Paediatric Urology is a surgical speciality dedicated to care for children with problems in the urinary tract and genitalia. Unlike adults, the urological problems in children are predominantly birth related and treatment options are diverse. Options need to be carefully chosen in discussion with the parents as the impact of the problem as well as the treatment can have long term consequences on the health of the child.

The common problems treated by paediatric urologists include:

These conditions require a thorough evaluation. Investigations that commonly include X ray studies to delineate the urinary tract, function of the kidneys and to evaluate for any blockage. Final treatment will depend on these findings.

Reconstructive urology restores both structure and function to the genitourinary tract. We are a high volume center for reconstructive urology and are proud of our excellent outcomes and long term follow up.

Our reconstructive expertise emphasises both open and minimally invasive approaches, including laparoscopic surgery, complex ureteral and urethral reconstruction. We remain particularly concerned with the quality-of-life of the patient.

We specialize both the minimally invasive surgery and the open approches to correct PUJ obstruction. Two common procedures performed obstruction include open and laparoscopic dismembered pyeloplasty. 

Fistulas may involve multiple parts of the genitourinary system, but most commonly are associated with the ureter, bladder, vagina, prostate or urethra. Occasionally, organs outside of the genitourinary system may be involved in a fistula e.g. small intestine, colon, rectum. Repair of a fistula tract involving the genitourinary system is a complex surgery. We have a history of excellence in the surgery for complex urinary fistulas and are proud of our success rate on long term follow up.

Female stress incontinence in women is commonly the result of pelvic floor laxity secondary to childbirth. Male stress incontinence is usually the result of previous surgery (e.g. transurethral resection of the prostate) or radiation. Occasionally there may be stress incontinence in neurovesical dysfunction.

There are multiple therapies that are tailored to treat different types of incontinence. While urge incontinence is generally medically managed, stress incontinence usually requires a surgical procedure (ie. placement of a sling or artificial urethral sphincter) for treatment.

Artificial urethral sphincter insertion – This procedure involves the placement of an “inflatable cuff” around the urethra that is connected both to a pump and a fluid reservoir. The cuff passively inflates and provides continuous occlusion of the urethra until a patient feels the need to void, at which time they squeeze the pump (generally placed in the scrotum in males or labia majora in females) and fluid is pumped from the “cuff” to the reservoir (generally placed in the abdominal cavity beside the bladder). This process removes pressure from the urethra and the patient is able to void normally. The balloon passively re-inflates after several minutes, and re-occludes the urethra, thus preventing leakage.

Ureteric strictures may be the result of recurrent stone disease, tuberculosis or may be present from birth. These may be initially managed endoscopically but many will recur. Reconstructive surgery on the ureter depends on the site of the stricture and the leng[IJ2]  of the segment affected. The treatment options range from excision of the strictured segment with reattachement of the ends or the upper end to the bladder to replacement of the entire ureter with small bowel.

Urethral strictures have multiple causes including prior urinary tract infection, catheter placement, injury to the urethra, pelvic radiation, and previous surgery on the urethra surgeries. It is important to have a urethral stricture treated because permanent injury to the bladder and/or kidneys may occur if it is not.

Strictures are managed surgically, either by endoscopic incision or open surgical reconstruction. While short segment, flimsy strictures may be managed well with endoscopic surgery, long segment and dense strictures do poorly with this type of treatment. We have a long tradition of successful urethral surgery for strictures. This may involve either graft (e.g. from the mucosa of the mouth, skin form the penis or thigh) to substitute for the diseased urethra or cutting the strictured segment out and rejoining the cut ends of the urethra. A flap from the penile skin may also be used in certain cases. Strictures are often a complex disease with a strong likelihood of recurrence, so optimal management is generally found at a tertiary care facility like CMC where there are urologists that specialize in these types of surgeries.

In cases of acute urinary retention due to stricture, a suprapubic catheter may be placed as an emergency treatment. This allows the bladder to drain through the abdomen.

Prosthetic devices for erectile dysfunction include semirigid non inflatable devices to malleable, two-piece inflatable and three-piece inflatable devices. These are implanted in men who have failed medical therapies for erectile dysfunction. The appropriate device is tailored toward individual patient desires and clinical condition, but satisfactory results are usually obtained.

Tuberculosis can cause extensive strictures of the ureter, cause fibrosis of the bladder and occasionally affect the prostatic urethra. Apart from ureteric reconstruction, the bladder may need to be enlarged with a segment of intestine. In very bad disease it may be necessary to divert the urine away from the bladder in the form of a non-continent conduit created from bowel. This is however rare.

Female urinary incontinence (UI) affect all age group, some have minimal leak on coughing or straining while some women have continuous incontinence. It can be embarrassing and distressing condition that can affect daily life keeping women away from many activities with family and friends.

Stress incontinence- Involuntary urine leak occurs on straining or cough or lifting weights, etc usually occur due to weak sphincter muscle that are injured after a prolonged child-birth, or post menopause.

Urge incontinence- Involuntary urine leak accompanied by or preceded by urgency.

Mixed urinary incontinence is involuntary urine leak associated with urgency and also with effort, or exertion, or on sneezing or coughing.

Overflow incontinence- Urine leak occurs in a partially obstructed bladder when there is an overly full bladder. The bladder is unable to empty completely and there is a frequent small quantity of urine leak.

Many women incontinence can be treated with lifestyle modification (Pelvic floor muscle exercises, control fluid intake, timed voiding, double voiding, etc) and medications. Few patients need surgical correction especially those with pelvic organ prolapsed.

Fistulas – Vesico-vaginal fistula (VVF) is an abnormal connection between the bladder and the vagina causing involuntary urine leak. It is caused due to complication of prolonged labour, hysterectomy, cervical cancer, radiation therapy, etc. Diagnosis is confirmed by cystoscopy intravenous urogram (IVU) or Computerized tomography (CT) scan.  Treatment of VVF is by Surgical repair which can be done through the vagina or through the abdomen (by open surgery or laparoscopic). 

The  accident and emergency medicine is well equipped to handle multi-organ trauma, road traffic accidents and mass casualty. The urology team is available round the clock when needed.  Urology trauma are difficult to detect at initial evaluation. Urethral trauma and pelvic fractures, renal injuries, scrotal injuries, etc are increasingly common following RTA and blunt trauma.

Urethral injuries are suspected when there is complete blockage of urine, blood in the urine or at the meatal opening, difficult or unsuccessful catheterization. They are usually associated with pelvic bone fracture and they are managed initially by urine bypass (supra pubic catheterization) and urologic reconstruction (urethroplasty) after few months.

Bladder rupture occurs in high velocity injury in patients with full bladder. The bladder can rupture into the peritoneum or extraperitoneal; the latter can be treated with non-operative management.

Renal injuries

The kidneys are paired organ, well protected in the back of the abdomen (retroperitoneum) under the rib cage and the muscles of the back. Kidney injuries occur following blunt or penetrating trauma and associated with other organ injury as well. They present with abdominal flank pain with or without hematuria. Ultrasound and CT scan the imaging of choice for diagnosis and grading of kidney injuries.  There are five grades of renal injuries with grade one being just mild bruising and grade five being shattered or devascularized kidney. Most renal injuries can be managed successfully by non-operative management; however, they need closed monitoring. Delayed bleeding, abscess formation and hypertension are few of the complication of renal injuries. They may be treated through angiogram (for bleeding, hypertension), drainage procedure (for abscess or hematoma).

The kidneys play the most vital role in removal of waste products from the body. Any disease condition affecting them has very detrimental effects on the normal functioning of the body. Although any renal diseases can be treated or controlled with medications and lifestyle modifications, some patients with extensive renal damage need renal replacement therapies. Dialysis and renal transplantation are the two ways of accomplishing this.

Dialysis

Dialysis is a method of removing waste products of metabolism through artificial means. There are two types of dialysis – peritoneal and hemodialysis.

Continuous ambulatory peritoneal dialysis (CAPD)

A plastic tube is inserted surgically into the patient’s abdomen and the body’s peritoneal membrane used as a filter to clear the waste products through fluid exchange. Our department has been performing this procedure since the 1960’s. This is done either laparoscopically or through the open surgical method in complex cases. We also have a team available round the clock to manage the problems and complications in patients who are on CAPD.

In this method of dialysis, the patient’s blood is purified by passing it through a machine. The access for this process can be temporary using plastic canulas or permanent through a surgical connection of an artery and vein (arteriovenous fistula, avf). We have been providing this facility since the 1960’s. Primary fistulas as well complex, particularly those on long term dialysis and access issues are perfomed and maintained by our department. In addition to a twice weekly outpatient services we have a team available 24 hours to provide vascular access support.

The first renal transplant was performed in our department in 1971 and we have come a long way since then. There is a live related renal transplantation program which has been continuously evolving and improving since then.  Healthy individuals between 20 – 60 years of age can donate after an extensive preoperative evaluation to ensure successful outcomes along with donor and recipient safety. The transplant team consists of both urologists and nephrologists. We have an outpatient clinic twice a week and weekly interdepartmental meetings to screen and plan for prospective donors and recipients. In addition to this any urological and surgical concerns of this group of patients are also met by us. We have crossed the blood barrier and performed our first across the blood group transplantation in 2009. There is also a deceased donor retrieval program which has been in effect since 1991.