Pediatric and Adolescent Urologic Imaging

490 Pages·2014·38.09 MB·English

by  Kate H. Kraft MD

Lane S. Palmer
Jeff rey S. Palmer Editors
Pediatric and
Adolescent Urologic
Imaging
123
Pediatric and Adolescent Urologic
Imaging

Lane S. Palmer (cid:129) Jeffrey S. Palmer
Editors
Pediatric and
Adolescent Urologic
Imaging
Editors
Lane S. Palmer, MD, FACS, FAAP Jeffrey S. Palmer, MD, FACS, FAAP
Hofstra North Shore LIJ School Pediatric and Adolescent
of Medicine Urology Institute
New Hyde Park, NY Cleveland , OH
USA USA
Division of Pediatric Urology
Cohen Children’s Medical Center
of New York
Long Island, NY
USA
ISBN 978-1-4614-8653-4 ISBN 978-1-4614-8654-1 (eBook)
DOI 10.1007/978-1-4614-8654-1
Springer New York Heidelberg Dordrecht London
Library of Congress Control Number: 2013957139
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This book is dedicated to our parents, whose love, support,
dedication, sacrifi ces, and example have enabled their children
to be the best that they could become. We thank them both.
Jeffrey S. Palmer, MD, FACS, FAAP
In addition, the loving support and understanding of my wife
and children allows me the opportunity to work on projects,
such as this one, aimed at helping others.
Lane S. Palmer, MD, FACS, FAAP

Foreword
S ince I began practicing pediatric uroradiology almost 40 years ago, there
have been many dramatic changes, not only in the diagnosis and treatment of
abnormalities of the urinary tract of the fetus, infant, and child but also
changes in the training of the people who do the diagnosing and the treating.
Some of these changes are obvious and are the result of advances in medi-
cine, but some are cultural and may be more subtle. I will mention but a few
of these changes here.
Vesicoureteral refl ux was thought by many to be secondary to infection or
secondary to obstruction at the bladder neck or in the urethra, leading to
many unnecessary operations. Vesicoureteral refl ux is now known to be pri-
mary, the result of abnormality or immaturity at the ureterovesical junction,
and refl ux often resolves spontaneously as the child grows. It was not known
that refl ux is often familial and that it is rare in black children. And it was also
not widely appreciated, as it is now, that refl ux is a dynamic phenomenon that
sometimes only occurs with voiding.
Another advance in the understanding of the child’s urinary tract concerns
the so-called megacystis-megaureter association. This is a condition in which
the massively enlarged bladder was thought to be the cause of the dilatation
of the ureters. Reduction cystoplasty (with incidental reimplantation of the
refl uxing ureters) was a common method of treatment. Then we learned that
the massive refl ux, with constant recycling of refl uxed urine, was the cause of
bladder enlargement. Reimplantation of the ureters, with cessation of the
refl ux, usually results in the gradual return of the bladder to normal size.
The ability to detect hydronephrosis and other abnormalities of the urinary
tract in the asymptomatic fetus by prenatal ultrasound means that the infant
can be evaluated and treated if necessary electively after delivery and not as
an emergency only after he or she becomes ill, as was often the case 40 years
ago. Prenatal detection of a urinary tract abnormality, such as posterior ure-
thral valves in the male fetus, affords the pediatric urologist the opportunity
to meet expectant parents before the baby is born, to provide advice and reas-
surance, and to establish a plan for postnatal management.
Prenatal detection and postnatal evaluation of the infant with a multicystic
dysplastic kidney (MCDK) revolutionized the treatment of the child with this
anomaly. Before prenatal detection was possible, most MCDKs were removed
when detected. A healthy infant would be found to have a mass in his or her
fl ank during a routine physical examination. An excretory urogram would
vii
viii Foreword
show a normal, hypertrophied contralateral kidney and no visible kidney on
the side of the mass. At the time of the almost inevitable operation, a MCDK
would be found and the kidney would be removed. Since the introduction and
widespread use of routine prenatal ultrasound, most MCDKs are detected in
utero. The diagnosis is confi rmed after delivery and the affected kidney is left
in situ. No operation or other treatment is needed. The fl uid in the cysts often
resorbs and the affected kidney shrinks and sometimes becomes invisible on
follow-up ultrasound examinations. It took awhile for this radical change in
treatment to be disseminated and accepted.
Prenatal detection of hydronephrosis has also changed our understanding
and hence management of primary megaureter. When I began practicing
pediatric uroradiology, a patient with this condition would usually present
with pyelonephritis in the fi rst few years of life. Since the infant or child was
sick and since imaging would show an underlying anatomic abnormality, vir-
tually all such children underwent excision of the distal ureteric segment and
reimplantation of the ureter, with ureteral tapering when needed. Now, how-
ever, hydronephrosis can be detected in the fetus and the infant evaluated,
electively, soon after delivery and kept free from infection. As a result of this
change in management, we have been able to see that the natural history of
this abnormality, without surgery, is often spontaneous improvement and
even resolution, and many if not most children with primary megaureter
never need an operation.
Chronic renal failure used to be the most common cause of death in
patients with neurogenic dysfunction of the bladder (so-called neurogenic
bladder) associated with myelomeningocele. Now, after evaluation of the
affected neonate by both the pediatric urologist (using urodynamic testing for
neurourologic evaluation) and pediatric radiologist, appropriate treatment is
instituted and maintained, and there need not be any renal deterioration at all.
When I was a medical student, I was taught that if one “contaminated” the
bladder of a patient with neurogenic dysfunction by catheterization, the
patient would be doomed to a lifetime of intractable bladder infections. Now,
one of the cornerstones of management of such a patient is clean, intermittent
catheterization.
Forty years ago, exstrophy of the bladder was diagnosed at the time of
birth, and the child was treated with either bladder closure at 3 or 4 years of
age or urinary diversion, usually by means of ureterosigmoidostomy. Now,
exstrophy is usually diagnosed prenatally by ultrasonography and sometimes
magnetic resonance imaging as well; prenatal counseling can be provided,
and complete primary repair can be undertaken, often in the neonatal period.
In the early 1970s, there were few pediatric urologists. Pediatric urologic
surgery was usually performed by either “adult” urologists or by pediatric
surgeons. If a rare person in North America wanted special training in pediat-
ric urology, he usually went to England for a year of training with a mentor.
Today, pediatric urology is practiced by men and women (a signifi cant
change, note the gender of the coauthors of this book), who have been trained
in a pediatric urology fellowship in the United States or Canada, for one or
more years after their general urology training. The same fellowship training
model and “gender equality” have also occurred in pediatric radiology.
Foreword ix
Another area of signifi cant change, clearly shown by this book, is the
working relationship between the pediatric radiologist and his or her pediatric
urology colleague. In the past, each group worked separately, with little
knowledge or appreciation of the other group’s needs and concerns. It is grat-
ifying for me, as this book clearly shows, to see how the practitioners of each
specialty now often work together as a team, to the great advantage of each
other, to each specialty, and of course to the care of the infant and child.
W hen I began, there was little knowledge of or concern for the deleterious
effects of radiation from diagnostic imaging. Recently, greater knowledge of
the potentially damaging effects of repeated doses of radiation from diagnos-
tic procedures has become much better understood and disseminated. This
understanding, and the need to address it, is the subject of the “Image Gently”
campaign begun by the Society of Pediatric Radiology and of Chapter 7 .
Still another area of signifi cant change, the last one I will mention, is the
recognition of the need for psychological support for the young patient and
his or her family. When I was in training, I met Emma Plank. She had begun
a unique training program for young women, teaching them how to work
with children and their parents in the hospital, to try to make the time there
more understandable and less scary. They were called Play Ladies. They are
now called Child Life Specialists and they are an integral part of most chil-
dren’s hospitals, especially in radiology and urology.
O ur ability in pediatric urology and uroradiology to understand, to diag-
nose, and to treat pediatric urologic problems has grown tremendously in the
past four decades. Children worldwide are better for it. Some things, how-
ever—the embryology, anatomy, and physiology of the urinary tract and what
can go wrong—have not changed. And, something else has not changed. It is
the need to treat the young patient and his or her parents with dignity, con-
cern, and sympathy and to provide the infant and the child with the most
up-to-d ate diagnostic and therapeutic care, in a cost effective way, always
striving to do things better and above all “to do no harm.”
Robert L. Lebowitz, MD
Professor of Radiology, Emeritus
Boston Children’s Hospital and Harvard Medical School
Boston, MA, USA