Children with anorectal malformations frequently have associated urological anomalies (50-85% incidence), requiring comprehensive evaluation including renal ultrasound, cystogram, and scintigraphy within the first 24 hours of life. Key urological complications include vesicoureteral reflux, ureteral obstruction, neurogenic bladder, and renal agenesis. Complex malformations such as cloaca in females or rectovesical fistulas in males carry higher risks of urinary tract infections and renal damage. Proper colostomy placement and distal stoma irrigation are critical to prevent fecal contamination of the urinary tract. Early and aggressive urological evaluation is essential to prevent long-term kidney damage and ensure optimal outcomes.
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Hello, hello, good morning everyone. It's Thursday, May 28th, 10 AM, Mexico time, and we're already broadcasting these classes that we do every Thursday.
Last week we had a new class because we weren't there, but we do this program of classes for attending residents, assistants, and those interested in pediatric colorectal surgery, which is something we love. We are here at the children's colorectal center. We are pediatric surgeons with a high specialty in pediatric colorectal surgery. We specialize in treating children born with certain colorectal problems, whether congenital or acquired, and we have been offering these classes for doctors who come to rotate through our facilities for a long time. Here are our doctors rotating with us, both from Monterrey, and they chose this class which is a class that says, "And why are Colon and Rectal surgeons talking about urology?"
Because it's super important and our children with rectal malformation go hand in hand, as you've seen, they have many urinary problems and it's our duty to be able to evaluate, understand and treat them, even though we work hand in hand with a pediatric urologist. Today, this is the topic we're going to discuss, and some parish announcements before we begin. The first is that we are already broadcasting on Facebook, our Facebook page and our Facebook profile. We are sharing it in our community for doctors who are passionate about pediatric surgery. As you know, we already have a completely free community for doctors on Facebook, where we share not only our classes, but also all the events of interest that take place in pediatric colorectal surgery, and when we have courses, they are the first to have some benefits.
We're also streaming now on Instagram, X, YouTube, and TikTok.
Welcome everyone. Feel free to comment, and please let us know if you can see and hear us well, because we have two microphones, one for each broadcast, and it helps us a lot to know that you can hear us properly. As you know, we have classes on our website www.centrocolorrectal.com/clases, centrocolorrectal.com/clases.
All the classes along with the articles, plus on our YouTube channel where Dr. Alex made a playlist so you can see all the classes by year, which we already have a lot of. Some parish announcements for dads. As you know, every month we hold a Q&A event on the first Friday of the month where we raffle off two video conference consultations. We also hold a theory event, and this month is a very special one that we dedicate to the children operated on by Histun. In other words, they are no longer just Histun children, but we have already operated on them. We believe there are many problems in the diagnosis and treatment of these children, and that is why we are holding an event just for them.
That's completely private, it's not public, it's only for parents. And the link will be shared tomorrow in our community for parents of children with gistro disease. It's completely free and anyone who wants to can join. Very good. Well, they tell us that it looks and sounds good. Tamara says it sounds good. And she says, "After a colostomy closure, is it normal for my daughter to feel itchy anus?" It's not frequent, it's rare and it's green, but the evacuation is already taking shape. Of course, it's completely normal because she's never pooped there before and it's something completely new for her, although it would help us a lot to know if it was due to a rectal malformation or not, or because of Gistron. Okay, let's get started. We already have quite a few people connected here, so let's get down to business, girls.
How are you? What have you read and even seen in this rotation month box specifically talking about neurology in anorectal malformations, okay? Because they are the ones with the most malformations, okay? What have you read about that, girls? Is this common or uncommon?
Uh, good morning. Well, this is very common. Well, the incidence is around 50%, although some literature says it can reach up to 85%.
It's right. It's very common. It's more common than you thought.
Dr. Peña's book says 85%, but as you rightly point out, what does 50% mean?
Every second. And you've already seen it, when the children come to rehabilitation, who come at the end because they get dirty, what do we do to all of them? We all need to check on the urological situation. Some of these children we have found did not receive an adequate approach, or they were given one initially, but then they were not followed up on.
Completely. And sometimes even parents who don't even know how their kidneys are doing. The latest recommendations this year in the American Congress have changed quite a bit. It is already moving towards being more aggressive, more incisive in the diagnosis and treatment of urological problems. Did you want to say something, Anel? Yes, it's interesting that the articles and the book mentioned that very few cases of urological malformations were reported before, and that was because an adequate approach wasn't taken; procedures that we're going to see now, like colonoscopy and cystoscopy, weren't performed. That's why some case series mention, for example, 35% or 20%, but that's not really the case. So, yes, it's very, very common.
Clear. And if you look for them, you'll find even more. But for us it 's not uncommon for a patient to come in with only one kidney and no prior medical history, okay? We'll look into that now. So, let's take it very slowly because there are many things to discuss, okay? They put on a face that says yes, there's a lot to talk about. We are going to talk about the neonatal approach because from here we can identify certain malformations and perform certain studies. Of course, invasive studies are not necessary for all patients, but it is said that within the first 24 hours we should do something for a child born with an anorectal malformation. What is it, Anabelen? Tell me.
It's an ultrasound.
An ultrasound of what?
Uh, renal.
Renal. What else? Specifically and urinary ideas. And what else?
Especially girls.
Very good. Pelvic. Why do you think this is important?
Because there are also some malformations that are associated with urological malformations, such as the absence of a double vagina or the absence of a uterus, or so on.
Sure, but that wouldn't have any impact on the urinary tract. Do you want to comment on anything? And for example, hydrocorposes in girls, especially those that can cause obstructive symptoms.
Tell me about that, about the destructive symptoms. Here we have our hydrocorpus which is ultimately liquid in the vagina. It is not known why this occurs because we do not have an obstruction as such. But what causes this large mass? Like a midline tumor over the urinary tract. What is the impact?
A compression.
Microorphys. Perfect. A compression.
Compression on what area?
Well, one could be compression on the bladder or on... But, on which area of the bladder?
Ah, about the neck.
About the trine. You don't do it over the neck. It would not have any repercussions on the neck like it does.
Regarding the trigon, what does it compress?
Brenda, what's wrong? Well, it would be the ureters. Then there will be hydrophrosis.
Very good. Be careful with that, especially since you're going to the council, okay?
We're talking about bilateral ureterohydronephrosis, okay? Because if it were only bilateral hydronephrosis, it would mean that only the kidneys were dilated and not the ureter. Therefore, this problem would never cause those symptoms. No symptoms, but an ultrasound finding was present.
OK? So if we have a girl with bilateral ureoidronephrosis, we need to consider this. But what else could cause bilateral ureteroidronephrosis in a girl? In a girl we had said hydrops.
What else? It is more frequent than hydrops in patients without anorectal malformation because a girl would have bilateral ureterohydronephrosis.
Sandra, I finally managed to get in. What happened to you? Tell us why you struggled so much. Who else can tell us about this?
Bilateral hydronephrosynephrosynephrosis of the ureter in one.
An obstruction at the V-junction.
Yes, that could be it. It is very rare, but it would be an obstruction at the bilateral ureterovesical junction, but even more frequent. What would we see? It is most common in a girl without anorectal malformation who has bilateral ureteroidonephrosis.
Who can tell me about this? We're going to participate. The most common is vesicoureteral reflux.
That's the most common thing. OK?
Whenever we talk about the urinary tract or the digestive tract, we always have compressive causes or causes that can be extrinsic or intrinsic, and the others are functional. Do you see that in Gispr?
You can have an anatomical obstruction or a functional obstruction, and the anatomical obstruction can be a tress, it can be intrinsic, but also something that compresses it. A flange would be an anatomical obstruction.
OK? And we also have the functional part which is the same here, it would be an intrinsic compression, the V stenosis, which is very rare to be bilateral, but we have seen it. An extrinsic compression.
Bilateral ureteroidronephrosis would be caused by hydrops or reflux that is functional. If it were in children, causes of bilateral ureteroidronephrosis in children. Posterior urethral valves.
Posterior urethral valves are the most common. And a child with bilateral urethrohypopnea has that.
Sandra says, "I have two accounts, the official one from the office and this one doesn't praise the league." Okay, perfect, you're here now, which is the important thing. Very good. So, indeed, bilateral ureterohydronephrosis in a child, valves until proven otherwise. What else?
Well, they would be the same, also functional and the down would have flown out and it would also be a V obstruction, but also very rare.
OK? So that's bilateral ureteroidonephrosis in a girl, what would cause unilateral ureteroidonephrosis in the pelvis? What do you think?
Who else around here can tell us? Brenda Carmen says, "Spina bifida, urinary incontinence." We're going to talk about that now because yes, children with spina bifida can have urinary incontinence, and for different reasons. What's going on, girls? Why aren't we talking about that? Unilateral ureterophrosis, it 's always the same.
Extrinsic compression, extrinsic or functional compression. Which is it?
unilateral reflux in a girl or ureterovesical stenosis or if a hydrocorpus is a midline mass that compresses the trigone and produces bilateral ureteroidenphrosis that can in the pelvis of a girl unilaterally cause ureteroidenphrosis on one side, an ovarian tumor.
OK? Central mass in a girl is hydrops. Lateral mass in a girl is an ovarian tumor. Until proven otherwise. OK? We're ok. They tell us, "My child suffers from [something] in some [girls], it's just that the chat is moving very fast today. It says, 'In some girls, a swelling in the vagina, absence of it?' Yes, of course. But in the end, it can be hydrops fetalis when it's an accumulation in the vagina. And Dr. Sandra explains it very well, when we have an absence of the vagina and blood accumulates, that would be an accumulation of blood in the uterus and it can cause the same symptoms, but of course, we're talking about the neonatal period, right? Very well.
So, we already do an ultrasound on our baby and we see that there's only one kidney. Do we do anything else or not? Well, we also have to verify that this kidney does n't have polycystic kidney disease, that it's structurally sound, and also see, because sometimes a kidney can not be functioning properly.
So that's why they make the false diagnosis that there's only one kidney, right?
Of course, but you have to focus on the questions because now we're going to talk about all of that. I'm saying that we do an ultrasound and that the patient He only has one kidney. Yes, he does, I do n't know anything else. What do we do now? If we leave it at that, further investigation isn't necessary.
A cystogram or a renal scan can be done to see how that kidney is doing, because if he already has reflux, then he may already have renal scarring.
Of course, but let's take it one step at a time. I've told you it's a kidney that looks normal. Do we do anything else for this child, or nothing at all?
Why or why not?
Yes, we have to do, as my colleague Belén said, we have to do the cystogram to verify that he doesn't have reflux, and because they might argue that in a single kidney, in the neonatal period, a cystogram should be done on a single kidney that looks healthy, because if he has reflux, for example, you would see it dilated or you would see ureteral dilation. I'm not saying it shouldn't be done, but perhaps not in the neonatal period, okay? But more studies do need to be done. I think A patient with a single kidney does need a cystogram to make sure everything is okay, right?
But maybe not right away, okay? We can discuss it, but more tests are needed. These are the most important ones. We see many children with a single kidney who haven't had any further tests. Okay? If I have a patient with hydronephrosis in one or both kidneys, would we do more tests on that patient? Of course, more tests are needed because they could have many things. What would be the next test to do on a patient with hydronephrosis or ureeroidronephrosis?
Not at that time, right then. Yes, of course.
If you find something abnormal on the ultrasound, then you do need to do something else. I was talking about a patient who looks completely normal, even with one or two kidneys, okay? You have to do a follow-up then.
Well, yes, the next one would be a cystogram. Mm. Absolutely a cystogram here, okay?
Let's put it on so it's clear Let me understand better. Let's talk about a patient whose two kidneys appear completely normal. Let's discuss this. It's very interesting. Two completely normal kidneys. Everything looks normal.
If I had that patient, maybe in 3 or 6 months, I'd do another ultrasound. Of course, because it's not uncommon for them to have, as Brenda mentioned, some problem that affects the kidney, okay? And if we had one kidney, we could decide whether to do a cystogram. I think the patient does need it, but doing a scintigraphy scan would be super important, okay? It could be that the other kidney is there but out of its usual place.
Of course, it could be that they have renal actopia and we didn't see it because the ultrasound looks for the usual areas.
We're going to talk about scintigraphy scans now, okay? And especially if there's ureterohydronephrosis, well, that's still important, okay? So, even in the prenatal period, if we find something, we have to do more studies, or even without finding anything, we have to monitor the patient. Okay? So far, so good.
Very good. Which patients require extra care, even those with other malformations?
Like, for example, sacral malformation or tethered spinal cord. Absolutely.
Sacral malformation, spinal cord malformation, single kidney. And what type of anorectal malformation do you think is the most complex and associated with the most urinary problems in both boys and girls?
Well, for example, in girls it would be a cloaca, and in boys it would be those with a fistula to the bladder neck, or a prostatic fistula. Absolutely. These are the latest indications that warrant a more aggressive approach to urinary evaluation in these patients.
Okay? They order a renal scan; the most common finding is ovarian tumors.
Absolutely. Absence of a vagina as well.
The thing is, in girls with an absence of a vagina, we generally don't see fluid accumulation, okay? We see it when they're older, right? In cases of vaginal absence. What we see, above all, is fluid accumulation. In the neonatal period, esophageal nephrosis.
Um, renal scintigraphy. Yes, we're going to talk about scintigraphy scans in a moment. And can PET scans be done on newborns? I don't know, we've never done them. The truth is, we rely on these types of studies. I don't know if PET radiotracers can be used on newborns. We don't use them.
Generally, PET scans are done on patients with tumor involvement to see the increase in metabolism according to the type of tumor.
Any opinions on horseshoe cases?
Oh, very many. We'll talk about that now.
Okay? Very good. We have a newborn patient without a fistula, with a fistula, but we've already done their renal evaluation, okay? Along with others. And if the patient doesn't have a fistula, what will they need as a first surgical step? We need to define, uh, if the fistula really exists or not, doing... Of course, it doesn't exist, it's not clinically evident. Be careful with that.
You can have a patient who has an absence A clinically evident fistula means that their buttocks are closed. It doesn't mean they don't have a fistula to the urinary tract. What it means is that they have nowhere else to go and need, what?
A cystoscopy. Oh, well, a urinary tract diversion.
Why urinary tract?
Because, well, a diversion from a colostomy. They're diversions.
Very good. We have a patient who, for whatever reason, whether it's because they have a rectal malformation with a fistula, and you decide to perform a colostomy, it wouldn't be an emergency, but above all, an emergency is a rectal malformation without a clinically evident fistula.
Okay?
That patient needs a colostomy.
Since we're in a urinary tract class, do you think there's anything we as surgeons can do from that point on to help reduce urinary tract infections, or is it something we have no control over? What do you think?
Uh, yes, definitely the location of where Let's do our colostomy. The location. Tell me about that.
Um, yes, well, normally we would do it in the descending colon, along the distal part of the descending colon with the sigmoid colon.
Um, it's also important how we position our openings, because if we put them close together, we can encourage fecal matter to pass from the proximal to the distal opening, and that will cause problems later, especially when they are very close. The parents have to put the bag on, and there's invariably some passage from the functioning stoma to the non- functioning one. And thinking about the fact that there's a fistula or a connection, where is that mucus, that poop, going to go?
Well, it's going to go to the colon.
Right. You saw yesterday the hologram we did of the girl with the cloaca. You saw what was inside the colon. Did you notice? It was like the colon.
What do you think is inside the colon?
I think it was very little.
When Alejandro did the first x-ray, he said, "The girl has what he mentioned first." He said, it seems he has a malformation of the sacrum, but oh but there is a lot of fecal matter.
Of course, why does it have fecal matter? A patient who is referred has a distal mucous fistula; the stomas are separated, and the mother puts a bag on the proximal one but not the distal one. Why would this happen?
The book also recommends that when a colostomy is performed, the colon should be washed or cleaned thoroughly.
And who performs distal stoma irrigation at your hospital?
In all honesty, that's not always the case.
The truth is that I've only ever had one surgeon who performed a colostomy himself, and obviously patients with these problems, right? 61 irrigation.
Absolutely, and it's something not everyone does, but it really helps parents: extracting the poop and then irrigating, and it can take quite a while. Dr. Peña and Dr. Andrea Bishop have described it in their book by making a purse-string suture, inserting a probe, inflating the balloon, and performing irrigation. What we do is a section of the stomata and at the distal end we extract the feces. Of course, we do many things, as you saw yesterday and the day before yesterday, that when we make a stoma we protect the skin, the cavity, a lot, so that no feces fall in, we do it in a certain way, but it is very important to irrigate the distal stoma looking for one where there is no feces to prevent feces from passing into the urinary tract and thus reduce urinary tract infections. Two, even a ball of poop can cause the colon to dilate, and three, it can even block the fistula and prevent you from seeing it in a study.
Alex, would you like to comment on irrigation in a patient when we are performing a colostomy? Of course, cleaning the distal end in children born with an anorectal malformation who need a shunt is a very important step in the patient's well-being.
One of the most frequent problems is that these children have recurrent urinary tract infections, especially if you clean the area, but if you don't clean it they have a greater chance of having a recurrent urinary tract infection at the level of the fistula they have with the urinary biopsy.
The next thing is that it prevents the distal end from dilating. Sometimes having content allows the distal end to dilate tremendously. And that can cause problems for reconstruction at an older age. And in other patients, having fecal matter that becomes solid afterwards can block the fistula and then in the contrast studies give you the false information that it may be a patient without a fistula.
When it's a patient who does have a fistula, but the amount of fecal matter that has accumulated in that area, uh, the mucus plus what was left after the surgery can cause problems.
So, it's an important and valuable step that adds about 30 minutes to the surgery, but it has a great benefit for the children who have an intestinal bypass.
And I marked the location here for several reasons. First, they said that a colostomy is done in the descending colon, which is correct, but there would be some detail that would require you to have a more proximal colostomy, higher than usual. Did you realize what we were talking about yesterday regarding the segment of the rectum he has?
What were we talking about yesterday in Colorado? that it was very, that it was very short, that it was very short and that it was very short and it is a cloaca that seemed the exploration uh less uh complex and it seems that it has a long common channel, vaginas of a small size and so there are some patients in whom it is worth doing a colostomy a little more proximal. And how is that done? Does anyone know?
Okay, which patients would it be easiest to start with first?
Well, in those patients where you see that they have a very complex malformation.
But how do you know?
How do you know?
You have to make a hologram.
Sure, but when you have the hologram, you already have the colostomy done. The damage is done. We're talking about what details you can see in a patient with an anorectal malformation that make you say, "I'm going to perform a more proximal colostomy than usual."
Hm. that it has some other type of malformations such as sacral malformations or that the physical examination visibly shows, well, for example, that it is a cloaca or that it has, well, I don't know what.
Okay, I'll accept the one about the sewer, but not the other one. OK?
When you examine a patient and they have a perineum that suggests a poor prognosis, such as flat buttocks, a sphincter close to the scrotum, or a small pit, that tells you it may be a more complex malformation. In almost all male patients, we perform a slightly more proximal colostromation with that scenario in mind, okay?
What is done is that with an angle you lift the colic parietoc. We did it yesterday to separate the colon and try to raise it in the girl for whom we performed the colostomy closure. With an angle, that fixation is cut and you can make it more proximal because remember that the left colon is fixed by the left paracolic gutter, okay?
So, in a sewer, in a patient who has a bad-looking perineum, okay? In those cases we would perform a more proximal colostomy, but there is another location for colostomies that is not recommended. Which is it? It is the transverse.
It's right. So, what problems do transverse colostomies cause?
It's because in the distal part, mucus will be generated all over. So, as Dr. Alex just mentioned, the distal end can continue to dilate.
Correct. What else? When we make a hologram, a certain amount of pressure is needed. What do you think happens when there is a very long distal end?
More contrast medium will be required to better visualize the pistula because, more than being more difficult, they are the ones that cause the most problems. The color can break. OK? So there's a problem with creating the hologram. And then the last one is, if there is a fistula between the urinary tract and the fecal tract, what will happen to the urinary tract? Oh, well, I also mentioned that there could be a disorder like hyperchloremic metabolic isosis.
Completely. What happens is that urine passes into the colon, and since it is a very long segment, it is absorbed, and that causes problems. So, we can also help this patient even from the colostomy stage. We cannot change its anatomy, but we can help reduce urinary tract infections.
We're going to look at anatomical problems of urology, urological alterations, okay? That's how it is in Dr. Peña's book, and there are many things to discuss and some details.
Which one do you want us to watch? We'll do it however you want.
Well, the most frequent one we saw is renal genesis, single kidney. Let's leave it at single kidney because the genetics is that it didn't form and it's super sad, but we do see patients who were born with two kidneys, and you explained it very well, they have some kind of problem with multicystic kidney, polycystic kidney, some kind of obstruction and that kidney disappears and it's not uncommon at all. The patient we operated on during the cystoscopy, who was a girl with a cloaca for exploration, that girl was born and told that she had two kidneys and at three months there was only one. It is superficial.
OK? But speaking of a single kidney, okay?
Tell me what we're going to do about these study patients. When you have a baby, they tell you it only has one kidney, but it's different if they tell you that the kidney seems healthy or if they tell you that it already has hydronephrosis or ureterohydronephrosis.
Okay, but let's look at a patient with a single kidney, what type of patient most frequently experiences this?
When they have complex anaractal malformations that are, for example, very frequent, especially bladder neck, okay? But we only have one kidney. What studies would you ask him to do?
Initially, ultrasound, of course. What else?
Uh, then we would do a cystogram.
Yes, I would also order a cystogram because ultimately what we want to know is that the single kidney is healthy, even if they tell us that it has normal parenchyma, a normal renal pelvis, and no ureteral dilation. What would a cystogram allow us to see?
If reflux is present.
Completely. If there is functional reflux, it is something functional. Very good. And a functional problem would also be a bladder problem, which we'll talk about now. They've already told us that our patient doesn't have reflux. Is there anything else we can do for you?
Yes, the gamma scan.
A gammagram. Tell me about the types of gamma rays.
Uh, it could be with DMCA, uh, with MAC 3.
Well, those two because there's another one, but let's talk about these two. Which one would you do for which patient?
What are you looking for with the gamma scan? What are you looking for? Several things.
Function. If we only have one kidney, it should be 100% functional, right? But what else?
Location. Perfect. Ana Belén, you may have a kidney that wasn't visible on an ultrasound, but that could be located elsewhere. We 've seen patients like that before, right? But what else?
that if they had recurrent eye infections or that the mother didn't notice, it could cause scarring.
Completely. And the scars would affect our function. OK?
But what else do we see in a specific type of gamma scan? Is there any obstruction?
Rather than showing an obstruction, it allows you to see the function in the draining process.
OK? That would give you a flattened curve. So what would we do for a patient with a single kidney?
especially because they have different costs and you know we take great care with that.
DMCA because we want to evaluate adequate function, but be careful, DMSA will give you parenchyma function, but it won't give you a function, okay?
The DMA will allow you location and function, but the MAC 3, which is no longer there, is the whole function, that is, the capture and also the emptying on top and also the emptying.
So, if we had a patient who, in terms of costs, has a single normal kidney, no reflux, no dilation, we could only order a DMSA scan because we only want to know how that kidney is doing. The thing is, this study is more comprehensive. So when we have a problem with emptying or expansion, we want to know what its curve is like. OK? They ask a lot about gamma scans in exams, okay? So, let's talk here for a moment about Ectopia, shall we?
You were saying, uh, that we could have a patient who has a kidney that looks unique on an ultrasound and suddenly we find that it is there, but it is in another place. What types of estopia are there?
Tell me.
Four of them depend on the location, I don't know.
It depends on the location; it's perfect, but you can have a single kidney that is atopic, or you can have one kidney that is in its place and the other is atopic. So, it can be simple, okay? The kidney is simply in a different location, okay?
It can be crossed, you can have them on the same side.
It's right. You can have one kidney on one side and the other underneath, okay? make a cross-copy of one side. H, okay? What does that mean? You have both kidneys in the same place, but it could also be a crossed exctopia of the two, okay? It can be bilateral, okay? And then there was someone here asking about the horseshoe kidney, okay? What is a merger, okay? Because there's also a crusade with a merger, okay?
So, the horseshoe kidney, okay?
Let's put it here.
Horseshoe kidney is a headache, especially when a vaginal replacement has to be done in girls because it is in the pelvis. But in all these cases, what is the main problem with these kidneys? Sandra was asking.
What is the main problem? The problem is that the kidney is in a different place, is n't it? They are often not functional, or they also have reflux or something else.
But why do they have reflux? Why do these kidneys have a higher reflux rate? That's true, because there may be a malposition of the ureter that is an execto. There may be a malposition of the ureter, and the fact that the ureter is malpositioned causes reflux, more infections, and favors the development of kidney stones. That's the most important thing about boil kidneys, Sandra, which have more reflux and kidney stones.
What happened to the last patient you saw in the clinic with a single ectopic kidney and kidney stones?
No, no, no, no. Alex, would you like to comment on kidney stones in a single kidney? They saw him the other day. The baby. Of course, girls, absolutely.
Clear. They already agreed. Ah, then you can comment. Do you remember that child? Okay, tell me what happened, it gave us a real fright.
That this caused an obstruction and that he was already experiencing acute and extremely serious kidney failure. That's the detail about the horseshoe kidneys, okay? So, we need to know its position, but we need, here it is, to do a cystogram to find out if there is reflux and often even more complex studies to see where the ureter inserts. OK? We're ok?
Perfect. Those are basic things about the single kidney, the stopia, the horseshoe kidney. What else, girls? What else does the book say about urological anomalies in patients with anorectal malformation?
Uh, there are a lot of them. Let's go one by one. I don't know. Bifid or good scrotum. Bifid scrotum. Alright. Bifid scrotum. Bifid scrotum. What is it?
Tell me.
It's a " Today they don't want to talk much."
It's a separation. There is a separation like in the scrotum and they commented that it was seen more in complex malformations. It's right.
It's especially noticeable when you see, for example, an anophoric malformation that has this scrotal problem; we would perform a more proximal colostomy on that patient because it already indicates that there is a malformation there. OK? So that's the most important thing, bladder neck or complex. Would we perform a more proximal colostomy? Is this how it will stay, or is there something that can be done to resolve it?
Yes, it can be resolved. This one is more aesthetic, but it can be done, the book said that the plastic surgery can be done in the corrective surgery.
Completely. They asked us on TikTok, very good question. Will every child with neurogenic bladder due to tethered cord experience incontinence? I love the question, Pao. And we're going to talk in just a few minutes about neurogenic bladder so you can see that not everyone has incontinence. And Candelaria says, "Some children may also have an inconspicuous penis. I don't know what you mean by inconspicuous, but they do have many malformations that we're going to see right now. So, indeed, there is a plastic surgery that Dr. Peña has described, it consists of removing the central part and making a plasty, but it's purely cosmetic." OK? What other malformations, girls? We're superb.
Uretopte.
Ah, but we'll talk about it now.
OK. But an ectopic ureter is different from an ectopic kidney. I love it.
Come on, let's watch it right now if you want. Come on. Ectopic ureter. The issue of ectopic ureters is completely different from renal ectopia. Renal ectopia, where the parenchyma is in another location, is usually associated with poor ureteral implantation, but the ureter is intravesical.
OK? An ectopic ureter is different because the ureter is outside.
And how are ectopic ureters classified?
According to what?
Also the localiz the localiz.
Yes, but especially if they are boys or girls. OK. If they are children, there are two possible locations. What are they?
Suprasphincteric.
Ah, yes, yes.
Perfect. You look great, girls.
Suprasphincteric.
Infrasphincteric. And where is the sphincter? Who can tell me? It is in the membranous portion.
Perfect. Let's draw a little picture here. If we have the urethra of males, that's why they are classified differently depending on whether they are boys or girls.
How many parts does the urethra have?
How many parts does the urethra have?
They're very quiet on social media. Perfect, girls. What are they?
The penis.
Very good. Penis. Perfect.
The vulvar.
The vulvar. And you're saying it superbly because that's how it's explained. It's in order, from distal.
approximate. The vulvar area is where the bulb of the urethra turns; it's said to be like the elbow.
OK? That's why the malformations are called vulvar urethra. What else? We're doing very well.
Venous, vulvar, membranous and prostatic.
Membranous. Why is it called membranous?
Because there's the finter. You said it, superb. Snap.
And on top of that, what do we have?
The prostate.
The prostate. That's why they're called that. This is how malformations are classified, and above the prostate we have in the bladder, well, the neck, the little neck, right? So when they are suprasphincteric, it means they are at the level of... where?
Suprasphincteric.
Brilliant. And which clinic is it?
The urethra has four parts. Yes, Sandra, you are absolutely right.
The girls did very well. What would the clinical presentation be in a suprasphincteric ureteroectopic case?
Obstructive symptoms.
Perfect. These are obstructive symptoms.
And what does that mean?
Microphone, please, so it can be heard on the broadcast. Can someone tell me what obstructive symptoms mean? The girls are absolutely right.
No, well, you might have difficulty with urination, right? Because the mission is in the urethra.
an obstructive ureter. Always imagine it as if it were a hose and you step on it, what will happen?
Well, the next part is going to be delayed. It will be delayed. So what happens? A chronic dilation over a kidney. Uh-huh. It may cause reflux or it may never cause reflux. Supraspinsterian ureterosophic ureters never cause reflux because they are inserted into the prostate, for example, or into the urethra. There is a cause of obstruction. There is a dilation of the lureter. Consequence on the kidney. Which is it?
What happens if the ureter becomes chronically dilated? That's it, it creates these infections.
Micro, please. Infections, right?
What happens in a ureter that cannot drain blood, affecting the life of that kidney?
Or it can cause kidney failure. It does n't cause kidney failure in the patient; rather, that kidney is lost, okay? The kidney is lost. That is why most children with a rectovesical fistula do not have agenesis.
What they have is a single kidney, because the other one that did form has a bad implantation of the ureter. It is its prefinger, obstructive. There's a really cute drawing in Dr. Peña's book that shows one kidney as normal and the other one is enlarged and disappearing, okay? or even a single enlarged kidney. OK? So, that's the clinical presentation of a suprasphincteric ectopic ureter. It usually acts quickly or that kidney is lost.
OK? That's why we see ureterohydronephrosis and more tests are needed. If I have ureteroidronephrosis, one might think reflux, but it may not be reflux. It may be an obstruction, as we saw earlier, of the ureterovesical junction, or it may be in another location. OK? That's why more studies are needed.
OK. Ureterohydrophrosis and recurrent urinary tract infections. Yes, that's correct. The thing is, hydronephrosis is not caused by this pathology. This causes urethral and hydronephrosis. There would never be an ureterectopic pregnancy with only pelvic dilation. There would be dilation of the pelvis and the entire ureter. OK. Infraestinteriano.
Which clinic is it?
Uh, incontinence.
Incontinence. Perfect. Tell me places where a suprasphincter and an infrasphincter would be. Where would a suprasphincter be located? Well, we already said so. Prostate.
Well, prostate. You are absolutely right.
Well, where would it be in a child, in an infra-emphinterian. In a child with an infrasphincter. Where would the peneaterine letter be? It's very strange. In the penis, it could be in the bulba, but more frequently, where?
In the perineum. OK. But he is incontinent. Uh-huh. Now let's talk about the girls. Girls do not have this urethral classification and therefore all have incontinence symptoms.
Where might a ureter be located in girls? That is different. In the perineum, but where else?
Vestibular.
vestibular, but well, it's to the perineum, but yes I'll give it to you for... Well, vestibular, but where else? Where else do you think we have the girl from the course? That's what was seen in her vagina.
OK?
Very good.
And specifically that girl has a ureteroendocrine tumor and it was obstructive, but it is not due to the implantation site. OK? That's regarding topical ureters. What is the cause of a norectal malformation? Phew, we'd get the Mel award. There is currently no established cause for anorectal malformation, okay? And it says, "Lower back pain due to the reduction of kidney function." Ah, yes, we'd have to know in the vagina. Perfect. Come on, girls. More things we have in patients with anorectal malformation at the level of urological alterations.
What else? Whichever one you want.
Vermontanum.
Come on, the Verum Montanum. Where?
pos in another location.
In another location they say, "I have a little girl who has two bacteria." Two bacteria. Let's see. Could it be a urinary tract infection? Where is the verum montan normally? That would be the first question. Uh, it would be at the prostate level, but in these cases it can be in the bladder.
In the bladder, that's correct. Seeing a montanum in the bladder. What are the consequences of seeing a montanum in the bladder? In fact, one of the articles talked about that, where those patients who had not been diagnosed had infertility problems because the sperm reached the bladder and there was no fertilization. Of course, his main problem is that his seminal fluid, because all the seminal fluid, the vas deferens, the vesicles, all of that is in the bladder.
So, when they have intimacy and have the expulsion of that fluid, it doesn't go through the urethra, but goes to the bladder. OK? So, is this considered retrograde ejaculation? What do you think?
What do you think?
The answer is no. Because a retrograde ejaculation would be when the semen is in the urethra and goes up to the bladder. This is not intravesical. OK? How is this diagnosed?
A cystoscopy.
Absolutely with a cystoscopy because it's something we can't see. And in which patients do you think it is more frequent?
Again, in those children who have complex malformations. Completely bladder neck, prostatic. And today it is suggested that all patients with anorectal malformation should have a cystoscopy. OK?
Alex, would you like to comment on this, as this recommendation is becoming increasingly common at conferences? Of course, the reality is that it is not currently done on all patients, but it would be ideal to be able to perform an endoscopy or a urethrocystoscopy study on all children who are going to be corrected for an anorectal malformation, because there is a fairly high percentage of urological anomalies diagnosed, and sometimes late, when they can be diagnosed early.
especially those types of anomalies that will have consequences at an older age and especially in the reproductive aspect of the patients. We believe that families and patients should know in advance what to expect in order to have a plan, a treatment plan, a management plan, a fertilization plan, for example, with males so that it does not affect their quality of life at an older age, right?
patients, to prevent patients who cannot have children from finding out at age 50 that they have a urogenital anomaly, which is the cause of their inability to have children.
So, all of this is very important and should be done in all children, regardless of the malformation you 're dealing with, right? That's my opinion.
Completely. And Sandra mentions it, cystoscopy. We didn't do it for all patients, but it's becoming increasingly common to recommend it.
OK? They say, "When a baby has a long, small, muscle-deficient spurt, is it possible that it will have incontinence?" S. Yes, because anatomy is important.
Okay, Mom? Then, see a mountain of clichés. What other malformations do these patients have? The neurogenic vegetative state.
Yes, but we'll leave it for the end because it's a broader topic. Let's look at anatomical things first if you want. Okay.
What else?
If we have an ectopic ureter, an ectopic vermoran, what else could be ectopic?
The deferents, okay? The different ectopics. The different ectopics. Ectopic vas deferens. Where do they usually drain?
To the ureter, okay? To the ureter. And if there is direct communication between the ureter and the vas deferens, what will happen when there is a urinary tract infection?
Uh, there can be orcheidipylitis.
Totally, orchi epididymitis. And what is this known as? That testicular pain, inflammation. What is the medical term? Acute scrotum.
Acute scrotum. Perfect. Acute scrotum.
When we have a patient with an acute scrotum of 13, 14, 15 years in our brain, what is the first diagnosis that comes to mind?
Well, testicular torsion.
Yes, testicular torsion, and we need to rule that out. Do you think children with anorectal malformations often have testicular torsion? What do you think about that?
Yes, yes, yes. They may develop testicular torsion.
We don't have any and Dr. Peña doesn't have any, that is, they may get them, but the first thing to consider is orchiopydymitis.
Completely. Therefore, in patients with anorectal malformation who have an acute scrotum, we have to consider orchiepiditis. What would be the treatment for acute scrotal torsion?
Surgical, surgery as soon as possible. What would be the treatment for acute spasm due to orchiepidemitis?
Antibiotic.
Antibiotic. Of course, girls. And do you think that recurrent orchiepidemitis can affect testicular tissue? Yes, absolutely. What could happen?
So, either they regain their fertility or they lose it, okay? Let it stay small. Do you want to say anything, Brenda?
Yes. Well, in fact, in one of the articles I also mentioned that, that perhaps I'm getting ahead of myself, that it was recommended to perform the basalt test on these patients to avoid recurrent infections and thus preserve the endocrine or hormonal function.
Completely. And you are absolutely right.
We haven't had to go this far in any case, but it's something that needs to be discussed in patients with a limit on recurrence.
OK? What else? What other urological pathologies can a patient with an anorectal malformation have? She says, "Why did n't they detect anything wrong with my baby on the ultrasound during pregnancy?" Because it ca n't be done. Anorectal malformation cannot currently be diagnosed by ultrasound. They say testicular hypotrophy scarring. Of course, Sandra, you're absolutely right. And they often lose their testicles. It's right. What else, girls?
The urethra. OK.
Meguretra.
Megalourethra. What does that mean?
Have you ever seen it?
No, not in real patients.
No real patients. Only in books, right? It is a very large urethra at the level of the urethra. Which?
Peneana. OK. And what they usually have is a very large meatus with a large meatus. We have one around here somewhere, okay? And what you make is a pill, okay? Because the rest of the urethra is normal, okay?
Regarding the urethra, we've said that it can be large, but it can also have a stricture due to injury, anatomical factors, it's a kinking, okay?
It's basically angled when we have an anorectal malformation, especially a rectus trochlear malformation, which causes a kinking, okay? A kinking is something that has a certain angle. What do you think is the problem with placing a bladder catheter in this group of patients? that one can go towards the fistula.
Absolutely, we can go towards Let's put this one over here. You insert a probe and it goes to... Where?
Here. Very good. How can we detect this? Which study do you think shows that?
By cystoscopy. Cystoscopy.
Yes, but before a cystoscopy; you wouldn't see it during the cystoscopy, because during the cystoscopy it would only be something that seems like something to you. Where did you see it? By image.
What tests do we perform on all patients? Contrasted.
A contrasting one. Which?
A histogram.
Never. It is seen in a hologram.
Ah, okay. High pressure.
It is seen in a hologram. And if we see this image, we have to predict that this can happen and that in the surgery to correct the anorectal malformation it will be complex to put the probe in.
What strategies could we implement in these patients if we identify them from the time we begin studying them until we reach the surgery stage? That's by cystoscopy.
Cystoscopy. And if that's not possible, the book recommended that at the time we are performing the surgery, it should be done manually, repositioning, well, repositioning. And there are also some special probes, okay? that have a pointed tip that are specially designed for probing these patients. With a cystoscopy you can see it effectively, and once you 're in the bladder you pass a guide, remove the cystoscope and probe it through the guide, and if you put it in and don't realize it, you could reposition it during the surgery. This has even led us to suspend surgery on occasion, sometimes even in a private patient. Do you want to comment on this, Alex? its importance.
Yes of course. The placement of the waves is extremely important, especially in cases of malformations. Well, I mean, especially in all malformations, although there have already been publications in which malformations theoretically without fistulas to the urinary system, such as perineal fistulas or vestibular fistulas, are operated on without a urinary catheter. We believe that could be unwise for the outcome of the surgery. Well, when a child cannot have a catheter inserted for any reason, such as a different urethral anatomy, a stenosis, an angulation, or something that prevents a urinary catheter from being safely placed in the patient, we believe the most prudent thing to do is to suspend the procedure. With these children, you can't play around with the possibility of placing or not placing the catheter during surgery because that could compromise the outcome. I do not consider it appropriate to operate on a patient without being certain that the urinary catheter is properly placed and will function as intended days after the operation.
That is my opinion.
Completely. Yes. It's happened to us. Or would you like to comment on something?
Yes. One of the articles also mentioned two groups, well, let's call them groups A and B, and that was precisely it, which ones had more complications and they made recommendations to prevent those complications from occurring. And one of those is that many don't place catheters, and another is that, well, we're not talking about injuries right now, but yes, but this is not uncommon. You might think the probe is in place, then find it's not positioned correctly and have to reposition it during surgery, but it's another thing entirely if you ca n't put it in at all, okay?
So what we do is arrange to have the cystoscope available with the urologist so that we can do it during the surgery. We are asked, "Can girls with spinach have children?" The answer is yes, because they have a normal uterus, normal ovaries, and normal fallopian tubes. OK?
But it would be a matter of understanding whether that patient can or cannot take care of a child once he has one. It will depend a lot on their family support and their ability to walk. OK? They tell us that we would do a contrast-enhanced CT scan with vibrinary reconstruction. When we have a patient with a urethral problem, we don't do it, okay? We do it when we have renal ectopia, when we have ectopic ureter, because these patients with ectopic ureters have to be reimplanted if they have renal function, other times they don't, right? But you have to choose which kidney to remove if it has no kidney function, if there is a urinary tract infection, if there is high blood pressure, a number of things to decide whether to remove it or not. Why do you have to be very careful when deciding to remove it? Because sometimes those ureters in a patient who has a complex malformation, who has a poor prognosis for fecal control, who has neurogenic malformation, could even help us to achieve a continent urinary tract. Okay, but well, if it has to be removed, it will be removed. What happens when they don't empty their bladder? Clau, right now we're only talking about neuropathic bladder, okay? And postpadias, is this common or uncommon?
Posadas.
frequent, infrequent. Yes, it is common.
It is said that up to 60% of patients may have some malformation of the beneficiary. They were asking that before, okay? They were asking if I had any kind of problem.
Well, it's very common. What's the debate here?
When? TRUE? We're always talking about the urologist, the surgeon, but well, at some point it has to be corrected. It will depend on whether it is more complex or simpler. Let's talk about injuries, okay? Who can tell me about urological injuries that can occur during surgery and cause problems?
Who can tell me?
Ah, for example, injuries to the seminal vesicles, to the vas deferens.
Brilliant. These would be injuries to the genital area. Okay, perfect. To the seminal vesicles, to the vas deferens. And what else?
What else do we need?
The urethra.
To the prostate. The urethra is urinary. The prostate is genital. Let's now turn to the urethra. Okay?
They were saying on Instagram, prolapses. Tell me what you mean by prolapse, okay? In what area or at what time? Okay, let's talk about the urethra.
Urethral injuries. What could they be? Two.
Uh, it could be a fistula, or fistula is one thing. OK. Now let's talk about fistulas, but urethral lesions.
Stenosis.
Perfect, Ana Belén. Stenosis and what else?
Stenosis and atresia.
The case was closed this morning, it wasn't a narrowing issue, okay? But stenosis is more common, right?
Why do you think stenoses occur? Sections of the urethra and sections of the urethra. Absolutely, Sandra, you're right, because when doing the dissection between the rectum and the orethra, there might be some injury there, so it's sutured and done very well. Let's assume there's an injury during surgery and you see it, it's noticed, okay? The probe is visible.
Sometimes the probe is visible because that's where the fistula is, but sometimes it's during the dissection. Remember that the most distal malformations have a super long common wall. All of us who perform this surgery have opened a urethra. The question is how to fix it. Do you know how to repair it?
With a Geniolit technique, if not, great. It's right. We saw it yesterday more or less in the anastomosis we performed. That was what the doctor who was with us was trying to explain. If you close it lengthwise, you can narrow it. That's why it's done like a geniculic technique with a few simple dots and that's it. And leave the probe in place and be very cautious.
OK? But let's assume they didn't notice, or that we were left with a stenosis in the area of the fistula. What symptoms might you, as doctors or a mother, notice that indicate a problem with the urethra? Anelen wants to share something, uh, difficulty with mixing or that, for example, the caliber of the jet, the mission. I love the stream. Great, Auntie, you're right that I have a drip. There's also a trickle, meaning there's a problem with the mission when there wasn't one before, okay? Parents who say, "Oh, he used to urinate in a stream and suddenly after the surgery he doesn't." OK. And what other information could we have? In other words, you see that a patient has a certain thing and you have to think that they have a problem in the urethra.
They say, "They have urinary tract infections; we have to drain the urine with catheters." Yes, in some cases it is, but in others it can be another problem. OK? It's not always because of having probes. Girls, what would we see in a patient that makes us think there is a problem in the urethra? Which one would it be?
Recurrent orchiepididymitis.
OK? Where do the verum, prostate, differentia, and seminal vesicles naturally end?
Exact. Here.
And if you have a stenosis in the vulvar region or in the membranous region, due to stenosis, as we were already talking about, urine will accumulate. If there is vesicular reflux, that is, from the urine, not vesicular reflux, but from the urethra to the vas deferens, stagnant urine that may be infected, it will cause recurrent epidurals.
And what study will tell us?
With a cyst, a cystogram. Of course, we'll see it with a cystogram, and sometimes we even see the passage of the contrast agent in the cystogram because they're always on one side; generally, it's orthopedic edema on only one side. And Jorge says, "Bladder distension."
Yes, you're right, we could have bladder distension when we remove the waves and there's an injury, it's not just difficulty in mixing. It could make it so the patient can't, it would mean you couldn't even pass a catheter through him.
Urinary retention is great, Jorge, very good comment. But speaking of orchidopydymitis, we would see that there is stenosis. How would you see it?
Front, back, or sideways? In the side cystogram. We need to see the phase and how the urethra is doing in a basic cystogram, and it's not very common for them to do that for us. OK? That's why we're going to do the studies, as you've seen, okay?
So, we turn it sideways, we see the urethra, we're going to see the stenosis, and then we turn it back from front to back and we're going to see the passage of contrast to a decider or a seminal vesicle. It looks like a rosary. If you'd like, we can show you some pictures at the end, okay?
And then we have a suspicion, but what do we need to do?
We have a cystogram, we already suspected it. What else?
A cystoscopy is absolutely necessary because we need to know if we have a stenosis, if the cystoscope can pass through without any repercussions, if it can be dilated, or if it is a very severe stenosis, in which case a diversion is necessary, which could be a cystostomy or a vesicostomy, and we need to see how to solve the problem for the patient. OK? What else? If we have a narrowing, what other problem could we have that is not an injury, but a post-surgical sequela?
The fistula.
The fistula. Okay. I was going to talk about the diverticulum first, but that's not a problem. The fistula is fine.
Let's talk about fistulas. Three fistulas that need to be started. What are they?
Post-surgical, right? Fistulas. Okay, okay, let's differentiate them.
Persistent. Perfect. What else? of recurrent or recurring resident.
And which one else?
The acquisition, the acquisition.
Perfect, girls. So, let's differentiate each one. Persistent, recurrent, and acquired. Which one is persistent? Was it a fistula that existed or that did not exist?
Yes, it existed.
Perfect. The patient had it, but it wasn't repaired. Well, it didn't close, it wasn't repaired during surgery. It was not repaired. Perfect, it wasn't repaired. And why would a fistula not be repaired if the patient has one?
Because the crystal hologram is not made at high pressure.
Tight. Did you see that it's going to be tight?
Exact. A hologram that does not have the appropriate pressure to show the fistula. So, the doctor thinks it's a malformation without a fistula, corrects the malformation, and the patient starts urinating through the anus. OK? That is a persistent fistula and the cause is the hologram.
A recurring issue either existed or it did not.
Yes, it existed, and it will be repaired.
And if it was repaired, then why would it happen?
For what reason? TRUE? Because in the surgery there was perhaps an injury to the nerve and the sutures were repaired and it was stuck together. Suture, with suture. Wow, perfect. You look perfect. It was a problem with an injury to the rectal wall that was repaired suture by suture, because of course, the fistula is in the urinary tract and there you have the fact.
OK. And the patient had the acquired one, didn't he, right? I didn't have it. So, what kind of malformations can have this problem?
The acquisition, like a person who rectum and perineum, and what else?
The symphistula.
Okay. And what is the cause? Why might a non-rectal malformation with a rectoperinal cyst have this effect, especially in children who did not have a catheter inserted and suffered an injury during repair? That's correct, when they don't have a catheter, you can section the tissue and it 's not uncommon for them to have acquired fistulas or even urethral prolapse, that is, for the urethra to be placed in the anus, which one would think is not possible, but it is possible. And indeed Jorge Trujillo says that it is a problem of atrogenesis.
That is correct. Alex, would you like to comment on fistulas? Which is not something uncommon to see. I do n't want to comment much. He declined to comment.
Well, it's a part we have to take care of because generally these types of fistulas will require a reintervention or a reoperation in children. And anorectal malformations should ideally be corrected in the first surgery because any reoperation is no longer guaranteed. Well, if the correction isn't guaranteed from the start, the result of a reoperation has no guarantees in terms of fecal control or correcting the problem as it should be. So it's important to have a very well-made plan, to have thoroughly studied the patient, to decide on the best time for surgery, to prepare in the best way possible, to know that we can solve it if we are aware that we won't be able to do it ourselves, to rely on someone who has more experience than us to do it and together be able to give a more positive result to the patients, right? To avoid reoperations, to avoid reinterventions, to avoid complications. I believe all children deserve to be included in a single procedure. That's my opinion.
Yes. The patient who underwent surgery in our course this year had a persistent fistula. OK? And among acquired injuries or problems, we have one left, which is the diverticulum. If the urethral problem is due to sticking too much or having a problem with it opening up, the diverticular would be the complete opposite, right? We have our male urethra with a fistula.
And what is this thing called a urethral diverticulum? Who can tell me? It's good, it's been seen when they've done laparoscopic or abdominal approaches that they don't completely dissect the rupa. Laparoscopic.
What type of fissure is it: rectal, urethral, vulvar? Sure, because the fistula is in the pelvis and the laparoscopic approach is abdominal, but the abdominal approach was more of an older procedure when surgeries were done for stefens and this type of thing where the tissue was sectioned, but you're absolutely right, it could also be due to an abdominal problem, okay? But it is in anorectal malformation with recturinary fistula.
What else, Brenda? tell me.
Uh, so it didn't completely separate and left that little piece behind, well, in fact it's the rectum that remains, if you notice, and this would be more or less the anatomy. How do we realize this? What symptoms might the patient have that would allow us to realize this is happening? Well, mucus discharge after urination; it could continue to drip or completely. That's very important to understand. It's also dribbling, but it's post-voiding, okay? Because? Because we had already said in these patients that the membranous part of the orethra is the one that has the spinner. Then the bladder fills up, the patient urinates, but part of the urine is expelled and another part goes into the diverticulum. The bladder neck closes and urine remains below the membranous area and the neck, and then you start to see dripping, dripping.
So it's post-micturition dribbling, says Jorge Trujillo. Perfectly dripping.
What else, girls? Other symptoms, urinary tract infections, of course, imagine. Yes, urine accumulated there, urinary tract infections. What else can cause pain when they ejaculate?
No, it 's not that common. What we have above all are lithiasis and also, since we leave the rectum here, we lower a colon that moves more, they usually have fecal incontinence, that is, a patient could have a normal sacrum, a normal spinal cord, but it doesn't contain as we would like, it's because this little piece is rectum.
OK? What tests would you perform on this patient?
Well, maybe a cystoscopy, a cystogram.
A cystogram. The first thing would be a cystogram, and we're going to do it with the patient lying on their side, okay? Very important, but you explain it very well later, a cystoscopy. And if it were a very large diverticulum, and you wanted to know more about the anatomy, what studies would you do?
A bracing moment.
A hoop. We also give them a harness to see a little bit about their anatomy. And what does this do? Should we leave it or remove it? It does n't come off. It has to be removed. Of course, it has to be removed because in the end that "eh eh fun" is causing problems because it's intestinal and at an older age it can become harmful. Finally, the intestine is ready to receive pee. It receives urine, a metaplasia occurs, which is a change in the tissue, and a metaplasia can evolve into an adeno, adeno, because the tissue it is on is intestinal mucosa that produces mucus which is with glands, adeno, an adeno CA, okay? And then they operate, they operate, we've had to operate on them, the rectum can be moved, the rectum can be opened in two, in the end it's still a reoperation. And what about reoperations? What's going on with reoperations? Beautiful people, are they good or bad for patients? They 're not that good, are they? And a reoperation affects it. And I left this part for the end to talk about a very important topic, which is the neurogenic bladder.
Clear. Neurogenic bladder.
Neurogenic bladder can be acquired or congenital. What do you think?
Ah, one of the articles mentioned that both. Just because? Why not?
What do you think? Why acquired?
Why congenital?
Congenital can occur in patients who have a sacrum, sacral malformation, or tethered spinal cord.
Sure, it's something that the patient has an innervation problem and will develop a bladder, but it could be acquired. It could be acquired through an injury during surgery. OK?
So, types of neurogenic bladders.
How is this classified? Let's see. Well, the simplest classification is that it's classified as flaccid, [ __ ], and mixed, but there's another type of classification, but that's done with urodynamics, right?
Okay, let's develop it at the level of the bladder. You said flaccid and sparic. What does flaccid mean?
Tell me about that, what is a large bladder that doesn't have the capacity of the detrusor muscle for this, so that it has good confidence. That 's right, he has little pressure, little confidence. You told him very well, but then it has a capacity at most, I mean, very large, very large, they are high capacity, they fill up a lot. Their problem is with the emptying, okay? And what is the other bladder, the one we call [ __ ], like? Their pressure, their compliance.
It is increased, has a very thick wall and is generally small.
It's right. She is very contracted. The detrusor muscle is very contracted and has low capacity. OK? What you were saying about aurodynamics is that it seeks to measure the spinter, right? Among other features. So, at the sphincter level, you can have a sphincter that is very hypertonic, with a lot of pressure. Perfect. This pressure is perfect. And this is where all the problems of neurogenic bladder come out, and we can have, which is what a mother asked before, everyone has urinary tract infections, everyone has incontinence, everyone has to be catheterized. There is a combination that we will see when talking about a bladder that has low pressure, it would be a flaccid bladder.
with a low spinner pressure.
Which clinic does that patient have? Incontinence.
Incontinence. It's right. What will happen is that the patient has a very large bladder that fills up with pee and since he does n't have good sphincter control, it leaks. This is high risk for the kidneys, medium risk, low risk. What do you think?
Well, it's low risk.
Sure, it's low risk for the kidneys. Those kidneys are not suffering. The problem is that they have no control over their pee.
OK? We're talking about a bladder that has low pressure, but a lot of pressure in the sphincter. What do you think about that? What will happen to those patients?
Well, that's higher risk, and they would be of intermediate risk, but urinary tract infections, but why do they have urinary tract infections?
They're going to have urine ecstasy.
Retention.
Retention. You saw it in a patient who came in whose bladder had changed. She used to play, but now she can't pee anymore. We don't know what type of bladder he has, but he gets urinary tract infections. The most likely outcome, pending further testing, which is what we're going to do now, is that he has post-void residual urine, urine accumulation, and control, okay?
And it causes urinary tract infections, but this causes urinary tract infections and is a moderately risky condition because ultimately urinary tract infections affect the kidneys. OK? So far so good.
Another type of bladder, high pressure, but with low pressure underneath. What else will it have? Incontinence.
She will have incontinence, but what else could she have from the high pressure?
reflux and urinary tract infections. If you notice, both of them have urinary tract infections, but this one can have reflux and is also of a more moderate risk because even though they lose urine, it can affect the kidneys, okay?
And what about the last bladders? These are the ones where the bladder has a lot of pressure, but the sphincter also has a lot of pressure. They have urinary incontinence, no, no. They have bladder control and the parents and patients are super happy. But what's wrong with them? They can have reflux, they do have reflux, they often have high-grade reflux, infections, and they are the most dangerous, okay? They are very risky for the kidneys. The problem is that the parents are super happy because they give notice, okay? which is to comment on high-risk veterinary care, Alex, which is a topic we always enjoy discussing. Of course, when we talk about neurogenic bladder, it's a problem that is sometimes misunderstood, especially because there are specialists who don't deal closely with the problem of neurogenic bladder associated with anorectal malformations, and sometimes there are incorrect decisions in the management of these bladders. We have seen it a lot: very high-pressure bladders that result in reflux, and this reflux, which is the consequence, is treated as if it were a normal bladder, right? With reimplantation, for example. That's something we see very frequently.
Sometimes parents—and this is why it's so important to mention this—are very pleased to know that their child has neurogenic [ __ ] bladder and urinary control, meaning a sphincter with good tone that allows them to avoid urine leakage. And this is truly dangerous for these patients because this combination of [ __ ] neurogenic bladders with seemingly perfect urinary control at the sphincter level in children is a very high risk to kidney health in the coming months or years. So this bladder condition is very important because children with a malformation problem who leak urine in their underwear is not a big deal, that's a social issue, but a bladder condition that is mistreated, misdiagnosed, with inadequate surgeries, with incorrect therapeutic decisions, leads to kidney failure and loss of kidney function at an older age. So it's proven that there are many children who lose kidney function right in front of the doctors. So, this needs to be avoided, and parents need to be made aware that the combination of a [ __ ] neurogenic bladder with good sphincter tone, where there are no urine leaks, is the most dangerous combination for these children. Even though it might be great for them that they don't wet the bed or leak, knowing that they have a [ __ ] bladder, this is a truly dangerous combination for kidney health.
Completely. We talk very quickly about the future now, but each patient needs a treatment, which is what the mother was asking before, all children need the same thing, right? If we have a patient with a very large bladder, with very little spinner pressure, what is their main problem?
Incontinence.
Incontinence. And you have to close the neck.
The neck. A neck closure needs to be done. The problem is that when we do a neck closure, what is the main problem with that bladder? To empty out, I need a nitro boost to be able to empty out.
A patient who has high blood pressure with a lot of waist pressure needs a neck closure. No, they only need a microphone, but you don't need to make a bigger bladder because you already have one.
OK? What does a patient who has low sphincter pressure but high bladder pressure need?
A zipper, but the bladder is small, what does it need?
An extension. When you enlarge it, you affect its ability to contract, and it needs a micro-surgical unit, okay? Then it needs more micro-enlargement and more closure. And these patients need to close their necks, right? They are continents. In fact, nothing is done because they have a certain possibility of having social urination, which is my social going to pee. But for some children it's important; they don't need it, but they need an amplifier and a microphone. So, what does each patient need? It depends on the type of bladder. OK? And finally, what have you read about adults? OK?
Uh, about fertility.
First, about the kidney. How are your kidneys? How is kidney function overall? What are we seeing?
They're perfect.
Oh, no.
It is said that a third are already in the kidney transplant program and in the girls with sewers what was presented last year is that half, 50% of the girls with sewers are reaching kidney failure and needing a transplant, which is tremendous. That is why, given the guidelines we put above, we now consider that we should be more aggressive in our diagnosis. Studies.
In fact, Dr. Peña has a protocol that involves studies at one month, three months, six months, and one year.
If after that time everything is fine, they are not discharged every 6 months, every year, depending on the type of neurogenic age, studies have to be done. Sexuality, what do the articles say? In boys and girls, women and men. What have you read? Well, he mentioned that only a few had problems with their sexuality, but that most were quite satisfied with their ability to have intimacy. But in terms of parenting, what have you read?
Well, regarding that, I did a comparative study, and uh, with those with HR versus those with malformation, it was seen that with those with malformation, the root was more affected in this part, and because they have more malformations.
OK. But men can be fathers.
Yes, they can.
Yes. If they don't have an anomaly. If they have an anomaly, they need to know it in order to have a different fertilization process with their partner. It's not that they can't be parents, but if you have a problem and they don't know about it, they're going to get frustrated. Speaking of women, they get pregnant.
Yes, they can be done. But who hasn't gotten pregnant?
Those who had vaginal agenesis and needed a replacement.
Beware of replacements. They don't have any patients yet. He doesn't really know why. OK. But they don't have them.
But they can get pregnant. What we need to watch out for is what, uh, well, that they don't have, I mean, how to be born, the way, okay?
That's what needs to be done, pregnancy.
And how does childbirth happen? OK?
Some patients can have a natural birth and others cannot, okay? And this is the direction medicine is heading, towards the transition, having gynecologists, having urologists, who can support us when the patient reaches adulthood.
OK? Alex, pregnancy and childbirth in adults. Would you like to discuss that, and then we can wrap up the class?
We still don't have much experience in these cases because of the older patients we have operated on, we don't have any patients with an anorectal malformation, whether non-complex or complex, who are pregnant. However, this must be taken into account because in Mexico and Latin America at least, transition services do not exist.
When we talk about transition, it means that at some point our children, not only those with colorectal cancer, but also children with congenital cardiovascular problems, children with cancer, and children with kidney disease, should have a transition to adult services because it is very frustrating for these patients that, at least in Mexico, there is a magic number, which is 18 years old, where the patient seems to become another human being.
So, from the age of 18, especially in some public institutions, you cannot treat a patient who is over that age and you have to transfer them to adult services.
The issue is that in adult services the treatment is different. The treatment in the ward for patients with congenital conditions who were used to the residents who are very affectionate with children and the treatment they give to families. You know it. How do you become attached to a child and how is the treatment different?
But when they set foot in an adult hospital, they hit a wall and find out what the treatment is like in adult medicine. So, in the end, they need that medicine because they already have comorbidities, they already have other health problems that have to be treated by other specialists, but that transition doesn't happen, at least not in Mexico. There are patients who are transferred from one day to the next to another hospital, not just children, but adults, and that can lead to complications, poor follow-up, abandonment of treatments, problems in patient control, and we reach a point where these patients will have pregnancies, they will have deliveries, and care becomes risky because sometimes the doctors don't understand what these patients have, right? So, those transition services do not exist in Mexico. which are so important in the United States. They're not perfect, but there is already a transition process underway between pediatric and adult medicine, and hopefully in Mexico and Latin America, at some point, we can have services where doctors can guide patients with congenital conditions through adult care, right? And sometimes treat them together. That 's my opinion. and work as a team. We're already starting to have patients, for example, the case Alex presented today wasn't a teenager, but he had precocious puberty, we had to inhibit his menstruation. We have had patients who have had gynecological problems and we have had to support each other. OK?
Pao says, "That explanation the doctor gave was really difficult. That stage is super complicated." Yes, but that's where we're headed. The girls are going to become teenagers whether they like it or not.
Marcí says, "Could a girl who has had obstructions, volvulus, and only a cystic malformation get pregnant?" It's a really good question. They can, but patients who have had peritonitis and multiple surgeries, adhesions or peritonitis can affect the fallopian tubes and can make pregnancy difficult or cause miscarriages or ectopic pregnancies.
OK? It's super important for moms to know this. Yes, they have the anatomy to have a pregnancy and childbirth, but be careful with ectopic pregnancies.
Okay, girls? Doubts, questions, complaints, or suggestions? Was there anything we missed?
Anything you'd like to add?
Brenda.
S. Very good. Well, if you agree, that's all for today.
Thank you all so much for participating. We had about 40 people on the stream, so superb. The class is recorded, of course. Next week a new class of what the doctors are left with, who knows what. And parish announcements for dads. As you know, we have our event this Saturday for children with Gisprun, operated on for Hisprun. My son, who had surgery for Hisprun, is still having problems.
What's next? That event is not open to the public; it is private due to the nature of what is being shared and the privacy of the patients. They're doing Zoom. To get the link, simply go to our community for parents of children with Histum disease, which is completely free. They are asked three security questions and then we grant them access, okay? And for the doctors, see you next Thursday.
Sandra, well, see you next Thursday. As you know, we have our class program, our rotation programs, and our face-to-face courses, the last one being on anorectal malformation, which we have recorded and can purchase. There were 24 lectures, and there's one more question here that says, "Patent urethra, which is the tube through which we urinate and it has to be patent, okay? That would be the term patent urethra." They say, "Excellent class, thank you so much." Well, thank you very much, Jorge, and we'll see you next week in a new class at the Colorectal Center.
What would you like? You have to start thinking about it. They have their list of classes, and they have to decide. It's Dr. Alex's turn next week, and we'll see what class the girls want. Well, thank you all for being here, and bye.
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