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414 Challenging Concepts in Urological Surgery
https://t.me/med1917
Table 42.3 Potential donor- derived infectious risks for transplant recipients,
grouped by type
Potential infections Examples
Viral Herpesviruses (cytomegalovirus, Epstein– Barr virus)
Hepatitis viruses (types C and C)
Retroviruses (HIV, human T- lymphotropic virus)
Bacterial Staphylococcus spp.
Pseudomonas aeruginosa
Mycobacteria tuberculosis
Nocardia asteroids
Fungal Candida spp.
Aspergillus spp.
Parasitic Toxoplasma gondii
Trypanosoma cruzi
The risk of malignancy after transplantation is increased compared to the general
population, due to the impact of immunosuppressing medication. Non- melanoma
skin cancers are the most common cancers in renal transplant patients, followed by
renal, bladder, and thyroid. Oncogenic viruses can play a role in the development
of lymphoma and lymphoproliferative disease after transplantation. Post- transplant
lymphoproliferative disorder is a malignancy primarily of B- cell origin and related to
Epstein– Barr virus proliferation. It affects only 1– 2% of kidney transplant recipients
but is a life- threatening disease.
Despite improvements in immunosuppression and donor selection, a chronic deterioration in graft function and eventual progression back to dialysis is inevitable.
This damage is a combination of immunological and non- immune effects resulting in
interstitial fibrosis, tubular atrophy, and glomerular sclerosis. It is therefore important
to identify and treat, or ideally prevent, the potential modifiable risk factors.
Learning point Risk factors for renal allograft damage
Following renal transplantation, modifiable risk factors for renal allograft damage and
deterioration in function should be addressed. Non- modifiable risk factors are also
described below.
Modifiable risk factors
● Calcineurin inhibitor toxicity.
● Ascending infection/ sepsis.
● Hypertension.
● Hyperlipidaemia.
● Smoking status.
● Non- compliance with medication.
Non- modifiable risk factors
● Deceased donor.
● Older donor.
● Reperfusion injury.
● Delayed graft function.
● Acute rejection.
● Recipient ethnicity.
● HLA mismatch.
A final word from the expert
https://t.me/med1917
Renal transplantation is an expanding, exciting, and developing surgical field. Despite an
increase in the number of transplants done, the waiting list continues to increase in many
countries due to the rising numbers of patients with CKD. Attempts have been made to
address this need by increasing the use of kidneys from donation after circulatory death, live
donation, and by extending the criteria for acceptable brain death donors in terms of age or
comorbidity. Research into new reconditioning technologies may further expand the potential
donor pool. Many transplant recipients will need more than one transplant over their lifetime
due to the still limited life expectancy of a transplanted organ. It is hoped that improvements
in immunosuppression may address this particular issue by preventing chronic allograft
nephropathy and return to dialysis.
415Case 42 Renal transplantation
Further reading
Gatz JD, Spangler R. Evaluation of the renal transplant recipient in the emergency department.
Emerg Med Clin North Am. 2019;37(4):679– 705.
Hadjianastassiou VG, Johnson RJ, Rudge CJ, Mamode N. 2509 living donor nephrectomies,
morbidity and mortality, including the UK introduction of laparoscopic donor surgery. Am J
Transplant. 2007;7(11):2532– 2537.
Hagen SM, Lafranca JA, Steyerberg EW, ≥zermans JN, Dor FJ. Laparoscopic versus open peri-
toneal dialysis catheter insertion: a meta- analysis. PLOS One. 2013;8(2):e56351.
Kwong J, Schiefer D, Aboalsamh G, Archambault J, Luke PP, Sener A. Optimal management of
distal ureteric strictures following renal transplantation: a systematic review. Transpl Int.
2016;29(5):579– 588.
Lentine KL, Lam NN, Axelrod D, et al. Perioperative complications after living kidney dona-
tion: a national study. Am J Transplant. 2016;16(6):1848– 1857.
Moers C, Smits JM, Maathuis MJ, et al. Machine perfusion or cold storage in deceased- donor
kidney transplantation. N Engl J Med. 2009;360(1):7– 19.
National Institute for Health and Care Excellence. Chronic kidney disease in adults: assess-
ment and management. NICE guideline [NG203]. National Institute for Health and Care
Excellence. 2021. https:// www.nice.org.uk/ guidance/ ng203
NHS Blood and Transplant. Kidney transplantation: deceased donor organ allocation. Policy
POL1 86/ 9. NHS Blood and Transplant. 2019. https:// nhsbtdbe.blob.core.windows.net/
umbraco- assets- corp/ 16915/ kidney- allocation- policy- pol186.pdf
NHS Blood and Transplant. Organ specific report: kidney transplantation annual report. NHS
Blood and Transplant. 2019. https:// nhsbtdbe.blob.core.windows.net/ umbraco- assets- corp/
17289/ kidney- annual- report- 2018- 19- november19.pdf
O’Callaghan J, Knight SR, Morgan RD, Morris PJ. Preservation solutions for static cold storage of
kidney allografts: a systematic review and meta- analysis. Am J Transplant. 2012;12(4):896– 906.
Ponticelli CE. The impact of cold ischemia time on renal transplant outcome. Kidney Int.
2015;87(2):272– 275.
Shi X, Lv J, Han W, et al. What is the impact of human leukocyte antigen mismatching on graft
survival and mortality in renal transplantation? A meta- analysis of 23 cohort studies involving 486,608 recipients. BMC Nephrol. 2018;19(1):116.
Sugi MD, Joshi G, Maddu KK, Dahiya N, Menias CO. Imaging of renal transplant complications
throughout the life of the allograft: comprehensive multimodality review. Radiographics.
2019;39(5):1327– 1355.
Summers DM, Johnson RJ, Allen J, et al. Analysis of factors that affect outcome after trans-
plantation of kidneys donated after cardiac death in the UK: a cohort study. Lancet.
2010;376(9749):1303– 1311.
416 Challenging Concepts in Urological Surgery
https://t.me/med1917
Visser IJ, van der Staaij JPT, Muthusamy A, Willicombe M, Lafranca JA, Dor FJMF. Timing of
ureteric stent removal and occurrence of urological complications after kidney transplantation: a systematic review and meta- analysis. J Clin Med. 2019;8(5):689.
UK Renal Association. Peritoneal dialysis in adults and children. Clinical Practice Guideline. UK
Renal Association. 2017. https:// ukkidney.org/ sites/ renal.org/ files/ final- peritoneal- dialysisguideline667ba231181561659443ff000014d4d8.pdf
UK Renal Association. Post- operative care of the renal transplant recipient. Clinical Practice
Guideline. UK Renal Association. 2017. https:// ukkidney.org/ sites/ renal.org/ files/
FINAL- Post- Operative- Care- Guideline- 1.pdf
UK Renal Association. Living donor kidney transplantation. Clinical Practice Guideline. UK Renal
Association. 2018. https:// ukkidney.org/ sites/ renal.org/ files/ Living- Donor.pdf
UK Renal Association. Vascular access for haemodialysis. Clinical Practice Guideline. UK Renal
Association. 2020. https:// ukkidney.org/ sites/ renal.org/ files/ vascular- access.pdf
Wilson C, Sanni A, Rix DA, Soomro NA. Laparoscopic versus open nephrectomy for live kidney
donors. Cochrane Database Syst Rev. 2011;11:CD006124.
https://t.me/med1917
SECTION 14
Paediatric surgery
Case 43 Recurrent urinary tract infections and non- neurogenic
neurogenic bladder in children
Case 44 Undescended testis
Case 45 Neurogenic bladder in children
Case 46 Haemorrhagic eschar of the glans: a case study in the
myriad manifestations of urethral pathology
Case 47 Vesicoureteral reflux in children
https://t.me/med1917
CASE
https://t.me/med1917
Recurrent urinary tract
infections and non- neurogenic
neurogenic bladder in children
Martin Skott
Expert commentary Imran Mushtaq
Case history
A 5- year- old girl with recurrent urinary tract infections (UTIs) was referred to our
clinic. No problems were detected on antenatal scans, and she was potty trained at
the age of 3– 5 years. She had slight constipation, which was managed with laxatives.
Recently, she had been suffering from frequent daytime incontinence and occasionally night- time incontinence. Her mother described a classic history of withholding
urination and urgency, although she had good sensation of bladder fullness. Mainly,
she had been asymptomatic with no temperatures or dysuria. She reported a good fluid
intake of 1.5 L per day. There was no relevant past medical history or family history of
any significance. Pending further investigations, she was commenced on trimethoprim
prophylaxis.
Expert comment UTI in children
UTI represents the most common bacterial infection in children.1 In infants and children, the
symptoms differ from those in neonates (Table 43.1). The incidence of UTIs varies depending on
age and sex. In the first year of life, UTIs are more common in boys (3.7%), especially if they are
uncircumcised, than in girls (2%). Later, the incidence changes, and about 3% of all prepubertal girls
and 1% of prepubertal boys suffer from UTIs.
Table 43.1 Presenting symptoms of UTIs at different ages
Symptoms Neonates Infants Children
Icterus +
Sepsis +
Failure to thrive + +
Vomiting + + +
Fever + + +
Diarrhoea +
Flank pain + +
Incontinence + +
Smelly urine + +
Lower urinary tract symptoms
(i.e. frequency, dysuria, urgency)
2
+
420
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Challenging Concepts in Urological Surgery
It is essential to differentiate between lower UTIs (cystitis) and pyelonephritis (infections of the
kidney parenchyma, with fever) because one- third of all pyelonephritis episodes will result in a
parenchymal scar.
In community acquired UTIs, Escherichia coli is found in approximately 75% of the urine cultures.
In contrast, in nosocomial UTIs, the most common organisms seen are Klebsiella pneumoniae,
Pseudomonas spp., Enterobacter spp., Enterococcus spp., and Candida spp.
3,4
Cardiovascular, respiratory, and abdominal examinations were normal with no evidence of faecal loading. The spine, lower extremities, and gait were normal and examination of external genitalia revealed normal anatomy.
Bladder function assessment showed a uroflow profile suggestive of abdominal
straining with post- void residual urine of 30 mL and a reasonable capacity with a
volume of 200 mL (estimated to be 188 mL). She voided eight to nine times per day,
Clinical tip Bladder capacity
Several studies have shown that
functional bladder capacity at
different ages can be accurately
estimated as a function of age with
no differences in sex. For young
infants, it can be expressed as
Bladder capacity (mL) = 38 +
(2.5 × age (months))
For older children:
Bladder capacity (mL) = 30 +
(age (years) × 30)
5,6
Learning point Residual
urine
Residual urine is assessed by
ultrasonography after a uroflow
measurement. It is well known that
healthy infants and toddlers do not
fully empty the bladder every time
they void, but should do so at least
once during a 4- hour observation
period.7 Older children, however,
are expected to empty their
bladder to completion.
with episodes of dampness and urgency.
An ultrasound scan of the urinary tract showed both kidneys to be of normal size
and echotexture, but with mild pelvicalyceal dilatation bilaterally. The bladder wall
appeared slightly irregular and thickened, and a residual volume of urine was present
post- void (Figure 43.1a). Diuretic renal scintigraphy using technetium- 99m (
mercaptoacetyltriglycine (MAG3) with indirect cystography was suggestive of func-
:
tional asymmetry (44% right side and 56% on the left side). Both kidneys and ureters
demonstrated some stasis of tracer in the collecting system and ureters. There was no
evidence of vesicoureteral reflux (VUR), though incomplete bladder emptying, on the
indirect cystography (Figure 43.1b).
Expert comment Diagnostic workup
There is controversy about whether imaging studies should be performed after the first or
after recurring episodes of UTI. In general, a maximum of two UTI episodes in girls and
one episode in boys should trigger imaging studies. In terms of febrile UTI in infants, renal
ultrasonography is strongly recommended as the first- line investigation.
Renal ultrasonography
Urinary tract imaging comprises of some form of renal and upper collecting system evaluation, usually
renal ultrasonography and, selectively, voiding cystourethrogram (VCUG) and functional studies.
As renal ultrasonography is not dependent upon renal function, it will detect both gross and subtle
99m
Tc)
Figure 43.1 (a) Irregular and thickened bladder wall pre micturition. (b) Renogram which shows a
functionally slight larger left kidney. No convincing evidence of renal scarring was noticed.
421Case 43 Recurrent urinary tract infections in children
https://t.me/med1917
abnormalities of the urinary tract, including those that involve poorly functioning or non- functioning
renal units. On the other hand, it is highly operator dependent and is not reliable to detect VUR.
VCUG
8
A VCUG is still the gold standard to investigate VUR. The VCUG may be performed either with
fluoroscopy and iodinated contrast medium or with nuclear imaging, but these studies give
different information. A fluoroscopic VCUG can show urethral and bladder abnormalities and VUR.
A radionuclide VCUG (usually
99m
Tc- MAG3) offers poor spatial resolution so anatomical details of
the urinary tract and the degree of reflux may not be so easy to assess. The radionuclide VCUG can
be performed using similar techniques as the traditional fluoroscopic VCUG with retrograde filling of
the bladder with the radionuclide or indirect in which the radionuclide is injected intravenously and
cleared from the kidneys into the bladder. VUR detection by either fluoroscopic or radionuclide VCUG
is dependent upon the child voiding and being compliant.
Nuclear renography (static)
Radionuclide scanning with
99m
TC dimercaptosuccinic acid (DMSA) can detect an area of acute renal
9,10
inflammation and chronic scarring. It is the gold standard in the detection of renal scarring, and
studies have shown a specificity and sensitivity for renal scarring up to 100% and 80%, respectively.11
When combining DMSA with high- resolution computed tomography (single- photon emission
computed tomography), a much better resolution, scar detection, and level of renal anatomic detail
is possible.12 On the other hand, if an assessment of renal parenchymal flow, function, and drainage is
acquired,
99m
TC- MAG3 is superior to DMSA.
The patient’s symptoms and findings on the ultrasound scan were suggestive of an
overactive bladder (OAB), and therefore lifestyle modifications such as an adequate
fluid intake of around 1.5 L a day without any bladder irritants (squash juices) were
suggested. In addition, she was commenced on anticholinergic medication in the form
of slow- release oxybutynin.
Expert comment OAB
OAB is the most common voiding dysfunction in children, occurring with a peak incidence between
the ages of 5 and 7 years. OAB is thought to be caused by a delay in the maturation of inhibitors of
non- voluntary detrusor contractions.13 During bladder filling, detrusor contractions not centrally
inhibited are recognized by the child as a sense of urgency, thereby prompting voluntary striated
sphincter and pelvic floor contractions, and various holding manoeuvres such as leg crossing and
attempts at external compression of the urethra.14 Despite the holding manoeuvres, the child still
may have leakage, mostly when tired, or at play when the child is distracted. Recurrent isometric
contraction of the detrusor against a closed tightened sphincter causes progressive detrusor muscle
hypertrophy, which will lead to decreased functional capacity and increased instability, perpetuating
the vicious circle of OAB. It has been shown that anticholinergic treatment of OAB in association with
a timed voiding regimen and adequate bowel management, significantly decreases the incidence of
recurrent UTIs.
15
After an interval of 6 months, the patient was reviewed in the clinic. A repeat
bladder function assessment revealed that her post- void residuals had increased significantly. In addition, she had suffered two lower UTIs with mixed growth cultures,
despite prophylactic antibiotics. The repeat ultrasound scan showed a significant increase in the bilateral hydronephrosis, the bladder was still thick- walled, but now
with trabeculation and diverticula. She still had some ongoing problems with chronic
constipation and day- and night- time accidents in between voids, despite regular
voiding and practising a double voiding. The oxybutynin was stopped and, based on
422
(a) (b)
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Challenging Concepts in Urological Surgery
Volume infused (mls)
(cmH2O)
P
ves
(cmH2O)
P
abd
(cmH2O)
P
det
Flow (ml/sec)
Volume voided (mls) (cmH
Figure 43.2 (a) Grossly trabeculated bladder. (b) Filling cystometry which shows some detrusor activity
towards end fill associated with leakage (blue arrow). The voiding phase was characterized by maximum
detrusor pressure (P
) of 43 cmH2O with associated abdominal straining.
det
O)
2
the deterioration of the upper urinary tract, the possibility of a neuropathic element
was considered.
A magnetic resonance imaging scan of her spine revealed no intraspinal abnormality. We then proceeded to cystoscopy, which confirmed an irregular, elongated,
and grossly trabeculated bladder (‘fir tree’) (Figure 43.2a). A video urodynamic study
showed reduced functional capacity bladder (180 mL) with some impaired compliance (a rise of 22 cmH2O for 180 mL infused) (Figure 43.2b). Voiding dynamics revealed a dyscoordinated pattern and incomplete bladder emptying (residual of 20 mL).
Fluoroscopy did not reveal any vesicourethral reflux, either during filling or voiding.
Learning point Invasive urodynamic investigations
If a suprapubic tube is inserted, a minimal delay of half a day is needed between tube placement and
urodynamic testing. If a transurethral catheter is used, it must be as small as possible, since a large
catheter can cause outflow obstruction.
The filling rate should be as physiological as possible, and the following can be used to calculate the
filling rate: body weight (kg) divided by 4 and expressed in millilitres per minute16 or as described by
Hjälmås, as 5% of expected bladder capacity (mL) expressed in millilitres per minute.
Bladder sensation can be challenging to assess in children. When filling exceeds expected bladder
capacity, and no sensation is reported, it can indicate reduced bladder sensation.
In infants and children, any involuntary detrusor contractions observed before voiding can be considered
pathological and are defined by an increase in detrusor pressure >15 cmH2O above baseline.
Bladder compliance is the relationship between change in bladder volume and change in detrusor pressure:
ΔDetrusor pressure (cmH2O)
Understanding bladder compliance is complicated in paediatric practice, as it tends to increase by
age and the detrusor pressure can be affected by the rate of bladder filling. Furthermore, there are,
at the moment, no reliable reference ranges available for bladder compliance in children. For this
reason, a rule of thumb is that a detrusor pressure of ≤10 cmH2O above baseline at expected bladder
capacity for age is acceptable.17 The clinical relevance of the pressure– flow relationship during voiding
is unclear, as high pressures and interrupted flow are observed during voiding in children with normal
lower urinary tracts.
disorders, characterized by a detrusor contraction concurrent with an involuntary contraction of the
urethra and/ or periurethral striated muscle leading to urinary flow interrupted during voiding.
Compliance (mL/cmH2O) =
18,19
However, detrusor sphincter dyssynergia is seen in neurogenic bladder
ΔBladder volume (mL)
6
Expert comment Non- neurogenic neurogenic bladder
https://t.me/med1917
The term non- neurogenic neurogenic bladder (NNNB) or subclinical neurogenic bladder and later
Hinman syndrome, is presumably an acquired form of bladder sphincter dysfunction in children
occurring after the age of toilet training.
with day- and- night wetting and incomplete bladder emptying; (2) trabeculated bladder; (3) recurrent
UTIs; (4) deterioration of the urinary tract with hydroureteronephrosis; (5) constipation and faecal
soiling; (6) significant behavioural issues with frequent anxiety, depression, and familial integration
disturbances; and (7) normal neurological physical examination and investigations.
The condition has all the clinical and urodynamic features typical of neuropathic bladder dysfunction,
but no neurological pathology can be demonstrated on imaging, and it may be conceivable that
the underlying neurological cause remains to be identified. In its severe form, the bladder sphincter
dysfunction can cause full- blown bladder decompensation with day/ night- time wetting, large
postmicturition residual urine volumes, recurrent UTIs, and significant damage to the upper urinary tracts.
NNNB is believed to be an acquired pathology, but evidence of prenatal presentations has also been
22,23
reported.
presenting early in childhood to those presenting at adolescence, and from children responding to
limited detrusor sphincter physiotherapy and bowel management to severe NNNB which requires
bladder augmentation and kidney transplant.
It is therefore likely that NNNB covers a wide range of disease, ranging from patients
20,21
The typical form includes (1) dyscoordinated voiding
24
Clean intermittent catheterization was attempted on several occasions, but the patient was very resistant and fearful. Therefore, a suprapubic tube (10- French Cystofix®)
was placed temporarily, with clamp and release every 3 hours during the daytime
and overnight free drainage. Following placement of the suprapubic tube, complete
resolution of upper urinary tract dilatation and episodes of UTIs was observed.
Subsequently, the suprapubic tube was replaced under general anaesthesia with a 10French Foley catheter, which is changed every 10– 12 weeks.
An up- to- date DMSA scan showed a functionally slight smaller right kidney (47%),
but no definite focal defects were identified.
423Case 43 Recurrent urinary tract infections in children
A final word from the expert
UTIs and incontinence are common problems referred to a paediatric urologist. In the majority
of cases, the problem can be remedied with simple dietary modifications and/ or anticholinergic
medication. This case illustrates, however, that some children are at risk of progressing to more
serious and irreversible upper and lower urinary tract pathology. This patient demonstrated
concerning features at presentation of mild hydronephrosis and bladder wall thickening, which
rapidly deteriorated over a short interval of 6 months to a classical Hinman syndrome. There is
probably very little which could have been done to prevent this deterioration, and it is likely that
on the basis of the current findings that the patient in the long- term, will need an augmentation
cystoplasty with or without a continent cutaneous catheterizable channel.
References
1. Stull TL, LiPuma JJ. Epidemiology and natural history of urinary tract infections in chil-
dren. Med Clin North Am. 1991;75(2):287– 297.
2. Winberg J, Andersen HJ, Bergström T, Jacobsson B, Larson H, Lincoln K. Epidemiology
of symptomatic urinary tract infection in childhood. Acta Paediatr Scand Suppl.
1974;252:1– 20.
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