Download MBBS (Bachelor of Medicine, Bachelor of Surgery) 1st Year, 2nd Year, 3rd Year and Final year Surgery 15 Congenital Anomalies of Urinary Bladder PPT-Powerpoint Presentations and lecture notes
Urinary Bladder:
Congenital Anomalies
trauma, cystitis, tumors, urethral trauma
Anatomy
The urinary bladder is a hol ow, muscular, and distensible (or elastic)
organ that sits on the pelvic floor .
It is the organ that col ects urine excreted by the kidneys prior to
disposal by urination. Urine enters the bladder via the ureters and exits
via the urethra.
In males, the base of the bladder lies between the rectum and the
pubic symphysis. It is superior to the prostate, and separated from the
rectum by the rectovesical pouch.
In females, the bladder sits inferior to the uterus and anterior to the
vagina. It is separated from the uterus by the vesicouterine pouch.
Anatomy.................
Embryology
The urogenital sinus is formed by the division of the cloaca
by the uro-rectal septum
The uro-genital sinus may be divided into three component
parts.
cranial portion which is continuous with the al antois and forms
the bladder proper.
The pelvic part of the sinus forms the prostatic urethra and
epithelium as wel as the membranous urethra and bulbo
urethral glands in the male and the membranous urethra and
part of the vagina in females.
the caudal portion forms the penile urethra in males and the
vestibule in females.
Embryology........
The bladder forms from the cranial end of the urogenital sinus.
However, the trigone portion is formed by the caudal ends of the
mesonephric ducts. As the bladder expands, the mesonephric ducts
begin to become incorporated into the wal of the bladder dragging the
ureters along with them. Further growth causes the ureters to
eventual y have their own opening into the bladder.
The bladder is initial y continuous with the al antois. Over time, the
al antois degenerates to form a cord-like structure, the urachus. The
urachus goes from the umbilicus to the apex of the bladder and forms
the median umbilical ligament which can be seen in adults. The medial
umbilical ligaments may also be seen in adults on both sides of the
median umbilical ligament, these are the vestigial remnants of the
umbilical arteries.
Congenital Anomalies
A major consideration with congenital abnormalities is that they tend to
be multiple.
Al of these anomalies are infrequent or rare, and each condition occurs
in both males and females
Diagnosed in infancy or childhood
Most are discovered in the evaluation of a urinary tract infection or, in
the case of urachal anomalies, periumbilical drainage or redness.
Classification
Urinary bladder anomalies are-
? bladder diverticula
? bladder ears
? congenital hypoplasia of the bladder
? megacystis
? bladder agenesis
? duplication anomalies of the bladder
? bladder septa
Urachal anomalies are
urachal sinus
urachal cyst
urachal diverticulum
patent urachus
Pathophysiology
The embryologic cause is unknown.
Bladder development occurs during the fifth to seventh
week of gestational development.
- Development depends upon many factors
- mesenchymal differentiation
- mesenchymal growth
- urine production
Bladder cycling, the process of sequential expansion and
contraction, is important in the anatomic and physiologic
development of the normal bladder.
Bladder Diverticulum
Bladder diverticula are herniations of the bladder mucosa through
bladder wal musculature (detrusor muscle).
? Diverticular size can vary
? Diverticula can be wide or narrow mouthed.(The size of
diverticular openings has functional implications because narrow-
mouthed diverticula often empty poorly).
? Stasis of urine within diverticula can also lead to stone formation
or epithelial dysplasia.
? may cause ureteral obstruction,bladder outlet obstruction or
vesicoureteral reflux
Bladder Diverticulum...............
MC Site lateral and superior to the ureteral orifices. [dome of the
bladder, in disorders as bladder outlet obstruction (ie, posterior
urethral valves) or Eagle Barrett syndrome (prune bel y
syndrome)].
Congenital or acquired. Congenital deficiency or weakness in the
Waldeyer fascial sheath has been implicated as a cause.
Solitary
located at the junction of the bladder trigone and detrusor
Congenital diverticula are usual y removed surgical y
Bladder Diverticula
Bladder ears
lateral protrusions of the bladder through the internal inguinal ring and
into the inguinal canal.
Bladder ears are often observed during voiding cystourethrography
(VCUG) or intravenous pyelography (IVP), when the bladder is fil ed
to capacity.
Bladder ears have also been seen on CT body imaging.
No treatment is necessary
Knowledge of this entity is important to surgeons during inguinal
herniorrhaphy because occasional reports have been made of
partial or near total cystectomy performed under the mistaken
notion that this was a large hernia sac.
Bladder agenesis
?
Rare
?
generally incompatible with life.
?
Ureters may enter into the urethra, vagina, Gartner duct cyst
(female), prostatic urethra, rectum, or the patent urachus.
?
Associated hydroureteronephrosis and renal dysplasia
(variable) are present.
?
Other associated anomalies include neurologic, orthopedic,
hindgut, and other urogenital anomalies, such as renal
agenesis and absence of the prostate, vagina, seminal
vesicles, epididymis, or penis
This condition requires urinary diversion and subsequent
reconstruction
Megacystitis
Megacystitis is an enlarged bladder, believed to be secondary to
overfil ing of the fetal bladder during development
Common presentations-
hydronephrosis.
Febrile urinary tract infection
high-grade vesicoureteral reflux
Megacystitis can be observed in other conditions, such as posterior
urethral valves, Ehlers-Danlos syndrome, urethral diverticulum,
microcolon hypoperistalsis syndrome, sacral meningomyelocele,
sacrococcygeal teratoma, and pelvic neuroblastoma.
Clean intermittent catheterization
Bladder duplication
v Rare
v Complete (2 urethras exist)
v Partial (the bladder joins distal y into one common
urethra)
v The 2 halves of the bladder are on either side of the midline,
with the corresponding ipsilateral ureter draining each bladder
half.
v Associated anomalies include duplication of the penis, vagina,
uterus, lumbar vertebrae, and hindgut. fistulas may be present
between the rectum, vagina, and urethra.
Duplication of Ur. bladder
Urachal cyst
is a fluid-fil ed structure occurring in between the two obliterated
ends of the urachus.
Most occur in the distal third of the urachus.
More commonly, the urachal cyst is detected in early childhood or
adolescence.
Symptoms -infection ,inflammation,suprapubic mass, fever, pain,
and bladder or irritative voiding symptoms.
? (Staphylococcus aureus is the most common bacterial organism).
? Death from intra-abdominal rupture has been reported.
Patent urachus
Communication from the umbilicus to the bladder. continuous or
intermittent drainage from the umbilicus.
The tract may become inflamed, resulting in tenderness, periumbilical
swel ing, and serosanguinous or purulent discharge.
May be associated with bladder outlet obstruction, such as posterior
urethral valves.
Correction of the obstruction may result in the spontaneous resolution
of the patent urachus.
Patent Urachus
Patent Urachus
Resected specimen of Urachus
Intra-operative photograph
Urachal sinus
derived from a persistently patent urachus
Children may present with
periumbilical tenderness
wet umbilicus
granulation tissue at the level of the umbilicus
In many instances, these children have undergone multiple sliver nitrate
cauterizations under the mistaken notion that this is simply
granulation tissue after severance of the remnant umbilical cord.
These can be observed in the first 4-8 weeks of life.
Ectopia Vesicae
open to the outside and turned inside-out, so that its inside is visible at birth,
protruding from the lower abdomen
Symptoms-
q Exposed posterior bladder wall
q Short lower abdominal wall
q Inguinal hernia
q Separated pubic rami
q Epispadias
q Incomplete fusion of genital tubercles
q Opening in abdominal wall
q Urine excretion through opening in abdominal wall
q Incontinence
q Dilated ureters
q Open pubic arch
q Wide-set ischial bones
q Constriction between ureter and bladder
q Ureteral reflux
Exostrophy of Urinary bladder
Cystitis
Cystitis
In women is common due to a number of reasons :
- short urethra
- pregnancy
- decreased estrogen production during menopause.
In men: mainly due to persistent bacterial infection of
the prostate.
In both sexes: common risk factors are :
- presence of bladder stone
- urethral stricture
- catheterization of the urinary tract
- diabetes mellitus
Pathogenesis of cystitis
Due to frequent irritation of the mucosal surfaces of
the urethra and the bladder.
Infection results when bacteria ascends to the urinary
bladder . These bacteria are residents or transient
members of the pereneal flora, and are derived from
the large intestine flora.
Toxins produced by uropathogens.
Condition that create access to bladder are:
- Sexual intercourse due to short urethral distance.
Pathogenesis of cystitis
Uncomplicated UTI usually occurred in non
pregnant , young sexually active female without
any structural or neurological abnormality
Risk factors :
- Catheterization of the urinary bladder ,
instrumentation
- structural abnormalities
- obstruction
Hematogenous through blood stream ( less
common) from other sites of infection
Etiologic agents
E.coli is the most common (90%) cause of cystitis.
Other Enterobacteria include ( Klebsiella pnumoniae, Proteus spp.) Other gram negative rods
eg. P.aeroginosa.
Gram positive bacteria :Enterococcus fecalis, group B Strept. and Staphylococcus
saprophyticus { honeymoon cystitis}.
Candida species
Venereal diseases ( gonorrhea, Chlamydia) may present with cystitis.
Schistosoma hematobium in endemic areas.
Pathogens involved
Uncomplicated UTI
Complicated UTI
E. coli
64%
Enterobacteriaceae 16%
E. coli
Enterococcus spp 20%
Enterobacteriaceae
% is
Pseudomona spp <1%
not
Pseudomonas spp
S. aureus
<1%
possibl
Acinetobacter spp
e to
Special cases
(judge often multiresistant
strains)
(S. epidermidis)
S. saprophyticus
Yeasts (catheter related result)
Viruses (Adeno, Varicel a)
Chlamydia trachomatis
Clinical presentation
Symptoms usually of acute onset
? Dysuria ( painful urination)
? Frequency ( frequent voiding)
? Urgency ( an imperative call for toilet)
? Haematuria ( blood in urine) in 50% of cases.
? Usually no fever.
Vaginitis (5%)
Candida spp.
T. vaginalis
Cystitis (80%)
Urethritis (10-
E. coli,
Dysuria and
15%)
S. saprophyticus
frequency
C. trachomatis,
Proteus spp.
N. gonorrhoeae
Klebsiella spp.
H. simplex
Other bacteria?
Non-infectious (<1%)
Hypoestrogenism
Functional obstruction
Mechanical obstruction
Chemicals
How to differentiate between cystitis and
urethritis ?
? Cystitis is of more acute onset
? More sever symptoms
? Pain, tenderness on the supra-pubic area.
? Presence of bacteria in urine ( bacteriuria)
? Urine cloudy, malodorous and may be
bloody
Differential diagnosis
( types of cystitis)
Non-infectious cystitis such as:
1. Traumatic cystitis in women
2. Interstitial cystitis ( unknown cause, may be
due to autoimmune attack of the bladder)
3. Eosinophilic cystitis due to S.hematobium
4. Hemorrahagic cystitis due to radiotherapy or
chemotherapy.
Laboratory diagnosis of cystitis
1. Specimen col ection
2. Microscopic examination
3. Chemical screening tests
Recurrent cystitis
3 or more episodes of cystitis /year
Requires further investigations such as
Intravenous Urogram ( IVU) or ultrasound to detect
obstruction or congenital deformity
Cystoscopy required in some cases
Treatment of cystitis
? Empiric treatment commonly used depending on
the knowledge of common organism and
sensitivity pattern
? Treatment best guided by susceptibility pattern
of the causative bacteria
? Common agents: Ampicil in, Cephradine,
Ciprofloxacin, Norfloxacin, Gentamicin or TRM-
SMX.
? Duration of treatment: 3 days for uncomplicated
cystitis
? 10-14 days for complicated and recurrent cystitis
? Prophylaxis required for recurrent cases by
Nitrofurantoin or TRM-SMX
? Prevention : drinking plenty of water and
prophylactic antibiotic
Bladder cancer
Aetiology
? Smoking ? 4x increased risk
? Causes 50% of cases
? Occupational ? rubber/dye industry
? Napthylamine, benzidine
? Schistosomiasis, chronic infection
? Medications ? cyclofosfamid, fenacetin
Histology
? 90-95%
transitional-cell carcinoma
? 3%
squamos-cell carcinoma
? 2%
adenocarcinoma
? <1%
smal -cell carcinoma
? 99%
primary tumors
Entities
? 75-85% superficial bladder cancer
pTa, pTis, pT1
? 10-15% muscle-invasive bladder cancer
pT2, pT3, pT4
? 5%
metastatic bladder cancer
N+, M+
Presentation
? Classically painless frank haematuria,
sometimes intermittent
? Frequent urination, urgency
? symptoms with involvement of neighbouring
organs,lymphoedema, pelvic pain
Examination
History
Physical examination
Urine examination / urinalysis, cultivation,
cytology ? can be only 60% sensitive/
Ultrasound
Examination
? Cystoscopy is mandatory
? Biopsy or TURBT
? Bimanual pelvic examination /before and after
TURBT
? Chest X-ray
? IVU ? no routinely, (5% chance upper tract
involvement)
Bladder cancer: Stage and Prognosis
Carcinoma in situ (CIS)
? Precursor infiltrating tumors
? Primary or secondary
? Subjectively ? frequent urination, urgency,
cystalgia
? Objectively ? no pathologies
? Laboratory
? Microhematuria
? Cytology positive (PAP IV-V)
CIS treatment
? Primary CIS: BCG
? Secondary CIS: TURB + BCG
? Recurrent CIS /after therapy/: cystectomy
Treatment
? Superficial Bladder Cancer
pTa, pT1, Tis
? Invasive bladder cancer
pT2-pT4
Superficial Bladder Cancer
pTa, pT1, Tis
Standard of care=intravesical therapy
transurethral resection bladder
tumors /TURBT/
Relapse rate: 70%
adjuvant therapy
TURBT
TURBT
TURBT
Superficial Bladder Cancer
Adjuvant Therapy
? Reduces relapse rate by 30-80%
? Mitomycin C ? in patient with
intermediate-risk BT
? BCG ? in patient with CIS, high risk BT
Invasive bladder cancer
? Standard of care = Radical cystectomy with
pelvic lymphadenectomy
? Only about 50% of patients with high-grade
invasive disease are cured
Radical cystectomy
Radical cystectomy
Chemotherapy for bladder cancer
? Bladder cancer is a chemosensitive disease
? Active single agents RR
? Cisplatin
30%
? Carboplatin
20%
? Gemcitabine
20-30%
? Ifosfamide
20%
Neoadjuvant chemotherapy
? Meta-analysis of ten randomised trials (2688 patients)
? 13% reduction in risk of death
? 5% absolute benefit at 5 years
? OS increased from 45% to 50%
? ABC Meta-analysis Collaboration. Lancet
2003;361:1927
Bladder-sparing therapy for invasive
bladder cancer
? High probability of subsequent distant metastasis after
cystectomy or radiotherapy alone (50% within 2 years)
? Radiotherapy in comparison with cystectomy has inferior
results (local control 40%)
? muscle-invasive bladder cancer is often a systemic
disease combined modality therapy
Bladder-sparing protocol
Transurethral resection
Induction Therapy: Radiation + chemotherapy
(cisplatin, paclitaxel)
Cystoscopy after 1 month
no tumor
tumor
Consolidation: RT + CT
cystectomy
Urinary diversion
? Diversion of urinary pathway from its natural path
? Types:
? Temporary
? Permanent
A nephrostomy is a
surgical procedure by
which a tube, stent, or
catheter is inserted
through the skin
into the kidney
Cutaneous
Ureterostomy...
One kidney drainage,
with short-live
prognosis
Complications
(infection, stone,
stenosis)
Permanent urinary diversion
? Uretero ? sigmoidostomy
? Ileal conduit
? Colon conduit
? Ileocaecaecal segment
Cutaneous urinary
diversions
Ileal conduit (ileal loop)
A 12 cm loop of ileum led out
through abdominal wall
Stents used
The space at cystectomy site
drained by a drainage system
After surgery a skin barrier
and a transparent disposable
urinary drainage bag
Constantly drains
Complications of ileal conduit
? Wound infection
? Wound dehiscence
? Urinary leakage
? Ureteral obstruction
? Small bowel obstruction
? Ileus
? Stomal gangrene
? Narrowing of the stoma
? Pyelonephritis
? Renal calculi
Continent Urinary Diversions
? Continent Ileal Urinary Reservoir
Indiana Pouch
? Most common continent urinary diversion
? Periodically catheterized
Koch Pouch
Ureterosigmoidostomy
? Voiding occurs from rectum
Uretero-
sigmoideostomy
Uretero- sigmoidostomy
? Complications:
? Reflux of urine
? Hyperchloraemic acidosis (ammonium chloride
reabsorption, bicarbonates secretion)
? Renal infection
? Stricture formation
Potential complications
? Peritonitis due to disruption of anastomosis
? Stoma ischaemia and necrosis due to
compromised blood supply to stoma
? Stoma retraction and separation of
mucocutaneous border due to tension or
trauma
Bladder Reconstruction
INJURIES OF THE URINARY BLADDER
? Bladder injuries occur most often from external force and are often associated
with pelvic fractures.
? Iatrogenic injury may result from gynecologic and other extensive pelvic
procedures as well as from hernia repairs and transurethral operations.
Classification
? closed and open
? isolated and combined
? intraperitoneal,
retroperitoneal and mixed.
Clinical Findings
? There is usually a history of lower abdominal trauma.
? Blunt injury is the usual cause
? Patients ordinarily are unable to urinate, but when
spontaneous voiding occurs, gross hematuria is usually
present
? Most patients complain of pelvic or lower abdominal pain.
Clinical Findings
? Heavy bleeding associated with pelvic fracture
may result in hemorrhagic shock, usual y from
venous disruption of pelvic vessels.
? An acute abdomen indicates intraperitoneal
bladder rupture.
? A palpable mass in the lower abdomen usual y
represents a large pelvic hematoma.
? On rectal examination, landmarks may be
indistinct because of a large pelvic hematoma.
Clinical Findings
? Laboratory Findings:
? Catheterization usually is required in patients
with pelvic trauma but not if bloody urethral
discharge is noted.
? When catheterization is done, gross or, less
commonly, microscopic hematuria is usually
present.
? Urine taken from the bladder at the initial
catheterization should be cultured to determine
whether infection is present.
X-Ray Findings
? A plain abdominal film generally
demonstrates pelvic fractures.
There may be haziness over the
lower abdomen from blood and
urine extravasation.
? An intravenous urogram should
be obtained to establish whether
kidney and ureteral injuries are
present.
X-Ray Findings
? Bladder disruption is shown on cystography.
? Retrogradual cystography help to differentiate
penetrating and unpenetrating, intraperitoneal
and retroperitoneal ruptures of the bladder,
locate urinary flow and approximate site of
rupture.
? The sign of retroperitoneal rupture is
accumulation of X-ray contrast matter in
perivesical fat tissue.
? With intraperitoneal extravasation, free
contrast medium is visualized in the
abdomen, highlighting bowel loops.
X-Ray Findings
Treatment
? A. Emergency Measures:
Shock and hemorrhage should be treated.
? B. Surgical Measures
Treatment
In a case of retroperitoneal complete rupture
of the bladder it is exposed by suprapubic
extraperitoneal access carefully inspected
and is juncture by two-row catgut junctures.
Drainage by means of epicystostomy is
necessary.
Operation finish with drainage of perivesical
and pelvic tissue.
In order to prevent formation of urinary flow,
in all cases of retroperitoneal rupture of
urinary bladder, perivesical space is
drainage through obturatorial foramen or
ischiorectal space.
Treatment
Intraperitoneal bladder ruptures should be
repaired via a transperitoneal approach after
careful transvesical inspection and closure of
any other perforations.
The peritoneum must be closed carefully
over the area of injury.
The bladder is then closed in separate
layers by absorbable suture.
All extravasated fluid from the peritoneal
cavity should be removed before closure.
At the time of closure, care should be taken
that the suprapubic cystostomy is in the
extraperitoneal position.
Urethral Injuries
? Urethral injuries are uncommon and
occur most often in men, usual y
associated with pelvic fractures or
straddle-type fal s.
? Various parts of the urethra may be
lacerated, transected, or contused.
? Management varies according to the
level of injury.
? The urethra can be separated into 2
broad anatomic divisions: the posterior
urethra, consisting of the prostatic and
membranous portions, and the anterior
urethra, consisting of the bulbous and
pendulous portions
Clinical Findings
Symptoms:
? lower abdominal pain and inability to urinate. A history of crushing
injury to the pelvis is usual y obtained.
Signs:
? Blood at the urethral meatus is the single most important sign of
urethral injury (Urethroragia).
? Suprapubic tenderness and the presence of pelvic fracture are noted
on physical examination.
? A large developing pelvic hematoma may be palpated.
? Perineal or suprapubic contusions are often noted.
? Rectal examination may reveal a large pelvic hematoma with the
prostate displaced superiorly.
Clinical Findings
? Laboratory Findings:
? Anemia due to hemorrhage may be noted.
? Urine usually cannot be obtained initially, since the patient
should not void and catheterization should not be
attempted.
X-Ray Findings
Fractures of the bony pelvis are
usually present.
A urethrogram (using 20-30 ml of
watersoluble contrast material)
shows the site of extravasation.
Ordinarily, there is free extravasation
of contrast material into the
perivesical space.
Incomplete prostatomembranous
disruption is seen as minor
extravasation, with a portion of
contrast material passing into the
prostatic urethra and bladder.
X-Ray Findings
Treatment
? Conservative therapy is effective for
patients with recent nonpenetrating
damage of urethra: rest, cool
compresses, and antibiotics.
? Within 7-8 days after trauma thermal
procedures and resorption agents are
prescribed.
? In case of ischuria instead of a high
cystotomy it is possible to perform
troacar epicystostomy.
? Shock and hemorrhage should be
treated.
Treatment
Surgical Measures:
? Urethral catheterization should be avoided.
? suprapubic cystostomy to provide urinary
drainage.
? The bladder should be opened and
carefully inspected for lacerations. If a
laceration is present, the bladder should
be closed with absorbable suture material
and a cystostomy tube inserted for urinary
drainage.
? The suprapubic cystostomy is maintained
in place for about 3 months. This allows
resolution of the pelvic hematoma, and the
prostate and bladder will slowly return to
their anatomic positions.
Film Suprapubic Cystostomy
Treatment
Urethral reconstruction ?
? Reconstruction of the urethra after prostatic
disruption can be undertaken within 3 months.
? Before reconstruction, a combined cystogram
and urethrogram should be done to determine
the exact length of the resulting urethral
stricture.
? The preferred approach is a single-stage
reconstruction of the urethral rupture defect
with direct excision of the strictured area and
anastomosis of the bulbous urethra directly to
the apex of the prostate.
?
? A 16F silicone urethral catheter should be left
in place along with a suprapubic cystostomy.
? Catheters are removed within a month, and
the patient is then able to void
Re-do end to end
Complications
? Stricture, impotence, and incontinence are complications of prostato
membranous disruption.
? Stricture fol owing primary repair and anastomosis occurs in about one-
half of cases. If the preferred suprapubic cystostomy approach with
delayed repair is used, the incidence of stricture can be reduced to
about 5%.
? The incidence of impotence after primary repair is 30-80% (mean, about
50%).
? Incontinence in primary reanastomosis is noted in one-third of patients.
? Delayed reconstruction reduces the incidence to less than 5%.
This post was last modified on 08 April 2022