hidronefrose na criança
DESCRIPTION
Aos residentes em pediatria e cirurgia pediátrica do Hospital das Clínicas da UFMG.TRANSCRIPT
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HIDRONEFROSE
Prof. Clécio Piçarro
Departamento de Cirurgia
Faculdade de Medicina da UFMG
facebook.com/cleciop
Slideshare.net/ClecioPicarro
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INTRODUÇÃO
• Doenças freqüentes
• US obstétrico – hidronefrose
• Devem ser acompanhadas pelo cirurgião e nefrologista
• Raramente – intervenção pré-natal
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Estenose de junção ureteropélvica
Estenose de junção ureterovesical
Ureterocele e duplicação ureteral
Refluxo vesicoureteral
Válvula de uretra posterior
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HIDRONEFROSE FETALdiagnóstico prénatal
• 48% resolução espontânea
• 15% dilatação sem obstrução (pelve extra-renal)
• 11% estenose de JUP
• 9% RVU
• 4% rim multicístico
• 2% ureterocele
• 1% VUP
Woodword M, Frank D. 2002 BJU Int :149156.
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• Tempo médio de acompanhamento de 24 meses
• 192 crianças
Sem achados significativos - 59%
Estenose de JUP – 28%
RVU – 8%
Megaureter – 3%
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ESTENOSE DE JUP
• Causa mais comum de hidronefrose
• Incidência de 1 / 1500
• Fetal x adquirida
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ESTENOSE DE JUP
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VASO ANÔMALO ANGULAÇÃO URETER
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DIAGNÓSTICO
• US pré-natal
• US pós-natal
• Cintilografia renal (DTPA e DMSA)
• Uretrocistografia miccional
• Uroressonância
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US OBSTÉTRICO
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US PÓS-NATAL
• Experiência do examinador
• Avaliar anatomia
• Dimensões
o Rim
o Pelve
o Parêmquima renal
o Ureter
• US dinâmico
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US VIAS URINÁRIAS
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US VIAS URINÁRIAS
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URETROCISTOGRAFIA
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CINTILOGRAFIA RENAL - DTPA
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CINTILOGRAFIA RENAL - DMSA
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RESSONÂNCIA NUCLEAR MAGNÉTICA
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SFU
Society of Fetal Urology
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SFU
I II
III IV
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PIELOPLASTIA ANDERSON-HYNES
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CATETER DUPLO J
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ESTENOSE DE JUNÇÃO
URETEROVESICAL
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ESTENOSE DE JUV
• Segunda causa de hidronefrose
• Megaureter obstrutivo primário
• Hidronefrose + megaureter
• Pode estar associado à estenose de JUP
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PROPEDÊUTICA
• US obstétrico
• US vias urinárias
• Cintilografia renal (DTPA e DMSA)
• Uretrocistografia
• urorresonânica
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US VIAS URINÁRIAS
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CINTILOGRAFIA RENAL
DTPA
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URETROCISTOGRAFIA
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UROGRAFIA EXCRETORA
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TRATAMENTO
• Conduta conservadora
• Displasia do trato urinário
• Cirúrgico piora do parênquima ou ITU
• Derivação
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CIRURGIA DE HENDREN
(ureteroplastia + reimplante ureteral)
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URETEROCELE
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INTRODUÇÃO
• Diagnóstico intra-útero
• Muito mais comum em meninas
• ITU
• Prolapso ureterocele
• 80% associado a duplicação ureteral
• Pode haver RVU
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DUPLICAÇÃO URETERAL
+
MEGAURETER
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US VIAS URINÁRIAS
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CISTOGRAFIA
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TRATAMENTO
• Heminefrectomia
• Punção endoscópica da ureterocele
• Anastomose ureteral
• Reimplante ureteral
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TRATAMENTO
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Heminefrectomia
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REFLUXO VESICOURETERAL
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US
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UCM
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Problema anatômico?
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CONDUTA
• Descartar vesicopatia
oBexiga neuropática
oDisfunção vesical
• US dinâmico
• Cintilografia - DMSA
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TRATAMENTO
• Tratar disfunção vesical
• Conservador – graus leves
• Tratamento cirúrgico – graus IV e V
• Avaliar função renal
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VÁLVULA DE URETRA POSTERIOR
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US PRÉ-NATAL
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URETROCISTOGRAFIA MICCIONAL
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UCM
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UCM
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US VIAS URINÁRIAS
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Cistoscopia
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TRATAMENTO
• Endoscópico
• Derivações
• Multidisciplinar
• Transplante
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INTERVENÇÃO INTRA-ÚTERO