VESICOURETERAL REFLUX/VUR (KIDNEY LEAK)
Normally, there are mechanisms that allow the urine to be expelled unidirectionally from the bladder during urination. The leakage of some of the urine towards the ureters and/or kidneys during urination due to disruptions in this mechanism for any reason is called vesicoureteral reflux.
The most common cause of kidney failure in our country is still urinary tract infections due to vesicoureteral reflux.
>How is VUR disease diagnosed?
Vesicoureteral reflux often manifests itself with febrile urinary tract infection or prenatal hydronephrosis. Diagnosis is made during the evaluation for urinary tract infection. The first evaluation test performed in a child with a urinary tract infection is urinary ultrasonography. The most important test that provides information in a child with suspected VUR is the x-ray film taken during the administration of a dyed liquid into the bladder with the help of a thin catheter in the urinary tract, called voiding cystourethrography or voiding cystourethrography.
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In the figure;in voiding cystography, the escape of the opaque substance given to the bladder from the ureter (the channel connecting the kidney to the bladder) backwards towards the kidney, from the 1st degree to the 5th degree(from left to right)The preferred method for determining kidney function and damage to kidney tissue is DMSA, that is, kidney scintigraphy. A prediction about the natural course of reflux can be made with the combined use of voiding cystography (voiding cystourethrography) and DMSArenal scintigraphy.
How often does VUR occur in whom?
Reflux is seen in only1-2%of all children. However, 25-40% of children with kidney inflammation have reflux. (hydronephrosis) 17%-37% of kidney swellings detected before birth have accompanying reflux. Therefore, it should be recommended that every child with a febrile urinary tract infection be screened for reflux.
Vesicoureteral Reflux Rating:
1st Degree:The contrast material filling the bladder only reaches the distal part of the ureter during urination. VUR of this degree occurs in 8% of all cases.
2. Degree:Contrast material reaches the renal calyces. However, there is no dilatation in the urinary system. 37% of the cases are in this stage.
3rd Degree:Despite moderate dilatation in the ureter, renal pelvis and calyces, the renal calyces have not yet become blunted. . 25-37% of the cases are in this group.
4. Degree:In addition to dilatation in the ureter, renal pelvis and calyces, the renal calyces are blunted. 14-24% of the cases are in this group.
5. Degree:There is advanced hydroureteronephrosis and a tortuous ureter on the side where the reflux is located. 5% of the cases are in this group.
VUR Treatment
The basis of treatment is early diagnosis and close follow-up, and this It is aimed to protect the kidney tissue in this way. Since reflux may resolve spontaneously as the child grows, the first step in treatment is to encourage all patients to drink large amounts of fluid until they are one year old, ensure complete emptying of their bladder, and prevent and monitor infections with low-dose antibiotic protection. In this period, it is recommended for male babies to be protected against infection. Circumcision is recommended.
Vesicoureteral reflux (VUR) may pass out at a rate of50%in the first 2 years. In necessary cases, 85% successful VUR treatment can be performed in experienced hands by endoscopically injecting some special fillers into the urinary tract. However, the situation is slightly different in children presenting with febrile urinary tract infection. The degree of reflux, the child's age and the level of kidney damage are important in deciding on treatment. The level of damage to the kidney can be measured numerically and visually by nuclear medicine examination (static renogram - DMSA). It usually resolves spontaneously by the age of 5, depending on the degree of vesicoureteral reflux. If you have urination disorder, y
PROSTATE CANCER
Prostate cancer is among the most important problems of aging men. It was determined that there were 2.6 million new cancer cases in Europe as of 2009. Again, in Europe, prostate cancer accounts for 11% of all cancer cases and 9% of cancer deaths. Currently, the strongest risk factor is genetics. Having a family history of prostate cancer. It is thought that changing eating habits may also be effective in the development of prostate cancer.
The pathological type of prostate cancer is usually called adenocarcinoma. The system used for classification is the TNM system. (T: tumor, N: lymph node, M: metastasis). A scoring system called Gleason score is used for pathological grading.
Diagnosis of Prostate Cancer
Prostate cancer is generally It is a disease of middle-aged men. The disease may progress slowly and cause late symptoms. When symptoms appear, advanced disease or metastasis It may become a disease that has reached the stage of a tactic disease. Symptoms of the disease may include frequent urination (polyuria), night urination, dysuria (painful urination) and difficulty in urination. In advanced disease, back and joint pain, weakness and weight loss may occur. Sometimes the disease may occur incidentally, without any symptoms, or with a biopsy performed during follow-up visits due to high PSA levels. The basic methods used for diagnosis are digital rectal examination, measurement of the PSA value in the blood, and ultrasound-guided prostate biopsy. Prostate cancer should be suspected in the presence of an enlarged prostate and a palpable hard and immobile mass during digital rectal examination. PSA, another method used in diagnosis, is a hormone and is released from the prostate gland. Since it is also released from cancerous tissues, it has an important place in diagnosis. High PSA increases the risk of cancer.
PSA valueProstate cancer risk3-4 ng/ml (Under 50)34%3-4 ng/ml (50-66 age range)13%6-10 ng/ml44%>10 ng/ml71%
F-PSA/t, as free PSA (f-PSA), which is also the subtype of PSA, will increase in cancerous tissue -If the PSA rate is below 20% and the annual PSA increase rate is
40-49 YearsPSA 0-2.5 ng/ml 50-59 YearsPSA 0-3.5 ng/ml 60-69 YearsPSA 0-4.5 ng/ml70 and abovePSA 0-6.5 ng/ml
With Ultrasound Guidance Biopsy:It is a procedure performed to definitively diagnose prostate cancer. It is performed by applying a local anesthetic substance from the prostate with an 18 G wide needle, accompanied by an ultrasound probe from the anus, and then taking 10 pieces. Cancerous tissue can be detected as a result of examination of the samples taken. A positive biopsy is a definitive diagnosis, but a negative biopsy does not necessarily mean there is no cancer. If the biopsy is negative and the patient has the same risk factors, a repeat biopsy should be performed. In studies, the cancer rate in these re-applied biopsies varies by 30-50%.
The type and degree of the tumor is determined in the pathologically examined parts. The majority of prostate cancers are pathologically adenocarcinomas. Rarely, it may occur in other pathological types. (sarcoma, lymphoma, etc..) The pathological grading system is the Gleason system. By grading the tumor according to this system, information can be obtained about the extent, progression and treatment of the disease. Gleason score is expressed as two numbers such as 1+2 and the total score is evaluated. Grading is made according to Gleason score as follows.
Gleason score (total)Grade2-4Well differentiated 5-6Moderately differentiated7Moderate-poorly differentiated8-10Poorly differentiated
STAGING
The staging and grading system required for the treatment of prostate cancer is made after making a pathological diagnosis. It is. After diagnosis, if the PSA value is above 20 ng/ml, a bone scan is performed to evaluate whether the disease has spread to the bones. Disease that spreads to the bones is an advanced stage disease and requires completely different treatment. The TNM system is used for staging. According to this system;
T: Primary tumor
• Tx: Primary tumor focus not detected
• T0: no evidence of primary tumor
• T1: Tumor clinical examination or imaging methods Not detected by
• T1a: Less than 5%tumor in TUR(transurethral prostate resection)material
• T1b: 5%in TUR material More than tumors
• T1c: Tumor diagnosed by needle biopsy as a result of PSA elevation, group with normal DRM (digital rectal examination)
• T2: Tumor has been detected in the prostate tissue
• T2a: Tumor has involved half or less than half of a lobe
• T2b: Tumor has involved more than half of a lobe
• T2c: Tumor has involved both lobes
• T3: The tumor has exceeded the prostate capsule
• T3a: Unilateral or bilateral extra-capsular spread
• T3b: There is spread to the seminal vesicles.
• T4: The tumor is fixed and has spread to other nearby organs such as the bladder neck, external sphincter, rectum and pelvic wall, other than the seminal vesicle.
N: Regional Lymph Nodes
• Nx: If spread to regional lymph nodes cannot be demonstrated
• N0: No spread to regional lymph nodes
• N1: There is spread to regional lymph nodes
M: Distant Metastasis (Spread)
• Mx: Distant If metastasis cannot be demonstrated
• M0: No distant metastasis
• M1: There is distant metastasis
• M1a: Metastasis to non-regional lymph nodes
• M1b: Bone metastasis greyhound
• M1c: Metastasis to distant organs.
Diagnosis and Staging Principles in Prostate Cancer
1. Abnormal digital rectal examination findings or increased serum PSA level warrant suspicion of prostate cancer.
2. Diagnosis of prostate cancer requires pathological confirmation. If the patient requires further treatment, prostate biopsy and advanced staging tools should be used.
3. Ultrasound guidance
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