopic surgery is gaining more importance in children as they are more sensitive to pain. In children, the operations of almost all organs within the scope of urology such as kidney, ureter (the channel connecting the urinary bladder and kidney), urinary bladder (bladder) can also be performed and preferred by laparoscopic method. In our hospital, laparoscopy is successfully applied to our pediatric patients in appropriate cases.
Robot in Pediatric Urology
Disadvantages such as the uncomfortable positions that the surgeon has to give to his body in order to perform the desired movements during laparoscopy, difficulties in the maneuverability of laparoscopic instruments and suturing with these instruments, and the use of 2D images in laparoscopic systems have led surgeons to seek other systems. The most important among them is robotic surgery. This surgery has many potential advantages.
1. A three-dimensional image is provided to the surgeon performing the operation.
2. In robotic surgery, magnification up to 12 times is possible.
3. Since the physiological hand tremor of the surgeon is filtered during the operation, it is not transmitted to the instruments and the surgeon can perform the operation without tremor.
4. Intra-body knot tying with robotic instruments is easier than laparoscopic knot tying,
5. Since the surgeon performing the operation sits throughout the case, he gets less tired during the operation.
Today, many operations such as pyeloplasty, nephrectomy, heminephrectomy, ureteral reimplantation and augmentation can be successfully performed with robotic systems. All robotic pediatric surgeries available in the world are successfully applied in our hospital.
Surgical Treatment of Pediatric Stone Disease
Childhood stone disease is an important health problem and it is an important disease that should be diagnosed and treated carefully, especially in regions such as Turkey where it is common. There are many treatment options in the surgical treatment of these stones. These; We can count the breaking of stones with shock waves created outside the body (ESWL), stone treatments performed by entering the urinary canal (ureterorenoscopy, retrograde intrarenal surgery), percutaneous stone surgery by reaching the kidney from the skin, and open stone surgery. All treatment options except ESWL are successfully applied to our pediatric patients of all age groups in our hospital.