Papers by Dmytro Shevchuk
Значна кількість дітей з дизуричними розладами, що виникли внаслідок спінальної дизрафії, має дос... more Значна кількість дітей з дизуричними розладами, що виникли внаслідок спінальної дизрафії, має досить
добрий клінічний ефект від консервативної терапії, до якої відносять застосування медикаментозних препаратів
та чистої інтермітуючої катетеризації. Однак 10–20% пацієнтів вказаної категорії підлягають тим
чи іншим методам хірургічного лікування. Враховуючи, що у хворих із мієлодисплазією розлади сечовипускання
становлять 95–98%, особливу увагу слід приділяти комплексному лікуванню нервово-м’язової
дисфункції сечового міхура (НМДСМ) у даної категорії хворих дітей (E. Smith, 1965; J.D. van Gool та співавт.,
2001). Однак на даний час не існує способів радикального хірургічного НМДСМ при порушенні його іннервації.
Мета: дослідити можливість хірургічного відновлення іннервації сечового міхура при рефрактерних
формах його нервово-м’язової дисфункції у дітей.
Пацієнти і методи. Враховуючи відсутність у доступній літературі уніфікованого методу хірургічного
лікування рефрактерної до терапії НМДСМ, особливо при порушенні іннервації сечового міхура, авторами
розроблено принципово новий метод хірургічного лікування, який передбачає реіннервацію (міоневротизацію)
сечового міхура (Спосіб іннервації нейрогенного сечового міхура. Патент на винахід
№102801 UA МПК (2013.01): А61В 17/00). Суть методу полягає у вживлянні нерва (який має соматичну та
вегетативну іннервацію), що формується вище місця ураження спинного мозку при спінальних дизрафіях,
у стінку сечового міхура.
Результати. Із застосуванням запропонованого методу починаючи із 2001 р., на клінічних базах Національної
медичної академії післядипломної освіти імені П.Л. Шупика (Київська міська дитяча клінічна лікарня
№1 та Житомирська обласна дитяча клінічна лікарня) було прооперовано 9 хворих на НМДСМ дітей.
Вік хворих становив від 4 до 14 років (у середньому 6,5 року). У ході контрольного обстеження, яке проводилось
5 (55,6%) хворим, відмічена позитивна динаміка у 4 (80%) хворих.
До суб’єктивних позитивних зрушень пацієнти відносили наступне: поява відчуття наповнення сечового
міхура – у 5 (100%) хворих, утримання сечі – у 4 (80%) хворих, сечопуск струменем – у 5 (100%) хворих.
До об’єктивних позитивних зрушень віднесено: зменшення кількості залишкової сечі – у 5 (100%) хворих;
зменшення ретенційних змін у верхніх сечових шляхах – у 5 (100%) хворих; зменшення ступеня чи повна ліквідація
міхурово-сечовідного рефлюксу – у 100% хворих, у яких був наявний рефлюкс; тривала ремісія інфекції
сечових шляхів зі зменшенням/ліквідацією бактеріурії – у 4 (80%) хворих. Жодних ускладнень не виявлено.
Висновки. Новий метод реіннервації сечового міхура – міоневротизація сечового міхура – є досить
ефективним методом лікування рефрактерної форми нервово-м’язової дисфункції сечового міхура у дітей.
Результати застосування методу потребують подальшого вивчення уродинамічних параметрів, що дасть
змогу рекомендувати метод для широкого впровадження у практику.
Ключові слова: нервово-м’язова дисфункція сечового міхура, міоневротизація сечового міхура, діти.
Встановлено, що у дітей існує тісний зв’язок між констипацією та проблемами сечового тракту, вклю... more Встановлено, що у дітей існує тісний зв’язок між констипацією та проблемами сечового тракту, включаючи інфекції, нічне нетримання сечі (енурез), міхурово-сечовідний рефлюкс та розширення верхніх сечових шляхів [Averbeck M.A., Madersbacher H., 2011; Muhammad S. et al, 2015]. J Pannek et al. (2009) описали випадки затримки сечопуску внаслідок масивної констипації, коли калові маси перекривали сечові шляхи. Erhun Kasirga et al. (2006) встановили значно більшу частоту інфекцій сечових шляхів у хворих дітей із констипаційним синдромом. Veiga ML et al. (2013) встановили, що діти із нейрогенною дисфункцію сечового міхура мають більші шанси на констипацію, ніж ті, у яких відсутні симптоми нижніх сечових шляхів.
На основі отриманих літературних даних та результатів власних спостережень, встановлено взаємозв’язок між констипаційним синдромом та нервово-м’язовою дисфункцію сечового міхура у дитячому віці.
Таким чином, порушення функції сечового міхура у контексті її кореляції із констипаційним синдромом, є актуальною проблемою, яка через свою багатовекторність потребує подальшого вивчення та розробки як новітніх діагностичних алгоритмів, так і комплексного лікування.
Children were found to have close connection between
constipation and urinary tract problems including infections, bedwetting (enuresis), vesicoureteral reflux, and the dilation of the upper urinary tract [Averbeck M.A., Madersbacher H., 2011; Muhammad S. et al, 2015]. J Pannek et al. (2009) described cases of urinary retention as a result of massive constipation when stool blocked urinary tract. Erhun Kasirga et al. (2006) found a significantly greater frequency of urinary tract infections in children of patients with constipation syndrome. Veiga ML et al. (2013) found that children with neurogenic bladder dysfunction have greater chances of constipation than those who have no lower urinary tract symptoms.
Based on the literature data and the results of our own observations, the interrelation between constipation syndrome and neuromuscular dysfunction of the bladder in children was established.
Thus, urinary bladder dysfunction in the context of its correlation with constipation syndrome is an urgent problem, which requires further study and development of a new diagnostic algorithms, and comprehensive treatment due to its multi-vector nature.
Considering that there are no official statistic data concerning the prevalence rate of pelvic va... more Considering that there are no official statistic data concerning the prevalence rate of pelvic varicose veins and clear diagnostic and treatment criteria of above mentioned disease and, besides, a presence of evidence-based negative impact of pelvic varices on internal sex organs in women of reproductive age, a detailed study of pelvic
congestion syndrome in paediatric practice is required. Moreover, well-informed physicians ensure early diagnostics and efficient treatment, which will permit to reduce the frequency of an unnecessary laparotomy in the case of
abdominal pains in girls. Thus, it is necessary to discuss the wider application of the minimally invasive surgery techniques in treatment of abdominal pains in girls.
Враховуючи відсутність статистичних даних стосовно поширеності варикозного розширення вен малого ... more Враховуючи відсутність статистичних даних стосовно поширеності варикозного розширення вен малого таза та чітких критеріїв діагностики та лікування вказаної патології, доведений негативний вплив ова-рикоцеле на функцію внутрішніх статевих органів у жінок репродуктивного віку, існує необхідність у більш детальному вивченні проблеми венозного повнокров'я малого таза у дитячому віці. Поінформованість спеціалістів стосовно оварикоцеле дозволить проводити своєчасну діагностику та ефективне лікування, що призведе до зменшення кількості непотрібних лапаротомій з приводу абдомінального болю у дівчаток. Необхідно обговорювати ширше застосування малоінвазивних технологій при хірургічному лікуванні абдомінального больового синдрому у дівчаток.
Urethral caruncle — a disease of the distal urethra, which occurs mainly in postmenopausal women.... more Urethral caruncle — a disease of the distal urethra, which occurs mainly in postmenopausal women.
It is located on the back meatal wall. The available literature describes few cases of urethral caruncle in girls.
The only treatment for caruncle is surgery, which consists of its excision. The following is a clinical case of treatment of urethral caruncle complicated with neuromuscular dysfunction of the bladder in a 9-year-old girl. Thus,
urethral caruncle in girls is a fairly rare disease. It may cause an obstruction below the bladder, leading to neuromuscular dysfunction of the bladder. Surgical removal for urethral caruncle eliminates the formation of obstruction below the bladder and improves evacuation function of the bladder
Актуальність. Пошкодження уретри при пошкодженні кісток таза в дітей відмічається рідше, ніж у до... more Актуальність. Пошкодження уретри при пошкодженні кісток таза в дітей відмічається рідше, ніж у дорослих (менше 1 %) (Tarman G.J. et al., 2002). Посттравматична стриктура уретри в дітей є досить рідкісною та складною урологічною патологією. З урахуванням анатомічних особливостей лікування стриктури уретри в дітей відрізняється від її лікування в дорослих (Onen A. et al., 2005; Nerli R.B. et al., 2008; Ranjan P. et al., 2011). М.М. Koraitim (2012) описав досвід лікування 20 хворих з ускладненнями після трансперинеальної пластики уретри. Автор відмітив, що у разі відсутності необхідності реконструкції шийки сечового міхура достатньо ефективним є ендоскопічне розсічення стриктури уретри. Т.Е. Helmy, А.Т. Hafez (2013) теж описали результати успішного застосування ендоскопічного обладнання (пряма візуальна уретротомія) після відкритих уретропластик. Важливим моментом, що спонукає до пошуку ефективних малоінвазивних методів лікування посттравматичних стриктур уретри в дітей, є розвиток еректильної дисфункції у подальшому, що, за даними деяких авторів (Koraitim M.M., 2014), становить до 47 %. Мета дослідження: на основі доступних літературних даних і власних результатів лікування дітей із стриктурами задньої уретри установити роль ендоскопічного лікування вказаної складної патології як методу профілактики та лікування нервово-м'язової дисфункції сечового міхура. Матеріали та ме-тоди. На базі хірургічних відділень Житомирської обласної дитячої клінічної лікарні широко впроваджені малоінвазивні ендоскопічні методи діагностики та лікування патології нижніх сечових шляхів. Наявне обладнання дає можливість проводити діагностичні процедури, починаючи з місячного віку. Виконується цілий ряд ендоскопічних оперативних втручань на нижніх сечових шляхах, а саме: видалення конкремен-тів, розсічення клапанів та стриктур задньої уретри, розсічення кіст уретри та ектопічних уретероцеле тощо. Також у 2010 році вперше виконано спробу за допомогою черезшкірної трипортової цистоскопії видалити вклинений у рубцево-змінену задню уретру конкремент. З 2013 року розпочато лікування посттравматичних стриктур задньої уретри під ендоскопічним контролем. Результати. Подано результати успішного малоінвазивного лікування із застосуванням сучасного ендоскопічного обладнання у двох хворих із посттравматичними стриктурами задньої уретри. Особливо наголошено на ефективності методу в діагностиці та лікуванні нервово-м'язової дисфункції сечового міхура в даної категорії хворих. Висновки. Отже, застосування сучасного малоінвазивного обладнання не лише дає можливість ефективно діагностувати пошкодження нижніх сечових шляхів, а й може бути дієвим механізмом малотравматичного хірургічного лікування при коротких посттравматичних стриктурах уретри в дитячому віці. Своєчасне якісне лікування рубцевих стриктур уретри в дітей зведе до мінімуму розвиток інфравезикальної обструкції та порушення евакуаторної функції сечового міхура із розвитком його нервово-м'язової дисфункції.
Background. Damage to the urethra in damaged pelvic
bones in children is marked less than in adults (less than 1 %) (Tarman G.J. et al., 2002). Post-traumatic urethral stricture in children is a quite rare and complex urologic pathology. Due to anatomical features, treatment for urethral stricture in children is different from its treatment in adults (Onen A. et al., 2005; Nerli R.B. et al., 2008; Ranjan P. et al., 2011). M.M. Koraitim (2012) described the experience of treating 20 patients with complications after transperyneal urethral plasty. The author noted that in the absence of need for reconstruction of the bladder neck, it is quite effective to use endoscopic incision of urethral stricture. T.E. Helmy, A.T. Hafez (2013) also described the results of the successful application of endoscopic equipment (direct visual urethrotomia) after open urethroplasty. The important point that leads to finding effective minimally invasive treatments for post-traumatic urethral strictures in children is the development of erectile dysfunction in the future, the incidence of which, according to some authors, (Koraitim M.M.,
2014) is up to 47 %. The aim of the study: based on the available published data and own treatment outcomes in children with posterior urethral strictures, to establish the role of endoscopic treatment of this complex pathology as a method of prevention and treatment of neuromuscular dysfunction of the bladder.
Materials and methods. At the premises of the surgical departments of Zhytomyr Regional Children’s Clinical Hospital, there were widely implemented invasive endoscopic methods for the diagnosis and treatment of pathologies of the lower urinary tract. Available equipment enables to carry out diagnostic procedures from 1 month old. A variety of endoscopic surgeries on the lower urinary tract is being performed, namely — the removal of calculi, incision of valves and strictures of the posterior urethra, dissection of urethral cysts and ectopic ureterocaele, etc. Also in 2010, the first attempt was made to remove a calculus from the posterior urethra by means of percutaneous 3-port cystoscope. From 2013, the treatment of post-traumatic strictures of the posterior urethra began using endoscopic control.
Results. The article presents the results of a successful minimally invasive treatment using modern endoscopic equipment in two patients with post-traumatic posterior urethral strictures.
A special attention was paid to the effectiveness of the method in the diagnosis and treatment of neuromuscular dysfunction of the bladder in these patients. Conclusions. Consequently, the use of minimally invasive modern equipment not only makes it possible to effectively diagnose the damage to lower urinary tract, but also can be an effective mechanism for low-impact surgery at short post-traumatic urethral strictures in children.
Timely adequate treatment of scar urethral strictures in children will minimize the incidence of infravesical obstruction and violation of the evacuation function of the bladder with the development of its neuromuscular dysfunction.
Інтерстиціальні клітини Кахаля (ІКК) були відкриті у 1893 році у стінці кишечника і лише майже че... more Інтерстиціальні клітини Кахаля (ІКК) були відкриті у 1893 році у стінці кишечника і лише майже через 100 років інтерес до ІКК відновився. Сучасні технології дали можливість виявити схожі клітини в інших органах, зокрема тих, що містять м'язові волокна та, відповідно, підлягають скороченню. Так, ІКК були виявлені у сечових шляхах, фаллопієвих трубах, сім'яних канальцях тощо. Подальше дослідження функції ІКК встановило зв'язок між порушенням периферичної інформації сечового міхура (нервово-м'язова дисфункція сечового міхура) та концентрацією ІКК. Таким чином, дослідження концентрації ІКК у стінці сечового міхура при його дисфункції може вплинути на тактику ведення хворих у перспективі.
Interstitial cells of Cajal (ICC) were first discovered in 1893 in the wall of the intestine, and only after almost 100 years of interest in the ICC recovered. In addition, modern technologies have allowed to identify similar cells in other organs, in particular those that contain the muscle fibers and, accordingly, shall be
subject to reduction. So, ICC was detected in the urinary tract, fallopian tubes, the seminiferous tubules etc. Further study of the functions of the ICC has established a link between human peripheral information of the bladder (neuromuscular dysfunction of bladder) and the concentration of ICC. Thus, the measurement of ICC in the bladder wall when it is dysfunction may affect the tactics of patient management in the future.
Introduction. Urolithiasis in children is an important clinical problem in pediatric urological p... more Introduction. Urolithiasis in children is an important clinical problem in pediatric urological practice. Note that while growth in the prevalence of urolithiasis in
pediatric populations, the frequency of bladder calculus significantly reduced. Acquires particular importance urolithiasis in violation of urodynamics caused
by neuro muscular dysfunction of the bladder (NMDB) (Kroovand R.L., 1997; Rizvi S.A.H. et al., 2002; Ramachandra P. et al., 2014).
The aim of the study. Analyze the causes and consequences of the formation of bladder calculus in childhood, especially in violation of its accumulation and/or evacuation functions, as well as modern methods of complex (including surgical) treatment of its disease.
Materials and methods. Since 2008 on the base of the Zhytomyr Regional Children's Clinical Hospital operated on 17 children urolithiasis. However, 3 (17.6%)
children perform endoscopic surgery (in 2 (66.6%) — 2 of deferred time attempts) failed (1 — herniation calculus in scar modified bladder neck, 1 — ureter
al stricture 1 — cystitis). Thus, 14 children generally performed 19 surgeries, including: 3 (15.8%) — open and 16 (84.2%) — endoscopically. So, 3 (17.6%)
children were operated more than 1 times: 1 child 2 times (1 — open + 1 — endoscopy); 1 child 2 times (both endoscopically); 1 child 4 times (1 — open + 3 — endoscopically). The average age of children was 11.95 yrs (4–17 yrs). Distribution by gender: 75% — boys, 25% — girls. Distribution
calculus localization (those who underwent surgery, and those in which the conduct surgery failed to): bladder — 3 (13.6%), ureter — 13 (59.1%),
kidney+ureter — 4 (18.2%), kidney — 2 (9.1%). The average hospital stay was 9.2 days. Found that in NMDB patients, the prevalence of microorganisms in the genus Proteus bacteriological examination of urine was 4.8% of all selected urine cul
tures in 2010, a significant increase to 15.4% in 2013 and 14,8% in 2015.
Results and discussion. These clinical cases of different types of surgery other complications NMDB children — stone. Confirmed important role Proteus
infection among etiological factors bladder calculus formation in childhood.
Conclusions. The problem of stone formation is a key issue in patients with bladder dysfunction. An important etiological link Proteaceae stone is urinary tract infection. Tactics of surgical treatment should be aimed exclusively at reducing urinary tract trauma. Minimally invasive treatment of urolithiasis in patients
with bladder dysfunction make it possible to minimize damage to the bladder wall, reduce postoperative period.
Introduction. Hydronephrosis in children is an
obstruction of pyeloureteral segment, which is usu... more Introduction. Hydronephrosis in children is an
obstruction of pyeloureteral segment, which is usually diagnosed antenatal by ultrasound screening in 1.5 % of pregnancies. Pathophysiology is still unknown. The most common pathogenetic reasonable treatment of congenital obstruction pelvicoureteral segment (hydronephrosis) in children is a surgical treatment. As a rule, open methods are applied (by Hynes-Anderson and other methods). Recently endoscopic treatment has being discussed. Increasingly there are reports of the use of robotic equipment. According to the data of different authors successful results of Hynes — Anderson techniques reach 95 %. The question on the upper urinary tract drainage is still discussed. The choice of stent placement usually depends on the surgeon, although the analysis of literature data indicates a decrease in percentage of complications after stent using. The aim of the study. To analyze the methods and ways of urinary diversion in the surgical treatment of congenital hydronephrosis in children. Materials and methods. On the basis of the surgical department № 2 Zhytomyr Regional Children’s Hospital (ZhRCH) for the period from 2000 to 2015 108 children were operated. The average age of patients was 3.8 years old. There were 38 (35.2 %) boys and 70 girls (64.8 %). The gold standard is Hynes — Anderson technique. Until 2006, external drainage of urinary tract surgery was mainly performed, while from 2006 close way was implemented, and from 2009 — the use of JJ-stent. Since 2010, videoassistant metnod was introduced (laparoscopic stage — mobilization of pelvicoureteral segment with further anastomosis through minilaparotomy access). In 2016 at the ZhRCH laparoscopic plastic was firstly performed for a boy aged 6 years old. The average duration of the intervention was 106 ± 32 min. Conclusions. The question on urinary tract drainage after pelvicoureteral segment plastic in children with congenital hydronephrosis should be considered individually only. The question on stent installation method remains unclear.
After the indications for surgical treatment of congenital hydronephrosis in children are determined the function of the lower urinary tract must be considered to ensure the efficient derivation of urine in the postoperative period (the presence of concomitant neuromuscular dysfunction of the bladder).
The Problem Of Stone Formation In Children With Neuromuscular Dysfunction Of Bladder
D. Shevchuk
... more The Problem Of Stone Formation In Children With Neuromuscular Dysfunction Of Bladder
D. Shevchuk
Zhytomyr Regional Children's Hospital, Zhytomyr, Ukraine
Zhytomyr State University named after Ivan Franko, Zhytomyr, Ukraine
National Medical Academy of Postgraduate Education named after PL Shupyk, Kyiv, Ukraine
Introduction. Urolithiasis in children is an important clinical problem in pediatric urological practice. Note that while growth in the prevalence of urolithiasis in
pediatric populations, the frequency of bladder calculus significantly reduced. Acquires particular importance urolithiasis in violation of urodynamics caused
by neuro muscular dysfunction of the bladder (NMDB) (Kroovand R.L., 1997; Rizvi S.A.H. et al., 2002; Ramachandra P. et al., 2014).
The aim of the study. Analyze the causes and consequences of the formation of bladder calculus in childhood, especially in violation of its accumulation and/or
evacuation functions, as well as modern methods of complex (including surgical) treatment of its disease.
Materials and methods. Since 2008 on the base of the Zhytomyr Regional Children's Clinical Hospital operated on 17 children urolithiasis. However, 3 (17.6%)
children perform endoscopic surgery (in 2 (66.6%) — 2 of deferred time attempts) failed (1 — herniation calculus in scar modified bladder neck, 1 — ureter
al stricture 1 — cystitis). Thus, 14 children generally performed 19 surgeries, including: 3 (15.8%) — open and 16 (84.2%) — endoscopically. So, 3 (17.6%)
children were operated more than 1 times: 1 child 2 times (1 — open + 1 — endoscopy); 1 child 2 times (both endoscopically); 1 child 4 times
(1 — open + 3 — endoscopically). The average age of children was 11.95 yrs (4–17 yrs). Distribution by gender: 75% — boys, 25% — girls. Distribution
calculus localization (those who underwent surgery, and those in which the conduct surgery failed to): bladder — 3 (13.6%), ureter — 13 (59.1%),
kidney+ureter — 4 (18.2%), kidney — 2 (9.1%). The average hospital stay was 9.2 days.
Found that in NMDB patients, the prevalence of microorganisms in the genus Proteus bacteriological examination of urine was 4.8% of all selected urine cul
tures in 2010, a significant increase to 15.4% in 2013 and 14,8% in 2015.
Results and discussion. These clinical cases of different types of surgery other complications NMDB children — stone. Confirmed important role Proteus
infection among etiological factors bladder calculus formation in childhood.
Conclusions. The problem of stone formation is a key issue in patients with bladder dysfunction. An important etiological link Proteaceae stone is urinary tract
infection. Tactics of surgical treatment should be aimed exclusively at reducing urinary tract trauma. Minimally invasive treatment of urolithiasis in patients
with bladder dysfunction make it possible to minimize damage to the bladder wall, reduce postoperative period.
Introduction. Prevalence of neuromuscular bladder
dysfunction (NMBD) in the population of childre... more Introduction. Prevalence of neuromuscular bladder
dysfunction (NMBD) in the population of children is significant.
The main manifestation of NMBD is urinary disorder, which consists is often/rare urination, incontinence. Consequently — the social maladjustment of the child and his parents. Typically, NMBD is the outcome of the innervation disorder of the bladder, but posterior
urethral valves, which are the main cause infravesical obstruction in childhood, are of great importance (Atwell J.D., 1983). To preserve kidney function and to prevent urinary tract infections are main tasks
in patients with NMBD, while urinary retention — a secondary one (Stein R. et al., 2012). In infants with posterior urethral valves and refluxing ureterohydronephrosis complicated by recurrent pyelonephritis and/or chronic renal failure, to ensure the efficient derivation of urine, vesicostomy or ureterocutaneostomycan be used. Efficacy
of using the drainage-free methods of urinary diversion, according to various authors, reaches 88 and 79 % (Kozyrev H.V., 2008; Nanda M. et al., 2012). Efficacy of vesicostomy in young children suffering from
anorectal pathology and myelodysplasia has been noted by domestic authors too (Makedonskyi I.O., 2013). J.C. Hutcheson et al. (2001) noted the positive effect of prolonged vesicostomy use in patients with
neuromuscular dysfunction of the bladder due to myelodysplasia.
Materials and methods. During the period of 2010–2015, in the Zhitomyr Regional Children’s Hospital, there were operated 10 patients with complications of neuromuscular dysfunction of the bladder (megaureter
obstructive/refluxing, urinary tract infection, reduced renal function, etc.). The protocol included examinations: laboratory one (general clinical, biochemical, microbiological), instrumental (ultrasound
of the kidneys (full and empty bladder) and bladder with
obligatory determination of residual urine; X-ray contrast — excretory urography in the absence of renal insufficiency with a glomerular filtration rate < 50 ml/min and voiding cystography (in correction
of urinary tract infection); dynamic renoscyntigraphy; urodynamic study). 3 patients before the surgery had partial renal dysfunction. 12 surgeries were carried out (in 1 child ureterocutaneostomy was made
simultaneously on both sides, in 1 — ureterocutaneostomy shifting
was made due to decompensated stenosis of bladder outlet). Of these, 3 vesicostomy were performed (by Blocksom method) (mean age of patients was 8 years old), 9 ureterocutaneostomy (by methods of Wilson — 6 cases and Sober — 3 cases) (mean age of patients — 7
months). By sex, there was marked the following distribution: 9 boys, 1 girl. All the patients before the surgery underwent diagnostic ureterocystoscopy
to assess the condition of the bladder wall, function
and anatomical location of the orifice of ureter, presence/absence of infravesical obstruction (posterior urethral valve and/or bladder neck stricture) etc. In 4 patients, imposition of vesicostomy/ureterocutaneostomy
was preceded by endoscopic dissection of the posterior
urethral valve due to diagnosed infravesical obstruction. In 1 patient, during control monitoring 1.5 years after the endoscopic dissection of
the posterior urethral valve and at the imposition of ureterocutaneostomy in unilateral megaureter, we confirmed the reduction of dilatation
of the upper urinary tract and restoration of the kidney and bladder function, that made it possible to close the ureterocutaneostomy without additional reconstructive surgeries. In one child, in which we carried out the imposition of cutaneostomy and its closure in 2 years
(in the clinic outside the region area) without additional endoscopic diagnosis and endoscopic dissection of posterior urethral valve, obstructive megaureter recovery was noted with the sharp decrease in
the excretory function of the kidney. A clinical case of the treatment for complications of neuromuscular dysfunction of the bladder using drainage-free methods (including vesicostomy) is presented.
Conclusions.
1. Neuromuscular dysfunction of bladder, caused by infravesical obstruction in particular, requires prompt surgical correction (in the neonatal period).
2. In case of endoscopic treatment failure, difficulties during permanent bladder catheterization, it is indicated to use drainage-free methods for urine diversion (vesicostomy/ureterocutaneostomy)
as a temporary measure to restore urodynamics.
3. Application of vesicostomy enables to reduce the phenomenon of dilatation of the upper urinary tract, to improve renal perfusion and to reduce the effects of uremia.
Foreign bodies bladder in children are rare. M. Rafique (2008) described the experience of treatm... more Foreign bodies bladder in children are rare. M. Rafique (2008) described the experience of treatment of 16 patients with foreign bodies bladder. With this author in 7 (43.8%) patients had foreign bodies iatrogenic origin. The method of removing a foreign body determined individually, but minimally invasive could remove only 50% of foreign bodies. K.A.R. Hutton and S.N. Huddart (1999) described a case of successful removal of foreign body in bladder (catheter fragment) percutaneous way under visual cystoscopy control in 4-month-old child. In this work the clinical case the use of percutaneous cystoscopy to remove a foreign body in bladder in patients with neuromuscular dysfunction of the bladder. So, percutaneous cystoscopy is a good alternative to open surgery for the pathology of the urinary bladder in children, especially in violation of its storage and/or evacuation functions.
D.V. SHEVCHUK1,2,3, P.S. RUSAK1,2, I.M. VYSHPINSKYY1, V.R. ZAREMBA1
1Zhytomyr Regional Clinical C... more D.V. SHEVCHUK1,2,3, P.S. RUSAK1,2, I.M. VYSHPINSKYY1, V.R. ZAREMBA1
1Zhytomyr Regional Clinical Children's Hospital; 2National Medical Academy of Postgraduate Education named after
PL Shupyk; 3Zhytomyr State University named after Ivan Franko
APPLICATION OF PERCUTANEOUS CYSTOSCOPY TO REMOVAL OF FOREIGN BODY IN CHILD PATIENTS
WITH NEUROMUSCULAR BLADDER DYSFUNCTION
Foreign bodies bladder in children are rare. M. Rafique (2008) described the experience of treatment of 16 patients
with foreign bodies bladder. With this author in 7 (43.8%) patients had foreign bodies iatrogenic origin. The
method of removing a foreign body determined individually, but minimally invasive could remove only 50% of foreign
bodies. K.A.R. Hutton and S.N. Huddart (1999) described a case of successful removal of foreign body in
bladder (catheter fragment) percutaneous way under visual cystoscopy control in 4-month-old child. In this work
the clinical case the use of percutaneous cystoscopy to remove a foreign body in bladder in patients with neuromuscular
dysfunction of the bladder. So, percutaneous cystoscopy is a good alternative to open surgery for the
pathology of the urinary bladder in children, especially in violation of its storage and/or evacuation functions.
Key words: neuromuscular dysfunction of bladder, percutaneous cystoscopy, foreign bodies
Microbiological description of urine of patients with neuromuscular
bladder dysfunction children
... more Microbiological description of urine of patients with neuromuscular
bladder dysfunction children
D.V. Shevchuk1, 2, 3, O.A. Danylov2, V.L. Tyndykevych1, L.H. Mahanova1
1 Zhytomyr Regional Children Clinical Hospital
2 P.L. Shupyk National Medical Academy of Postgraduate Education
3 Zhytomyr State University named after Ivan Franko
Objective. Explore the microbiological characteristics of urine in patients with neuromuscular dysfunction of bladder children,
including antibiotic resistance of pathogens that often cause catheter-associated bacteriuria and/or urinary tract infection.
Materials and methods. We analyzed the results of bacteriological studies in the urine of patients with urinary tract infection
who were treated at the offices of the Zhytomyr Regional Child’s Clinical Hospital in 2010 and 2013. Overall in 2010 studied 259
samples of urine, while in 2013 — 309. In 2010 with positive results detected 107 samples, representing 41.3 % of total bacteriological
urine cultures, and in 2013 — 108 (35 %). Etiologic factor in inflammatory processes of the urinary tract were often such
microorganisms: E. coli, E. faecalis, Ps. aeruginosa, Kl. pneumonia, bacteria p. Proteus and others. This stood out as mono- (88.8 %
in 2010 and 87 % in 2013) and the mixed culture.
During 2010 bacteriologically examined 22 children suffering from neuromuscular dysfunction of the bladder, which was
performed 29 bacteriological studies of urine. Of these 27 positive results (25.2 % of all during the year positive bacteriological
seeding urine). Among all hanging in this group of sick children monoculture were 21 (77.8 %), while the combination of cultures
was 6 (22.2 %) cases. In 2013 was bacteriologically examined 16 children with neuromuscular dysfunction of the bladder. Completed
21 urine samples, obtained 15 positive results (13.9 % of all positive bacteriological seeding year).
Results and discussion. After analyzing the results of bacteriological studies can be noted that in 2013 compared to 2010 is 3 times
the percent of infections caused by bacteria Proteus mirabilis and vulgaris, and Enterococcus faecalis, a 30 % increase in the proportion
of infections caused by E. coli. In contrast, 2.5 times the percentage of infection pathogen which was Kl. pneumoniae, 30 % —
Ps. aeruginosa. In addition, nearly 2 times the percentage of complex mixed infections. Established that Kl. pneumoniae represented
50 % of mixed infections with neuromuscular dysfunction of the bladder in 2010, while in 2013 — 100 % of cases. It was established
that the observed reduction in the number of microbial contamination on all the most common pathogens. For antibiotic
susceptibility observed dynamic reduction to almost all products.
Conclusions. Implementation of effective methods of derivation of urine in patients with neuromuscular dysfunction of the
bladder in children led to a decrease of catheter-associated bacteriuria and microbial load on the body of a child. The widespread
use of antibiotics leads to reduced sensitivity of microorganisms to most common antibiotics. There is a need for a differentiated
approach to the integrated use of antibiotics in patients with violations of urination children.
Key words: neuromuscular dysfunction of bladder, catheter-associated bacteriuria, pathogens, antibiotic resistance, children.
Summary. This work is dedicated to the early analysis of the using endoscopic treatment for vesic... more Summary. This work is dedicated to the early analysis of the using endoscopic treatment for vesicoureteral reflux in child. Two techniques of endoscopic treatment for vesicoureteral reflux in Zhytomyr regional child hospital is comprised.
Summary. An economical calculation of the treatment varicocele in child and adolescents by use of... more Summary. An economical calculation of the treatment varicocele in child and adolescents by use of different methods in the paediatric surgery clinic is shown in this article. Remote calculation in addition to modern publishing datas about the most typical complications of operations for varicocele (more frequent is persistent) is shown too.
Summary. In patients with miyelodysplazia urination disorders are 95–98%. Found that 62% of patie... more Summary. In patients with miyelodysplazia urination disorders are 95–98%. Found that 62% of patients with miyelodysplazia discoordination detrusor contraction and sphincter (sphincter-detruzo dyssynerhia) and are likely to use adequate permanent catheterization and anticholinergic drugs. In addition, 45% of patients observed a violation of the locking properties sphincter. Botulinum toxin A - neurotoxic protein produced by the bacterium Clostridium botulinum with the presynaptic blocking effect, which provides the selective blockade of the detrusor during its intramuscular injection. It is proved that the BTA blocks muscle M2, M3, and R2H2 R2H3 receptors, which makes it possible to increase the volume of the bladder in children. Also, there is evidence that botulinum toxin A reduces the level of nerve growth factor (nerve growth factor (NGF)). In general, the positive effect of the use of botulinum toxin A is observed in 75% of children with miyelodysplazia. In this paper the clinical example of effective use of botulinum toxin A in a child with neuromuscular dysfunction of the bladder as a result of spinal dyzrafia. Thus, it was found that injection of botulinum toxin A intradetruzor is sufficiently effective and safe alternative in the surgical treatment of resistant forms of neuromuscular bladder dysfunction in children operated on dyzrafia spinal cord. The technique is simple in execution, is well tolerated by patients, the effect occurs in a relatively short time, has a prolonged effect. Intradetruzor injection of botulinum toxin A may be offered to all patients with sphincter-detruzor dyssynerhia and/or cistalgia anywhere in life.
Objective. Explore the microbiological characteristics of urine in patients with neuromuscular dy... more Objective. Explore the microbiological characteristics of urine in patients with neuromuscular dysfunction of bladder children,
including antibiotic resistance of pathogens that often cause catheter-associated bacteriuria and/or urinary tract infection.
Materials and methods. We analyzed the results of bacteriological studies in the urine of patients with urinary tract infection who were treated at the offices of the Zhytomyr Regional Child’s Clinical Hospital in 2010 and 2013. Overall in 2010 studied 259 samples of urine, while in 2013 — 309. In 2010 with positive results detected 107 samples, representing 41.3 % of total bacteriological urine cultures, and in 2013 — 108 (35 %). Etiologic factor in inflammatory processes of the urinary tract were often such microorganisms: E. coli, E. faecalis, Ps. aeruginosa, Kl. pneumonia, bacteria p. Proteus and others. This stood out as mono- (88.8 % in 2010 and 87 % in 2013) and the mixed culture.
During 2010 bacteriologically examined 22 children suffering from neuromuscular dysfunction of the bladder, which was
performed 29 bacteriological studies of urine. Of these 27 positive results (25.2 % of all during the year positive bacteriological seeding urine). Among all hanging in this group of sick children monoculture were 21 (77.8 %), while the combination of cultures was 6 (22.2 %) cases. In 2013 was bacteriologically examined 16 children with neuromuscular dysfunction of the bladder. Completed 21 urine samples, obtained 15 positive results (13.9 % of all positive bacteriological seeding year).
Results and discussion. After analyzing the results of bacteriological studies can be noted that in 2013 compared to 2010 is 3 times the percent of infections caused by bacteria Proteus mirabilis and vulgaris, and Enterococcus faecalis, a 30 % increase in the proportion of infections caused by E. coli. In contrast, 2.5 times the percentage of infection pathogen which was Kl. pneumoniae, 30 % — Ps. aeruginosa. In addition, nearly 2 times the percentage of complex mixed infections. Established that Kl. pneumoniae represented 50 % of mixed infections with neuromuscular dysfunction of the bladder in 2010, while in 2013 — 100 % of cases. It was established
that the observed reduction in the number of microbial contamination on all the most common pathogens. For antibiotic susceptibility observed dynamic reduction to almost all products.
Conclusions. Implementation of effective methods of derivation of urine in patients with neuromuscular dysfunction of the
bladder in children led to a decrease of catheter-associated bacteriuria and microbial load on the body of a child. The widespread use of antibiotics leads to reduced sensitivity of microorganisms to most common antibiotics. There is a need for a differentiated approach to the integrated use of antibiotics in patients with violations of urination children.
Авторами висвітлено проблеми діагностики абдомінальної форми крипторхізму у дітей та успішне ліку... more Авторами висвітлено проблеми діагностики абдомінальної форми крипторхізму у дітей та успішне лікування цієї патології за допомогою лапароскопічного методу. The problems of diagnostics abdominal form of cryptorchism children and succesfull laparoscopic treatment of this disease are shown in this article.
Ureteral duplication is a comparatively frequent urinary tract anomaly. Ureteral triplication is ... more Ureteral duplication is a comparatively frequent urinary tract anomaly. Ureteral triplication is rare, but quadruplication is extremely rare. In this study, we describe a case of ureteral quintuplication, the first such report in the English-language literature. A newborn female baby was diagnosed with left ureteral quintuplication. The left ureter was divided into 5 ureters with 5 renal pelvises within approximately 3 cm of the urinary bladder, and trace parenchyma of the kidney was noted. The patient was born within 60 km of the epicenter of the 1986 Chernobyl disaster, 24 years after the catastrophic nuclear accident, and is currently aged 3 years. UROLOGY 83: 211e213, 2014. Ó 2014 Elsevier Inc.
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Papers by Dmytro Shevchuk
добрий клінічний ефект від консервативної терапії, до якої відносять застосування медикаментозних препаратів
та чистої інтермітуючої катетеризації. Однак 10–20% пацієнтів вказаної категорії підлягають тим
чи іншим методам хірургічного лікування. Враховуючи, що у хворих із мієлодисплазією розлади сечовипускання
становлять 95–98%, особливу увагу слід приділяти комплексному лікуванню нервово-м’язової
дисфункції сечового міхура (НМДСМ) у даної категорії хворих дітей (E. Smith, 1965; J.D. van Gool та співавт.,
2001). Однак на даний час не існує способів радикального хірургічного НМДСМ при порушенні його іннервації.
Мета: дослідити можливість хірургічного відновлення іннервації сечового міхура при рефрактерних
формах його нервово-м’язової дисфункції у дітей.
Пацієнти і методи. Враховуючи відсутність у доступній літературі уніфікованого методу хірургічного
лікування рефрактерної до терапії НМДСМ, особливо при порушенні іннервації сечового міхура, авторами
розроблено принципово новий метод хірургічного лікування, який передбачає реіннервацію (міоневротизацію)
сечового міхура (Спосіб іннервації нейрогенного сечового міхура. Патент на винахід
№102801 UA МПК (2013.01): А61В 17/00). Суть методу полягає у вживлянні нерва (який має соматичну та
вегетативну іннервацію), що формується вище місця ураження спинного мозку при спінальних дизрафіях,
у стінку сечового міхура.
Результати. Із застосуванням запропонованого методу починаючи із 2001 р., на клінічних базах Національної
медичної академії післядипломної освіти імені П.Л. Шупика (Київська міська дитяча клінічна лікарня
№1 та Житомирська обласна дитяча клінічна лікарня) було прооперовано 9 хворих на НМДСМ дітей.
Вік хворих становив від 4 до 14 років (у середньому 6,5 року). У ході контрольного обстеження, яке проводилось
5 (55,6%) хворим, відмічена позитивна динаміка у 4 (80%) хворих.
До суб’єктивних позитивних зрушень пацієнти відносили наступне: поява відчуття наповнення сечового
міхура – у 5 (100%) хворих, утримання сечі – у 4 (80%) хворих, сечопуск струменем – у 5 (100%) хворих.
До об’єктивних позитивних зрушень віднесено: зменшення кількості залишкової сечі – у 5 (100%) хворих;
зменшення ретенційних змін у верхніх сечових шляхах – у 5 (100%) хворих; зменшення ступеня чи повна ліквідація
міхурово-сечовідного рефлюксу – у 100% хворих, у яких був наявний рефлюкс; тривала ремісія інфекції
сечових шляхів зі зменшенням/ліквідацією бактеріурії – у 4 (80%) хворих. Жодних ускладнень не виявлено.
Висновки. Новий метод реіннервації сечового міхура – міоневротизація сечового міхура – є досить
ефективним методом лікування рефрактерної форми нервово-м’язової дисфункції сечового міхура у дітей.
Результати застосування методу потребують подальшого вивчення уродинамічних параметрів, що дасть
змогу рекомендувати метод для широкого впровадження у практику.
Ключові слова: нервово-м’язова дисфункція сечового міхура, міоневротизація сечового міхура, діти.
На основі отриманих літературних даних та результатів власних спостережень, встановлено взаємозв’язок між констипаційним синдромом та нервово-м’язовою дисфункцію сечового міхура у дитячому віці.
Таким чином, порушення функції сечового міхура у контексті її кореляції із констипаційним синдромом, є актуальною проблемою, яка через свою багатовекторність потребує подальшого вивчення та розробки як новітніх діагностичних алгоритмів, так і комплексного лікування.
Children were found to have close connection between
constipation and urinary tract problems including infections, bedwetting (enuresis), vesicoureteral reflux, and the dilation of the upper urinary tract [Averbeck M.A., Madersbacher H., 2011; Muhammad S. et al, 2015]. J Pannek et al. (2009) described cases of urinary retention as a result of massive constipation when stool blocked urinary tract. Erhun Kasirga et al. (2006) found a significantly greater frequency of urinary tract infections in children of patients with constipation syndrome. Veiga ML et al. (2013) found that children with neurogenic bladder dysfunction have greater chances of constipation than those who have no lower urinary tract symptoms.
Based on the literature data and the results of our own observations, the interrelation between constipation syndrome and neuromuscular dysfunction of the bladder in children was established.
Thus, urinary bladder dysfunction in the context of its correlation with constipation syndrome is an urgent problem, which requires further study and development of a new diagnostic algorithms, and comprehensive treatment due to its multi-vector nature.
congestion syndrome in paediatric practice is required. Moreover, well-informed physicians ensure early diagnostics and efficient treatment, which will permit to reduce the frequency of an unnecessary laparotomy in the case of
abdominal pains in girls. Thus, it is necessary to discuss the wider application of the minimally invasive surgery techniques in treatment of abdominal pains in girls.
It is located on the back meatal wall. The available literature describes few cases of urethral caruncle in girls.
The only treatment for caruncle is surgery, which consists of its excision. The following is a clinical case of treatment of urethral caruncle complicated with neuromuscular dysfunction of the bladder in a 9-year-old girl. Thus,
urethral caruncle in girls is a fairly rare disease. It may cause an obstruction below the bladder, leading to neuromuscular dysfunction of the bladder. Surgical removal for urethral caruncle eliminates the formation of obstruction below the bladder and improves evacuation function of the bladder
Background. Damage to the urethra in damaged pelvic
bones in children is marked less than in adults (less than 1 %) (Tarman G.J. et al., 2002). Post-traumatic urethral stricture in children is a quite rare and complex urologic pathology. Due to anatomical features, treatment for urethral stricture in children is different from its treatment in adults (Onen A. et al., 2005; Nerli R.B. et al., 2008; Ranjan P. et al., 2011). M.M. Koraitim (2012) described the experience of treating 20 patients with complications after transperyneal urethral plasty. The author noted that in the absence of need for reconstruction of the bladder neck, it is quite effective to use endoscopic incision of urethral stricture. T.E. Helmy, A.T. Hafez (2013) also described the results of the successful application of endoscopic equipment (direct visual urethrotomia) after open urethroplasty. The important point that leads to finding effective minimally invasive treatments for post-traumatic urethral strictures in children is the development of erectile dysfunction in the future, the incidence of which, according to some authors, (Koraitim M.M.,
2014) is up to 47 %. The aim of the study: based on the available published data and own treatment outcomes in children with posterior urethral strictures, to establish the role of endoscopic treatment of this complex pathology as a method of prevention and treatment of neuromuscular dysfunction of the bladder.
Materials and methods. At the premises of the surgical departments of Zhytomyr Regional Children’s Clinical Hospital, there were widely implemented invasive endoscopic methods for the diagnosis and treatment of pathologies of the lower urinary tract. Available equipment enables to carry out diagnostic procedures from 1 month old. A variety of endoscopic surgeries on the lower urinary tract is being performed, namely — the removal of calculi, incision of valves and strictures of the posterior urethra, dissection of urethral cysts and ectopic ureterocaele, etc. Also in 2010, the first attempt was made to remove a calculus from the posterior urethra by means of percutaneous 3-port cystoscope. From 2013, the treatment of post-traumatic strictures of the posterior urethra began using endoscopic control.
Results. The article presents the results of a successful minimally invasive treatment using modern endoscopic equipment in two patients with post-traumatic posterior urethral strictures.
A special attention was paid to the effectiveness of the method in the diagnosis and treatment of neuromuscular dysfunction of the bladder in these patients. Conclusions. Consequently, the use of minimally invasive modern equipment not only makes it possible to effectively diagnose the damage to lower urinary tract, but also can be an effective mechanism for low-impact surgery at short post-traumatic urethral strictures in children.
Timely adequate treatment of scar urethral strictures in children will minimize the incidence of infravesical obstruction and violation of the evacuation function of the bladder with the development of its neuromuscular dysfunction.
Interstitial cells of Cajal (ICC) were first discovered in 1893 in the wall of the intestine, and only after almost 100 years of interest in the ICC recovered. In addition, modern technologies have allowed to identify similar cells in other organs, in particular those that contain the muscle fibers and, accordingly, shall be
subject to reduction. So, ICC was detected in the urinary tract, fallopian tubes, the seminiferous tubules etc. Further study of the functions of the ICC has established a link between human peripheral information of the bladder (neuromuscular dysfunction of bladder) and the concentration of ICC. Thus, the measurement of ICC in the bladder wall when it is dysfunction may affect the tactics of patient management in the future.
pediatric populations, the frequency of bladder calculus significantly reduced. Acquires particular importance urolithiasis in violation of urodynamics caused
by neuro muscular dysfunction of the bladder (NMDB) (Kroovand R.L., 1997; Rizvi S.A.H. et al., 2002; Ramachandra P. et al., 2014).
The aim of the study. Analyze the causes and consequences of the formation of bladder calculus in childhood, especially in violation of its accumulation and/or evacuation functions, as well as modern methods of complex (including surgical) treatment of its disease.
Materials and methods. Since 2008 on the base of the Zhytomyr Regional Children's Clinical Hospital operated on 17 children urolithiasis. However, 3 (17.6%)
children perform endoscopic surgery (in 2 (66.6%) — 2 of deferred time attempts) failed (1 — herniation calculus in scar modified bladder neck, 1 — ureter
al stricture 1 — cystitis). Thus, 14 children generally performed 19 surgeries, including: 3 (15.8%) — open and 16 (84.2%) — endoscopically. So, 3 (17.6%)
children were operated more than 1 times: 1 child 2 times (1 — open + 1 — endoscopy); 1 child 2 times (both endoscopically); 1 child 4 times (1 — open + 3 — endoscopically). The average age of children was 11.95 yrs (4–17 yrs). Distribution by gender: 75% — boys, 25% — girls. Distribution
calculus localization (those who underwent surgery, and those in which the conduct surgery failed to): bladder — 3 (13.6%), ureter — 13 (59.1%),
kidney+ureter — 4 (18.2%), kidney — 2 (9.1%). The average hospital stay was 9.2 days. Found that in NMDB patients, the prevalence of microorganisms in the genus Proteus bacteriological examination of urine was 4.8% of all selected urine cul
tures in 2010, a significant increase to 15.4% in 2013 and 14,8% in 2015.
Results and discussion. These clinical cases of different types of surgery other complications NMDB children — stone. Confirmed important role Proteus
infection among etiological factors bladder calculus formation in childhood.
Conclusions. The problem of stone formation is a key issue in patients with bladder dysfunction. An important etiological link Proteaceae stone is urinary tract infection. Tactics of surgical treatment should be aimed exclusively at reducing urinary tract trauma. Minimally invasive treatment of urolithiasis in patients
with bladder dysfunction make it possible to minimize damage to the bladder wall, reduce postoperative period.
obstruction of pyeloureteral segment, which is usually diagnosed antenatal by ultrasound screening in 1.5 % of pregnancies. Pathophysiology is still unknown. The most common pathogenetic reasonable treatment of congenital obstruction pelvicoureteral segment (hydronephrosis) in children is a surgical treatment. As a rule, open methods are applied (by Hynes-Anderson and other methods). Recently endoscopic treatment has being discussed. Increasingly there are reports of the use of robotic equipment. According to the data of different authors successful results of Hynes — Anderson techniques reach 95 %. The question on the upper urinary tract drainage is still discussed. The choice of stent placement usually depends on the surgeon, although the analysis of literature data indicates a decrease in percentage of complications after stent using. The aim of the study. To analyze the methods and ways of urinary diversion in the surgical treatment of congenital hydronephrosis in children. Materials and methods. On the basis of the surgical department № 2 Zhytomyr Regional Children’s Hospital (ZhRCH) for the period from 2000 to 2015 108 children were operated. The average age of patients was 3.8 years old. There were 38 (35.2 %) boys and 70 girls (64.8 %). The gold standard is Hynes — Anderson technique. Until 2006, external drainage of urinary tract surgery was mainly performed, while from 2006 close way was implemented, and from 2009 — the use of JJ-stent. Since 2010, videoassistant metnod was introduced (laparoscopic stage — mobilization of pelvicoureteral segment with further anastomosis through minilaparotomy access). In 2016 at the ZhRCH laparoscopic plastic was firstly performed for a boy aged 6 years old. The average duration of the intervention was 106 ± 32 min. Conclusions. The question on urinary tract drainage after pelvicoureteral segment plastic in children with congenital hydronephrosis should be considered individually only. The question on stent installation method remains unclear.
After the indications for surgical treatment of congenital hydronephrosis in children are determined the function of the lower urinary tract must be considered to ensure the efficient derivation of urine in the postoperative period (the presence of concomitant neuromuscular dysfunction of the bladder).
D. Shevchuk
Zhytomyr Regional Children's Hospital, Zhytomyr, Ukraine
Zhytomyr State University named after Ivan Franko, Zhytomyr, Ukraine
National Medical Academy of Postgraduate Education named after PL Shupyk, Kyiv, Ukraine
Introduction. Urolithiasis in children is an important clinical problem in pediatric urological practice. Note that while growth in the prevalence of urolithiasis in
pediatric populations, the frequency of bladder calculus significantly reduced. Acquires particular importance urolithiasis in violation of urodynamics caused
by neuro muscular dysfunction of the bladder (NMDB) (Kroovand R.L., 1997; Rizvi S.A.H. et al., 2002; Ramachandra P. et al., 2014).
The aim of the study. Analyze the causes and consequences of the formation of bladder calculus in childhood, especially in violation of its accumulation and/or
evacuation functions, as well as modern methods of complex (including surgical) treatment of its disease.
Materials and methods. Since 2008 on the base of the Zhytomyr Regional Children's Clinical Hospital operated on 17 children urolithiasis. However, 3 (17.6%)
children perform endoscopic surgery (in 2 (66.6%) — 2 of deferred time attempts) failed (1 — herniation calculus in scar modified bladder neck, 1 — ureter
al stricture 1 — cystitis). Thus, 14 children generally performed 19 surgeries, including: 3 (15.8%) — open and 16 (84.2%) — endoscopically. So, 3 (17.6%)
children were operated more than 1 times: 1 child 2 times (1 — open + 1 — endoscopy); 1 child 2 times (both endoscopically); 1 child 4 times
(1 — open + 3 — endoscopically). The average age of children was 11.95 yrs (4–17 yrs). Distribution by gender: 75% — boys, 25% — girls. Distribution
calculus localization (those who underwent surgery, and those in which the conduct surgery failed to): bladder — 3 (13.6%), ureter — 13 (59.1%),
kidney+ureter — 4 (18.2%), kidney — 2 (9.1%). The average hospital stay was 9.2 days.
Found that in NMDB patients, the prevalence of microorganisms in the genus Proteus bacteriological examination of urine was 4.8% of all selected urine cul
tures in 2010, a significant increase to 15.4% in 2013 and 14,8% in 2015.
Results and discussion. These clinical cases of different types of surgery other complications NMDB children — stone. Confirmed important role Proteus
infection among etiological factors bladder calculus formation in childhood.
Conclusions. The problem of stone formation is a key issue in patients with bladder dysfunction. An important etiological link Proteaceae stone is urinary tract
infection. Tactics of surgical treatment should be aimed exclusively at reducing urinary tract trauma. Minimally invasive treatment of urolithiasis in patients
with bladder dysfunction make it possible to minimize damage to the bladder wall, reduce postoperative period.
dysfunction (NMBD) in the population of children is significant.
The main manifestation of NMBD is urinary disorder, which consists is often/rare urination, incontinence. Consequently — the social maladjustment of the child and his parents. Typically, NMBD is the outcome of the innervation disorder of the bladder, but posterior
urethral valves, which are the main cause infravesical obstruction in childhood, are of great importance (Atwell J.D., 1983). To preserve kidney function and to prevent urinary tract infections are main tasks
in patients with NMBD, while urinary retention — a secondary one (Stein R. et al., 2012). In infants with posterior urethral valves and refluxing ureterohydronephrosis complicated by recurrent pyelonephritis and/or chronic renal failure, to ensure the efficient derivation of urine, vesicostomy or ureterocutaneostomycan be used. Efficacy
of using the drainage-free methods of urinary diversion, according to various authors, reaches 88 and 79 % (Kozyrev H.V., 2008; Nanda M. et al., 2012). Efficacy of vesicostomy in young children suffering from
anorectal pathology and myelodysplasia has been noted by domestic authors too (Makedonskyi I.O., 2013). J.C. Hutcheson et al. (2001) noted the positive effect of prolonged vesicostomy use in patients with
neuromuscular dysfunction of the bladder due to myelodysplasia.
Materials and methods. During the period of 2010–2015, in the Zhitomyr Regional Children’s Hospital, there were operated 10 patients with complications of neuromuscular dysfunction of the bladder (megaureter
obstructive/refluxing, urinary tract infection, reduced renal function, etc.). The protocol included examinations: laboratory one (general clinical, biochemical, microbiological), instrumental (ultrasound
of the kidneys (full and empty bladder) and bladder with
obligatory determination of residual urine; X-ray contrast — excretory urography in the absence of renal insufficiency with a glomerular filtration rate < 50 ml/min and voiding cystography (in correction
of urinary tract infection); dynamic renoscyntigraphy; urodynamic study). 3 patients before the surgery had partial renal dysfunction. 12 surgeries were carried out (in 1 child ureterocutaneostomy was made
simultaneously on both sides, in 1 — ureterocutaneostomy shifting
was made due to decompensated stenosis of bladder outlet). Of these, 3 vesicostomy were performed (by Blocksom method) (mean age of patients was 8 years old), 9 ureterocutaneostomy (by methods of Wilson — 6 cases and Sober — 3 cases) (mean age of patients — 7
months). By sex, there was marked the following distribution: 9 boys, 1 girl. All the patients before the surgery underwent diagnostic ureterocystoscopy
to assess the condition of the bladder wall, function
and anatomical location of the orifice of ureter, presence/absence of infravesical obstruction (posterior urethral valve and/or bladder neck stricture) etc. In 4 patients, imposition of vesicostomy/ureterocutaneostomy
was preceded by endoscopic dissection of the posterior
urethral valve due to diagnosed infravesical obstruction. In 1 patient, during control monitoring 1.5 years after the endoscopic dissection of
the posterior urethral valve and at the imposition of ureterocutaneostomy in unilateral megaureter, we confirmed the reduction of dilatation
of the upper urinary tract and restoration of the kidney and bladder function, that made it possible to close the ureterocutaneostomy without additional reconstructive surgeries. In one child, in which we carried out the imposition of cutaneostomy and its closure in 2 years
(in the clinic outside the region area) without additional endoscopic diagnosis and endoscopic dissection of posterior urethral valve, obstructive megaureter recovery was noted with the sharp decrease in
the excretory function of the kidney. A clinical case of the treatment for complications of neuromuscular dysfunction of the bladder using drainage-free methods (including vesicostomy) is presented.
Conclusions.
1. Neuromuscular dysfunction of bladder, caused by infravesical obstruction in particular, requires prompt surgical correction (in the neonatal period).
2. In case of endoscopic treatment failure, difficulties during permanent bladder catheterization, it is indicated to use drainage-free methods for urine diversion (vesicostomy/ureterocutaneostomy)
as a temporary measure to restore urodynamics.
3. Application of vesicostomy enables to reduce the phenomenon of dilatation of the upper urinary tract, to improve renal perfusion and to reduce the effects of uremia.
1Zhytomyr Regional Clinical Children's Hospital; 2National Medical Academy of Postgraduate Education named after
PL Shupyk; 3Zhytomyr State University named after Ivan Franko
APPLICATION OF PERCUTANEOUS CYSTOSCOPY TO REMOVAL OF FOREIGN BODY IN CHILD PATIENTS
WITH NEUROMUSCULAR BLADDER DYSFUNCTION
Foreign bodies bladder in children are rare. M. Rafique (2008) described the experience of treatment of 16 patients
with foreign bodies bladder. With this author in 7 (43.8%) patients had foreign bodies iatrogenic origin. The
method of removing a foreign body determined individually, but minimally invasive could remove only 50% of foreign
bodies. K.A.R. Hutton and S.N. Huddart (1999) described a case of successful removal of foreign body in
bladder (catheter fragment) percutaneous way under visual cystoscopy control in 4-month-old child. In this work
the clinical case the use of percutaneous cystoscopy to remove a foreign body in bladder in patients with neuromuscular
dysfunction of the bladder. So, percutaneous cystoscopy is a good alternative to open surgery for the
pathology of the urinary bladder in children, especially in violation of its storage and/or evacuation functions.
Key words: neuromuscular dysfunction of bladder, percutaneous cystoscopy, foreign bodies
bladder dysfunction children
D.V. Shevchuk1, 2, 3, O.A. Danylov2, V.L. Tyndykevych1, L.H. Mahanova1
1 Zhytomyr Regional Children Clinical Hospital
2 P.L. Shupyk National Medical Academy of Postgraduate Education
3 Zhytomyr State University named after Ivan Franko
Objective. Explore the microbiological characteristics of urine in patients with neuromuscular dysfunction of bladder children,
including antibiotic resistance of pathogens that often cause catheter-associated bacteriuria and/or urinary tract infection.
Materials and methods. We analyzed the results of bacteriological studies in the urine of patients with urinary tract infection
who were treated at the offices of the Zhytomyr Regional Child’s Clinical Hospital in 2010 and 2013. Overall in 2010 studied 259
samples of urine, while in 2013 — 309. In 2010 with positive results detected 107 samples, representing 41.3 % of total bacteriological
urine cultures, and in 2013 — 108 (35 %). Etiologic factor in inflammatory processes of the urinary tract were often such
microorganisms: E. coli, E. faecalis, Ps. aeruginosa, Kl. pneumonia, bacteria p. Proteus and others. This stood out as mono- (88.8 %
in 2010 and 87 % in 2013) and the mixed culture.
During 2010 bacteriologically examined 22 children suffering from neuromuscular dysfunction of the bladder, which was
performed 29 bacteriological studies of urine. Of these 27 positive results (25.2 % of all during the year positive bacteriological
seeding urine). Among all hanging in this group of sick children monoculture were 21 (77.8 %), while the combination of cultures
was 6 (22.2 %) cases. In 2013 was bacteriologically examined 16 children with neuromuscular dysfunction of the bladder. Completed
21 urine samples, obtained 15 positive results (13.9 % of all positive bacteriological seeding year).
Results and discussion. After analyzing the results of bacteriological studies can be noted that in 2013 compared to 2010 is 3 times
the percent of infections caused by bacteria Proteus mirabilis and vulgaris, and Enterococcus faecalis, a 30 % increase in the proportion
of infections caused by E. coli. In contrast, 2.5 times the percentage of infection pathogen which was Kl. pneumoniae, 30 % —
Ps. aeruginosa. In addition, nearly 2 times the percentage of complex mixed infections. Established that Kl. pneumoniae represented
50 % of mixed infections with neuromuscular dysfunction of the bladder in 2010, while in 2013 — 100 % of cases. It was established
that the observed reduction in the number of microbial contamination on all the most common pathogens. For antibiotic
susceptibility observed dynamic reduction to almost all products.
Conclusions. Implementation of effective methods of derivation of urine in patients with neuromuscular dysfunction of the
bladder in children led to a decrease of catheter-associated bacteriuria and microbial load on the body of a child. The widespread
use of antibiotics leads to reduced sensitivity of microorganisms to most common antibiotics. There is a need for a differentiated
approach to the integrated use of antibiotics in patients with violations of urination children.
Key words: neuromuscular dysfunction of bladder, catheter-associated bacteriuria, pathogens, antibiotic resistance, children.
including antibiotic resistance of pathogens that often cause catheter-associated bacteriuria and/or urinary tract infection.
Materials and methods. We analyzed the results of bacteriological studies in the urine of patients with urinary tract infection who were treated at the offices of the Zhytomyr Regional Child’s Clinical Hospital in 2010 and 2013. Overall in 2010 studied 259 samples of urine, while in 2013 — 309. In 2010 with positive results detected 107 samples, representing 41.3 % of total bacteriological urine cultures, and in 2013 — 108 (35 %). Etiologic factor in inflammatory processes of the urinary tract were often such microorganisms: E. coli, E. faecalis, Ps. aeruginosa, Kl. pneumonia, bacteria p. Proteus and others. This stood out as mono- (88.8 % in 2010 and 87 % in 2013) and the mixed culture.
During 2010 bacteriologically examined 22 children suffering from neuromuscular dysfunction of the bladder, which was
performed 29 bacteriological studies of urine. Of these 27 positive results (25.2 % of all during the year positive bacteriological seeding urine). Among all hanging in this group of sick children monoculture were 21 (77.8 %), while the combination of cultures was 6 (22.2 %) cases. In 2013 was bacteriologically examined 16 children with neuromuscular dysfunction of the bladder. Completed 21 urine samples, obtained 15 positive results (13.9 % of all positive bacteriological seeding year).
Results and discussion. After analyzing the results of bacteriological studies can be noted that in 2013 compared to 2010 is 3 times the percent of infections caused by bacteria Proteus mirabilis and vulgaris, and Enterococcus faecalis, a 30 % increase in the proportion of infections caused by E. coli. In contrast, 2.5 times the percentage of infection pathogen which was Kl. pneumoniae, 30 % — Ps. aeruginosa. In addition, nearly 2 times the percentage of complex mixed infections. Established that Kl. pneumoniae represented 50 % of mixed infections with neuromuscular dysfunction of the bladder in 2010, while in 2013 — 100 % of cases. It was established
that the observed reduction in the number of microbial contamination on all the most common pathogens. For antibiotic susceptibility observed dynamic reduction to almost all products.
Conclusions. Implementation of effective methods of derivation of urine in patients with neuromuscular dysfunction of the
bladder in children led to a decrease of catheter-associated bacteriuria and microbial load on the body of a child. The widespread use of antibiotics leads to reduced sensitivity of microorganisms to most common antibiotics. There is a need for a differentiated approach to the integrated use of antibiotics in patients with violations of urination children.
добрий клінічний ефект від консервативної терапії, до якої відносять застосування медикаментозних препаратів
та чистої інтермітуючої катетеризації. Однак 10–20% пацієнтів вказаної категорії підлягають тим
чи іншим методам хірургічного лікування. Враховуючи, що у хворих із мієлодисплазією розлади сечовипускання
становлять 95–98%, особливу увагу слід приділяти комплексному лікуванню нервово-м’язової
дисфункції сечового міхура (НМДСМ) у даної категорії хворих дітей (E. Smith, 1965; J.D. van Gool та співавт.,
2001). Однак на даний час не існує способів радикального хірургічного НМДСМ при порушенні його іннервації.
Мета: дослідити можливість хірургічного відновлення іннервації сечового міхура при рефрактерних
формах його нервово-м’язової дисфункції у дітей.
Пацієнти і методи. Враховуючи відсутність у доступній літературі уніфікованого методу хірургічного
лікування рефрактерної до терапії НМДСМ, особливо при порушенні іннервації сечового міхура, авторами
розроблено принципово новий метод хірургічного лікування, який передбачає реіннервацію (міоневротизацію)
сечового міхура (Спосіб іннервації нейрогенного сечового міхура. Патент на винахід
№102801 UA МПК (2013.01): А61В 17/00). Суть методу полягає у вживлянні нерва (який має соматичну та
вегетативну іннервацію), що формується вище місця ураження спинного мозку при спінальних дизрафіях,
у стінку сечового міхура.
Результати. Із застосуванням запропонованого методу починаючи із 2001 р., на клінічних базах Національної
медичної академії післядипломної освіти імені П.Л. Шупика (Київська міська дитяча клінічна лікарня
№1 та Житомирська обласна дитяча клінічна лікарня) було прооперовано 9 хворих на НМДСМ дітей.
Вік хворих становив від 4 до 14 років (у середньому 6,5 року). У ході контрольного обстеження, яке проводилось
5 (55,6%) хворим, відмічена позитивна динаміка у 4 (80%) хворих.
До суб’єктивних позитивних зрушень пацієнти відносили наступне: поява відчуття наповнення сечового
міхура – у 5 (100%) хворих, утримання сечі – у 4 (80%) хворих, сечопуск струменем – у 5 (100%) хворих.
До об’єктивних позитивних зрушень віднесено: зменшення кількості залишкової сечі – у 5 (100%) хворих;
зменшення ретенційних змін у верхніх сечових шляхах – у 5 (100%) хворих; зменшення ступеня чи повна ліквідація
міхурово-сечовідного рефлюксу – у 100% хворих, у яких був наявний рефлюкс; тривала ремісія інфекції
сечових шляхів зі зменшенням/ліквідацією бактеріурії – у 4 (80%) хворих. Жодних ускладнень не виявлено.
Висновки. Новий метод реіннервації сечового міхура – міоневротизація сечового міхура – є досить
ефективним методом лікування рефрактерної форми нервово-м’язової дисфункції сечового міхура у дітей.
Результати застосування методу потребують подальшого вивчення уродинамічних параметрів, що дасть
змогу рекомендувати метод для широкого впровадження у практику.
Ключові слова: нервово-м’язова дисфункція сечового міхура, міоневротизація сечового міхура, діти.
На основі отриманих літературних даних та результатів власних спостережень, встановлено взаємозв’язок між констипаційним синдромом та нервово-м’язовою дисфункцію сечового міхура у дитячому віці.
Таким чином, порушення функції сечового міхура у контексті її кореляції із констипаційним синдромом, є актуальною проблемою, яка через свою багатовекторність потребує подальшого вивчення та розробки як новітніх діагностичних алгоритмів, так і комплексного лікування.
Children were found to have close connection between
constipation and urinary tract problems including infections, bedwetting (enuresis), vesicoureteral reflux, and the dilation of the upper urinary tract [Averbeck M.A., Madersbacher H., 2011; Muhammad S. et al, 2015]. J Pannek et al. (2009) described cases of urinary retention as a result of massive constipation when stool blocked urinary tract. Erhun Kasirga et al. (2006) found a significantly greater frequency of urinary tract infections in children of patients with constipation syndrome. Veiga ML et al. (2013) found that children with neurogenic bladder dysfunction have greater chances of constipation than those who have no lower urinary tract symptoms.
Based on the literature data and the results of our own observations, the interrelation between constipation syndrome and neuromuscular dysfunction of the bladder in children was established.
Thus, urinary bladder dysfunction in the context of its correlation with constipation syndrome is an urgent problem, which requires further study and development of a new diagnostic algorithms, and comprehensive treatment due to its multi-vector nature.
congestion syndrome in paediatric practice is required. Moreover, well-informed physicians ensure early diagnostics and efficient treatment, which will permit to reduce the frequency of an unnecessary laparotomy in the case of
abdominal pains in girls. Thus, it is necessary to discuss the wider application of the minimally invasive surgery techniques in treatment of abdominal pains in girls.
It is located on the back meatal wall. The available literature describes few cases of urethral caruncle in girls.
The only treatment for caruncle is surgery, which consists of its excision. The following is a clinical case of treatment of urethral caruncle complicated with neuromuscular dysfunction of the bladder in a 9-year-old girl. Thus,
urethral caruncle in girls is a fairly rare disease. It may cause an obstruction below the bladder, leading to neuromuscular dysfunction of the bladder. Surgical removal for urethral caruncle eliminates the formation of obstruction below the bladder and improves evacuation function of the bladder
Background. Damage to the urethra in damaged pelvic
bones in children is marked less than in adults (less than 1 %) (Tarman G.J. et al., 2002). Post-traumatic urethral stricture in children is a quite rare and complex urologic pathology. Due to anatomical features, treatment for urethral stricture in children is different from its treatment in adults (Onen A. et al., 2005; Nerli R.B. et al., 2008; Ranjan P. et al., 2011). M.M. Koraitim (2012) described the experience of treating 20 patients with complications after transperyneal urethral plasty. The author noted that in the absence of need for reconstruction of the bladder neck, it is quite effective to use endoscopic incision of urethral stricture. T.E. Helmy, A.T. Hafez (2013) also described the results of the successful application of endoscopic equipment (direct visual urethrotomia) after open urethroplasty. The important point that leads to finding effective minimally invasive treatments for post-traumatic urethral strictures in children is the development of erectile dysfunction in the future, the incidence of which, according to some authors, (Koraitim M.M.,
2014) is up to 47 %. The aim of the study: based on the available published data and own treatment outcomes in children with posterior urethral strictures, to establish the role of endoscopic treatment of this complex pathology as a method of prevention and treatment of neuromuscular dysfunction of the bladder.
Materials and methods. At the premises of the surgical departments of Zhytomyr Regional Children’s Clinical Hospital, there were widely implemented invasive endoscopic methods for the diagnosis and treatment of pathologies of the lower urinary tract. Available equipment enables to carry out diagnostic procedures from 1 month old. A variety of endoscopic surgeries on the lower urinary tract is being performed, namely — the removal of calculi, incision of valves and strictures of the posterior urethra, dissection of urethral cysts and ectopic ureterocaele, etc. Also in 2010, the first attempt was made to remove a calculus from the posterior urethra by means of percutaneous 3-port cystoscope. From 2013, the treatment of post-traumatic strictures of the posterior urethra began using endoscopic control.
Results. The article presents the results of a successful minimally invasive treatment using modern endoscopic equipment in two patients with post-traumatic posterior urethral strictures.
A special attention was paid to the effectiveness of the method in the diagnosis and treatment of neuromuscular dysfunction of the bladder in these patients. Conclusions. Consequently, the use of minimally invasive modern equipment not only makes it possible to effectively diagnose the damage to lower urinary tract, but also can be an effective mechanism for low-impact surgery at short post-traumatic urethral strictures in children.
Timely adequate treatment of scar urethral strictures in children will minimize the incidence of infravesical obstruction and violation of the evacuation function of the bladder with the development of its neuromuscular dysfunction.
Interstitial cells of Cajal (ICC) were first discovered in 1893 in the wall of the intestine, and only after almost 100 years of interest in the ICC recovered. In addition, modern technologies have allowed to identify similar cells in other organs, in particular those that contain the muscle fibers and, accordingly, shall be
subject to reduction. So, ICC was detected in the urinary tract, fallopian tubes, the seminiferous tubules etc. Further study of the functions of the ICC has established a link between human peripheral information of the bladder (neuromuscular dysfunction of bladder) and the concentration of ICC. Thus, the measurement of ICC in the bladder wall when it is dysfunction may affect the tactics of patient management in the future.
pediatric populations, the frequency of bladder calculus significantly reduced. Acquires particular importance urolithiasis in violation of urodynamics caused
by neuro muscular dysfunction of the bladder (NMDB) (Kroovand R.L., 1997; Rizvi S.A.H. et al., 2002; Ramachandra P. et al., 2014).
The aim of the study. Analyze the causes and consequences of the formation of bladder calculus in childhood, especially in violation of its accumulation and/or evacuation functions, as well as modern methods of complex (including surgical) treatment of its disease.
Materials and methods. Since 2008 on the base of the Zhytomyr Regional Children's Clinical Hospital operated on 17 children urolithiasis. However, 3 (17.6%)
children perform endoscopic surgery (in 2 (66.6%) — 2 of deferred time attempts) failed (1 — herniation calculus in scar modified bladder neck, 1 — ureter
al stricture 1 — cystitis). Thus, 14 children generally performed 19 surgeries, including: 3 (15.8%) — open and 16 (84.2%) — endoscopically. So, 3 (17.6%)
children were operated more than 1 times: 1 child 2 times (1 — open + 1 — endoscopy); 1 child 2 times (both endoscopically); 1 child 4 times (1 — open + 3 — endoscopically). The average age of children was 11.95 yrs (4–17 yrs). Distribution by gender: 75% — boys, 25% — girls. Distribution
calculus localization (those who underwent surgery, and those in which the conduct surgery failed to): bladder — 3 (13.6%), ureter — 13 (59.1%),
kidney+ureter — 4 (18.2%), kidney — 2 (9.1%). The average hospital stay was 9.2 days. Found that in NMDB patients, the prevalence of microorganisms in the genus Proteus bacteriological examination of urine was 4.8% of all selected urine cul
tures in 2010, a significant increase to 15.4% in 2013 and 14,8% in 2015.
Results and discussion. These clinical cases of different types of surgery other complications NMDB children — stone. Confirmed important role Proteus
infection among etiological factors bladder calculus formation in childhood.
Conclusions. The problem of stone formation is a key issue in patients with bladder dysfunction. An important etiological link Proteaceae stone is urinary tract infection. Tactics of surgical treatment should be aimed exclusively at reducing urinary tract trauma. Minimally invasive treatment of urolithiasis in patients
with bladder dysfunction make it possible to minimize damage to the bladder wall, reduce postoperative period.
obstruction of pyeloureteral segment, which is usually diagnosed antenatal by ultrasound screening in 1.5 % of pregnancies. Pathophysiology is still unknown. The most common pathogenetic reasonable treatment of congenital obstruction pelvicoureteral segment (hydronephrosis) in children is a surgical treatment. As a rule, open methods are applied (by Hynes-Anderson and other methods). Recently endoscopic treatment has being discussed. Increasingly there are reports of the use of robotic equipment. According to the data of different authors successful results of Hynes — Anderson techniques reach 95 %. The question on the upper urinary tract drainage is still discussed. The choice of stent placement usually depends on the surgeon, although the analysis of literature data indicates a decrease in percentage of complications after stent using. The aim of the study. To analyze the methods and ways of urinary diversion in the surgical treatment of congenital hydronephrosis in children. Materials and methods. On the basis of the surgical department № 2 Zhytomyr Regional Children’s Hospital (ZhRCH) for the period from 2000 to 2015 108 children were operated. The average age of patients was 3.8 years old. There were 38 (35.2 %) boys and 70 girls (64.8 %). The gold standard is Hynes — Anderson technique. Until 2006, external drainage of urinary tract surgery was mainly performed, while from 2006 close way was implemented, and from 2009 — the use of JJ-stent. Since 2010, videoassistant metnod was introduced (laparoscopic stage — mobilization of pelvicoureteral segment with further anastomosis through minilaparotomy access). In 2016 at the ZhRCH laparoscopic plastic was firstly performed for a boy aged 6 years old. The average duration of the intervention was 106 ± 32 min. Conclusions. The question on urinary tract drainage after pelvicoureteral segment plastic in children with congenital hydronephrosis should be considered individually only. The question on stent installation method remains unclear.
After the indications for surgical treatment of congenital hydronephrosis in children are determined the function of the lower urinary tract must be considered to ensure the efficient derivation of urine in the postoperative period (the presence of concomitant neuromuscular dysfunction of the bladder).
D. Shevchuk
Zhytomyr Regional Children's Hospital, Zhytomyr, Ukraine
Zhytomyr State University named after Ivan Franko, Zhytomyr, Ukraine
National Medical Academy of Postgraduate Education named after PL Shupyk, Kyiv, Ukraine
Introduction. Urolithiasis in children is an important clinical problem in pediatric urological practice. Note that while growth in the prevalence of urolithiasis in
pediatric populations, the frequency of bladder calculus significantly reduced. Acquires particular importance urolithiasis in violation of urodynamics caused
by neuro muscular dysfunction of the bladder (NMDB) (Kroovand R.L., 1997; Rizvi S.A.H. et al., 2002; Ramachandra P. et al., 2014).
The aim of the study. Analyze the causes and consequences of the formation of bladder calculus in childhood, especially in violation of its accumulation and/or
evacuation functions, as well as modern methods of complex (including surgical) treatment of its disease.
Materials and methods. Since 2008 on the base of the Zhytomyr Regional Children's Clinical Hospital operated on 17 children urolithiasis. However, 3 (17.6%)
children perform endoscopic surgery (in 2 (66.6%) — 2 of deferred time attempts) failed (1 — herniation calculus in scar modified bladder neck, 1 — ureter
al stricture 1 — cystitis). Thus, 14 children generally performed 19 surgeries, including: 3 (15.8%) — open and 16 (84.2%) — endoscopically. So, 3 (17.6%)
children were operated more than 1 times: 1 child 2 times (1 — open + 1 — endoscopy); 1 child 2 times (both endoscopically); 1 child 4 times
(1 — open + 3 — endoscopically). The average age of children was 11.95 yrs (4–17 yrs). Distribution by gender: 75% — boys, 25% — girls. Distribution
calculus localization (those who underwent surgery, and those in which the conduct surgery failed to): bladder — 3 (13.6%), ureter — 13 (59.1%),
kidney+ureter — 4 (18.2%), kidney — 2 (9.1%). The average hospital stay was 9.2 days.
Found that in NMDB patients, the prevalence of microorganisms in the genus Proteus bacteriological examination of urine was 4.8% of all selected urine cul
tures in 2010, a significant increase to 15.4% in 2013 and 14,8% in 2015.
Results and discussion. These clinical cases of different types of surgery other complications NMDB children — stone. Confirmed important role Proteus
infection among etiological factors bladder calculus formation in childhood.
Conclusions. The problem of stone formation is a key issue in patients with bladder dysfunction. An important etiological link Proteaceae stone is urinary tract
infection. Tactics of surgical treatment should be aimed exclusively at reducing urinary tract trauma. Minimally invasive treatment of urolithiasis in patients
with bladder dysfunction make it possible to minimize damage to the bladder wall, reduce postoperative period.
dysfunction (NMBD) in the population of children is significant.
The main manifestation of NMBD is urinary disorder, which consists is often/rare urination, incontinence. Consequently — the social maladjustment of the child and his parents. Typically, NMBD is the outcome of the innervation disorder of the bladder, but posterior
urethral valves, which are the main cause infravesical obstruction in childhood, are of great importance (Atwell J.D., 1983). To preserve kidney function and to prevent urinary tract infections are main tasks
in patients with NMBD, while urinary retention — a secondary one (Stein R. et al., 2012). In infants with posterior urethral valves and refluxing ureterohydronephrosis complicated by recurrent pyelonephritis and/or chronic renal failure, to ensure the efficient derivation of urine, vesicostomy or ureterocutaneostomycan be used. Efficacy
of using the drainage-free methods of urinary diversion, according to various authors, reaches 88 and 79 % (Kozyrev H.V., 2008; Nanda M. et al., 2012). Efficacy of vesicostomy in young children suffering from
anorectal pathology and myelodysplasia has been noted by domestic authors too (Makedonskyi I.O., 2013). J.C. Hutcheson et al. (2001) noted the positive effect of prolonged vesicostomy use in patients with
neuromuscular dysfunction of the bladder due to myelodysplasia.
Materials and methods. During the period of 2010–2015, in the Zhitomyr Regional Children’s Hospital, there were operated 10 patients with complications of neuromuscular dysfunction of the bladder (megaureter
obstructive/refluxing, urinary tract infection, reduced renal function, etc.). The protocol included examinations: laboratory one (general clinical, biochemical, microbiological), instrumental (ultrasound
of the kidneys (full and empty bladder) and bladder with
obligatory determination of residual urine; X-ray contrast — excretory urography in the absence of renal insufficiency with a glomerular filtration rate < 50 ml/min and voiding cystography (in correction
of urinary tract infection); dynamic renoscyntigraphy; urodynamic study). 3 patients before the surgery had partial renal dysfunction. 12 surgeries were carried out (in 1 child ureterocutaneostomy was made
simultaneously on both sides, in 1 — ureterocutaneostomy shifting
was made due to decompensated stenosis of bladder outlet). Of these, 3 vesicostomy were performed (by Blocksom method) (mean age of patients was 8 years old), 9 ureterocutaneostomy (by methods of Wilson — 6 cases and Sober — 3 cases) (mean age of patients — 7
months). By sex, there was marked the following distribution: 9 boys, 1 girl. All the patients before the surgery underwent diagnostic ureterocystoscopy
to assess the condition of the bladder wall, function
and anatomical location of the orifice of ureter, presence/absence of infravesical obstruction (posterior urethral valve and/or bladder neck stricture) etc. In 4 patients, imposition of vesicostomy/ureterocutaneostomy
was preceded by endoscopic dissection of the posterior
urethral valve due to diagnosed infravesical obstruction. In 1 patient, during control monitoring 1.5 years after the endoscopic dissection of
the posterior urethral valve and at the imposition of ureterocutaneostomy in unilateral megaureter, we confirmed the reduction of dilatation
of the upper urinary tract and restoration of the kidney and bladder function, that made it possible to close the ureterocutaneostomy without additional reconstructive surgeries. In one child, in which we carried out the imposition of cutaneostomy and its closure in 2 years
(in the clinic outside the region area) without additional endoscopic diagnosis and endoscopic dissection of posterior urethral valve, obstructive megaureter recovery was noted with the sharp decrease in
the excretory function of the kidney. A clinical case of the treatment for complications of neuromuscular dysfunction of the bladder using drainage-free methods (including vesicostomy) is presented.
Conclusions.
1. Neuromuscular dysfunction of bladder, caused by infravesical obstruction in particular, requires prompt surgical correction (in the neonatal period).
2. In case of endoscopic treatment failure, difficulties during permanent bladder catheterization, it is indicated to use drainage-free methods for urine diversion (vesicostomy/ureterocutaneostomy)
as a temporary measure to restore urodynamics.
3. Application of vesicostomy enables to reduce the phenomenon of dilatation of the upper urinary tract, to improve renal perfusion and to reduce the effects of uremia.
1Zhytomyr Regional Clinical Children's Hospital; 2National Medical Academy of Postgraduate Education named after
PL Shupyk; 3Zhytomyr State University named after Ivan Franko
APPLICATION OF PERCUTANEOUS CYSTOSCOPY TO REMOVAL OF FOREIGN BODY IN CHILD PATIENTS
WITH NEUROMUSCULAR BLADDER DYSFUNCTION
Foreign bodies bladder in children are rare. M. Rafique (2008) described the experience of treatment of 16 patients
with foreign bodies bladder. With this author in 7 (43.8%) patients had foreign bodies iatrogenic origin. The
method of removing a foreign body determined individually, but minimally invasive could remove only 50% of foreign
bodies. K.A.R. Hutton and S.N. Huddart (1999) described a case of successful removal of foreign body in
bladder (catheter fragment) percutaneous way under visual cystoscopy control in 4-month-old child. In this work
the clinical case the use of percutaneous cystoscopy to remove a foreign body in bladder in patients with neuromuscular
dysfunction of the bladder. So, percutaneous cystoscopy is a good alternative to open surgery for the
pathology of the urinary bladder in children, especially in violation of its storage and/or evacuation functions.
Key words: neuromuscular dysfunction of bladder, percutaneous cystoscopy, foreign bodies
bladder dysfunction children
D.V. Shevchuk1, 2, 3, O.A. Danylov2, V.L. Tyndykevych1, L.H. Mahanova1
1 Zhytomyr Regional Children Clinical Hospital
2 P.L. Shupyk National Medical Academy of Postgraduate Education
3 Zhytomyr State University named after Ivan Franko
Objective. Explore the microbiological characteristics of urine in patients with neuromuscular dysfunction of bladder children,
including antibiotic resistance of pathogens that often cause catheter-associated bacteriuria and/or urinary tract infection.
Materials and methods. We analyzed the results of bacteriological studies in the urine of patients with urinary tract infection
who were treated at the offices of the Zhytomyr Regional Child’s Clinical Hospital in 2010 and 2013. Overall in 2010 studied 259
samples of urine, while in 2013 — 309. In 2010 with positive results detected 107 samples, representing 41.3 % of total bacteriological
urine cultures, and in 2013 — 108 (35 %). Etiologic factor in inflammatory processes of the urinary tract were often such
microorganisms: E. coli, E. faecalis, Ps. aeruginosa, Kl. pneumonia, bacteria p. Proteus and others. This stood out as mono- (88.8 %
in 2010 and 87 % in 2013) and the mixed culture.
During 2010 bacteriologically examined 22 children suffering from neuromuscular dysfunction of the bladder, which was
performed 29 bacteriological studies of urine. Of these 27 positive results (25.2 % of all during the year positive bacteriological
seeding urine). Among all hanging in this group of sick children monoculture were 21 (77.8 %), while the combination of cultures
was 6 (22.2 %) cases. In 2013 was bacteriologically examined 16 children with neuromuscular dysfunction of the bladder. Completed
21 urine samples, obtained 15 positive results (13.9 % of all positive bacteriological seeding year).
Results and discussion. After analyzing the results of bacteriological studies can be noted that in 2013 compared to 2010 is 3 times
the percent of infections caused by bacteria Proteus mirabilis and vulgaris, and Enterococcus faecalis, a 30 % increase in the proportion
of infections caused by E. coli. In contrast, 2.5 times the percentage of infection pathogen which was Kl. pneumoniae, 30 % —
Ps. aeruginosa. In addition, nearly 2 times the percentage of complex mixed infections. Established that Kl. pneumoniae represented
50 % of mixed infections with neuromuscular dysfunction of the bladder in 2010, while in 2013 — 100 % of cases. It was established
that the observed reduction in the number of microbial contamination on all the most common pathogens. For antibiotic
susceptibility observed dynamic reduction to almost all products.
Conclusions. Implementation of effective methods of derivation of urine in patients with neuromuscular dysfunction of the
bladder in children led to a decrease of catheter-associated bacteriuria and microbial load on the body of a child. The widespread
use of antibiotics leads to reduced sensitivity of microorganisms to most common antibiotics. There is a need for a differentiated
approach to the integrated use of antibiotics in patients with violations of urination children.
Key words: neuromuscular dysfunction of bladder, catheter-associated bacteriuria, pathogens, antibiotic resistance, children.
including antibiotic resistance of pathogens that often cause catheter-associated bacteriuria and/or urinary tract infection.
Materials and methods. We analyzed the results of bacteriological studies in the urine of patients with urinary tract infection who were treated at the offices of the Zhytomyr Regional Child’s Clinical Hospital in 2010 and 2013. Overall in 2010 studied 259 samples of urine, while in 2013 — 309. In 2010 with positive results detected 107 samples, representing 41.3 % of total bacteriological urine cultures, and in 2013 — 108 (35 %). Etiologic factor in inflammatory processes of the urinary tract were often such microorganisms: E. coli, E. faecalis, Ps. aeruginosa, Kl. pneumonia, bacteria p. Proteus and others. This stood out as mono- (88.8 % in 2010 and 87 % in 2013) and the mixed culture.
During 2010 bacteriologically examined 22 children suffering from neuromuscular dysfunction of the bladder, which was
performed 29 bacteriological studies of urine. Of these 27 positive results (25.2 % of all during the year positive bacteriological seeding urine). Among all hanging in this group of sick children monoculture were 21 (77.8 %), while the combination of cultures was 6 (22.2 %) cases. In 2013 was bacteriologically examined 16 children with neuromuscular dysfunction of the bladder. Completed 21 urine samples, obtained 15 positive results (13.9 % of all positive bacteriological seeding year).
Results and discussion. After analyzing the results of bacteriological studies can be noted that in 2013 compared to 2010 is 3 times the percent of infections caused by bacteria Proteus mirabilis and vulgaris, and Enterococcus faecalis, a 30 % increase in the proportion of infections caused by E. coli. In contrast, 2.5 times the percentage of infection pathogen which was Kl. pneumoniae, 30 % — Ps. aeruginosa. In addition, nearly 2 times the percentage of complex mixed infections. Established that Kl. pneumoniae represented 50 % of mixed infections with neuromuscular dysfunction of the bladder in 2010, while in 2013 — 100 % of cases. It was established
that the observed reduction in the number of microbial contamination on all the most common pathogens. For antibiotic susceptibility observed dynamic reduction to almost all products.
Conclusions. Implementation of effective methods of derivation of urine in patients with neuromuscular dysfunction of the
bladder in children led to a decrease of catheter-associated bacteriuria and microbial load on the body of a child. The widespread use of antibiotics leads to reduced sensitivity of microorganisms to most common antibiotics. There is a need for a differentiated approach to the integrated use of antibiotics in patients with violations of urination children.
380
NMDB in children. The most common causes of dysfunction mainly consider congenital malformations (myelodysplasia, extrophy/epispadias etc.). In the US myelodysplasia occurs with a frequency of 1 in 1000 births and in 95% of cases accompanied NMDB [11]. While 30% of children with disorders of voiding in case myelodysplasia to primary surgery had urodynamic disorders and other complications associated with spinal cord defect [8]. The big problem is the condition in those countries where the law prohibits abortion even in the case of antenatal diagnosed anomalies of the spine and spinal cord (e.g., Poland). Each year in the United States for treatment NMDB spent 26.3 billion dollars, indicat-ing that the huge economic importance of this disease [14].
These aspects of the disease, the lack of standardized whole complex (ex-cept conservative therapy) treatments determine the relevance of the search for additional methods of complex treatment NMDB.
Increasingly conduct research activities on urinary incontinence, more common takes neurourology. Searching methods treatment of this disease, which would enable to achieve long-term normalization of voiding that contrib-utes to the physiological and social adaptation patient [5, 10].
The study protocol NMDB children should consist of ultrasound of the kidneys and SM voiding cystography and urodynamic research. Some authors suggest benefits performance uroflowmetry at home that makes it possible to get the best results of the study [6]. If a combination of neurogenic dysfunction of recurrent urinary tract infection should conduct DMSA to determine the degree of kidney damage. Great importance is attached neuroimaging methods of diag-nosis of pelvic floor (CT and MRI).
So, determined that only 37.2% of children with myelodysplasia have re-nal disease, and 78% of those who observed pathology of the upper urinary ways had bladder-ureteral reflux (mostly high degree) [4, 7, 9, 12].
Given the nature NMDB, it should be noted that in 37% of cases – a lack of sphincter apparatus of urine bladder and deficit its capacity, 22% – only lack of sphincter apparatus, 11% – high pressure in bladder background spastic con-traction sphincter, 4% – detrusor overactivity in 26% of patients causes urinary incontinence were mixed. Revealed that 69.4% of patients with urinary inconti-nence myelodysplasia [2, 7]. Other authors emphasize that urodynamic studies indicate that 62% of patients with myelodysplasia with detrusor contraction and discoordination sphincter, and in some cases sufficient to apply permanent cath-eterization and anticholinergic drugs. In 45% of patients observed violations locking properties sphincter [5].
Violations urine bladder innervations leads to severe hypoxic changes its walls that worsens impact of drug use means for correcting the pathology uro-dynamics [5, 9].
Results of treatment of patients with NMDB indicate the need for an inte-grated approach to problem-solving treatment of severe urinary incontinence in children. The most important aspect NMDB treatment – is prevention of kidney
381
damage. The effectiveness of neurosurgical treatment of urinary incontinence during myelodysplasia achieved only in 28.6% of cases [3, 9].
Only 22.1% for patients with myelodysplasia social adaptation rather complex conservative treatment, patients need rest various surgical correction (not only urological but neurosurgical) [9]. Others authors [1, 5] argue that the positive effect conservative therapy can achieve in 72% of patients, but this pos-itive effect is regarded as an adequate preoperative preparation. Some authors emphasize that in the absence effect of conservative therapy NMDB children with myelodysplasia for 18 months there is a need in the surgical treatment of defects [7].
By the choice of surgical treatment should be approached strictly individual-ly, taking into account the type of incontinence, a condition wall NMDB and cen-tral nervous system treatments which were applied in individual patients [13].
Thus, for successful treatment NMDB, particularly in myelodysplasia re-quired hard work urologist, and it is very useful collaboration with neurosur-geon. Only when patients and/or their relatives aware of the need, importance and complexity of surgical treatment NMDB then can be a satisfactory outcome.
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сечовому міхурі у дітей вказали на такі як дієта, порушення сечовипускання і нескориговані анатомічні вади (клапани задньої уретри чи міхурово-сечовідний рефлюкс).
Наводимо клінічний випадок успішного лікування конкрементів сечового міхура у дитини із спінальним сечовим міхуром як наслідок перенесеної хребетної спино-мозкової травми.
Дитина М., 17 років (історія хвороби №5919) госпіталізований в хірургічне відділення №2 Житомирської обласної дитячої клінічної лікарні 20.05.13 із скаргами на неможливість самостійного сечопуску, зміни в сечі. Із анамнезу відомо, що у 2010 році отримав важку ХСМТ, оперований. В тому ж році у зв’язку із порушенням функції тазових органів дитині накладалась епіцистостома. У 2012 році діагностовано конкременти сечового міхура. Госпіталізований для проведення літотрипсії. Результати обстежень: Загальний аналіз крові Нв – 123 г/л, ер. – 3,9 х 109/л, КП – 0.9, лейк. – 11.0 х 109/л, ШОЕ – 10 мм/год. Загальний аналіз сечі: 21.05. білок 0,198 г/л, лейк вел к-ть в п/з, еп пл 8-10 в п/з. 29.05. білок 0,257 г/л, лейк 70-80 в п/з, ер зм вел к-ть в п/з, ер незм 35-40 в п/з, еп перех 5-6 в п/з, слиз +, бактерії ++. УЗД нирок: дифузні зміни паренхіми обох нирок з явищами набряку. Ехоознаки деформації збиральної системи з обох боків. Ехоознаки конкрементів (д 3-4 мм) лівої нирки. Лівобічна пієлокалікоектазія (лох 7 мм, чаш 3 мм). Оглядова урографія: конкременти сечового міхура (ЕЕД 1 мЗв). Біохімія крові: заг білок 75 г/л, альб 43 г/л, заг білірубін 11,7 мкмоль/л, креатинін 70 мкмоль/л, сечовина 5,2 ммоль/л, калій 4,08 ммоль/л. Бак висів сечі: proteus mirabilis м.ч. 1 млн/мл (стійкий до всіх препаратів). Дитина консультована педіатром, окулістом, нейрохірургом. В ході обстеження встановлено діагноз: Сечокамяна хвороба: конкременти сечового міхура. Спінальний сечовий міхур. Вториний хронічний цистіт. Стан після перенесеної важкої ХСМТ. Переломовивих Т12, L1 хребців з компресією спиного мозку. Нижній парапарез з порушенням функції тазових органів. Стан після операцій (2010 р.). Після курсу проведеної антибактеріальної терапії, дитині 24.05.2013 р. проведена контактна цистолітотрипсія (Хід операції: після обробки зовнішніх статевих органів неостерилом виконано встановлення уретероцистоскопа 23 Шр. Інстиляція фурациліну 100,0. Ревізія уретри та сечового міхура. Виявлено бульозно-змінену слизову сечового міхура. Стінка сечового міхура трабекулярно змінена, відмічається маса псевдодивертикулів, поширення вічок сечоводів, 4 конкременти максимальним розміром до 2,3 см. Виконано літотрипсію (пневматичний літотриптор «Літокласт»), видалення дрібних фрагментів конкрементів, санацію фурациліном (у об’ємі до 5 літрів). Слизова контактно кровоточить. Уретероцистоскоп видалено, встановлено катетер Фолея 20 Шр.) під загальним в/в наркозом. Тривалість операції 1 год 25 хв. В післяопераційному періоді призначено інфузійну терапію, транексамову кислоту, антибактеріальну терапію (цефтріаксон), промивання сечового міхура (фурацилін+гентаміцин). 30.05.13р. виписаний додому у відносно
задовільному стані.
Таким чином, проблема каменеутворення є актуальним питанням у хворих із дисфункцією сечового міхура любої етіології з огляду на те, що для деривації сечі існує необхідність постановки епіцистостомічних дренажів на тривалий час.
Малоінвазивні методи лікування СКХ у хворих із дисфункцією сечового міхура дають можливість мінімізувати пошкодження стінки сечового міхура,
скоротити післяопераційний період.