Module Title: GENITO-URINARY TRACT Date: May 2013 Module Rationale and Competencies

Transcription

1 Module Title: Date: May 2013 Module Rationale and Competencies A paediatric surgeon is required to have a thorough understanding of normal anatomy and physiology, pathophysiology, investigations, differential diagnosis and operative and non operative of paediatric genito-urinary surgical conditions. It is important that paediatric surgeons maintain a current understanding of the most time and manner of intervention and with this knowledge determine the service level for competent of individual patients. A paediatric surgeon must at all times have knowledge of their obligation in regard to consent and guardianship. A paediatric surgeon will exhibit professionalism in only performing those procedures for which they are competently trained. The Graduating Trainee will be able to: Diagnose and manage pathological conditions that pertain to the paediatric genito-urinary tract. Communicate information to patients and their family about procedures, potentialities, and risks associated with surgery in ways that encourage their participation in informed decision making, including antenatal counselling. Select investigative tools Develop a plan that takes into account the physical, social, cultural and psychological needs of the child Identify and manage risk Recognise the need to refer patients to other professionals Participate in critical analysis of and discussion of controversies in of neonatal conditions Embryology Anatomy Suggested Reading Learning Opportunities, Resources and Methods How this unit will be assessed Trainees should have a thorough knowledge of the embryology of the: urinary tract, urogenital tracts, descent of the testis, the female and male external genitalia, retro-peritoneum, pelvis, abdominal and pelvic vasculature. Trainees should have a thorough knowledge of the anatomy: of the kidney; ureter; bladder; urethra; internal and external genitalia; bony pelvis; gonads; internal and external sphincters; pelvis and its contents; pelvic floor and retro-peritoneum. Refer to Paediatric Surgery reading list available on the College website. Trainees will be expected to keep abreast with current literature. ANZ Paediatric Urology Club meetings and teaching courses, Annual Scientific Congress of ANZAPS, Critical Appraisal Tasks, Directed Online Group Studies, MOUSE, Trainees should attend public and private outpatients and operating sessions at every opportunity and participate in the decision-making process as well as the operative procedure and perioperative care, Compulsory courses. Fellowship, written papers. Trainee evaluation forms and logbooks. Paediatric Anatomy and Paediatric Pathophysiology Examination. The level of competence in application of knowledge to clinical situations, judgment in case, interpretation of investigations and clinical diagnosis will be assessed during day to day work and as a component of work-based s such as case based discussions, mini-cex, MOUSE, 360, quarterly trainee evaluation s, ward rounds and case presentations. This curriculum module should be read in conjunction with the template of Expected Performance Technical Expertise and Judgement Competencies. (Paediatric Surgery Genito-urinary)

2 The use of the following key will define in which areas the trainee should have be competent in knowledge of basic paediatric surgery science and application of knowledge to relevant situations at the end of the SET level. End EARLY SET End MID SET SENIOR SET Extended explanation of levels of technical competencies key : A. B. Non-operative : Presents and discusses fully with consultant or senior registrar and is instructed on further and Operative : Performs procedure under full supervision or is being actively instructed on procedure as part of training process. C. Non-operative : Presents and discusses with consultant or senior registrar, but rarely needs correction or instruction on further Operative : Performs procedure with supervision and needs assistance for more difficult cases. D. Non-operative : es case with consultant and starting to take lead responsibility on the case Consultant confident in registrar s and diagnostic accuracy. Operative : Consultant will be available to come in and assist, or will confidently supervise un-scrubbed. Procedures: Can outline operative plans and options. E. Non-operative : Fully able to manage and investigate condition ly (as per D), has leadership role in case and can supervise junior colleague in Operative : Can perform as a safe independent professional and may supervise and instruct junior colleagues in procedure. Procedures: Can detailed plans and operative approaches and techniques due to own experience and observations as active participant in surgical team in similar cases. F. This category is intended for those procedures/conditions for which it is usual for a paediatric surgeon to provide care with assistance of a colleague or within a tertiary sub-specialised paediatric surgery unit. Non-operative : Fully able to coordinate investigations and manage condition (as per D). Will ly consult with sub-specialty surgical and medical units. Operative Management: Active senior participant in surgical procedure as part of a sub-specialty surgical team. procedures: Can detailed plans and operative approaches and techniques due to own experience and observations as active participant in surgical team in similar cases.

3 Hydronephrosis Multicystic dysplastic kidney Posterior urethral valves Explain the development of hydronephrosis in children and the differential diagnosis including current theories of embryological basis. associated conditions particularly of renal tract anomalies and impact on outcome and Explain the development of the multicystic kidney and the differential diagnosis of congenital renal cystic lesions. Describe the embryological basis of posterior urethral valves and the associated anatomical and functional Be able to discuss patho-physiology of clinical investigations of the condition known as Valve Bladder presentation both antenatally and later in childhood. Describe limitations in interpretation of functional Outline timelines for timing of Outline Pyeloplasty, Laparoscopic options, both non ureteric nephrectomy operative and reimplantation, operative, including Cystourethroscopy, timing of surgery, procedural options, Ureteric stent long term follow-up insertion and removal how Heminephrectomy anatomical variations and functional results Nephrectomy of investigations affect Explain of antenatal diagnosis related to cause and severity. options, including of antenatal diagnosis. Elucidate controversies in indications and timing of surgery, procedural options, long term follow-up and complications. options and procedural options. Know issues and procedures for long term follow-up and managent in this condition. Nephrectomy Bladder catheterisation, ablation of posterior urethral valves, vesicostomy. Laparoscopic Nephrectomy Appendicovesicostomy, bladder augmentation, urodynamics.

4 Posterior urethral valves continued Ureterocele Disorders of sexual development Bladder Exstrophy and Epispadias Describe the embryology and anatomy of ureterocele and the associated structural differences between single system and duplex ureteroceles. Describe the embryology of the urogenital tracts with reference to disorders of normal development and endocrinological and chromosomal control of sexual differentiation. Describe the embryology of the external genitalia, urethra and bladder neck and relate : imaging and endocrinological and chromosomal Explain of antenatal diagnosis. the role of involvement of tertiary level paediatric urologist and multidisciplinary team. Bladder options, both non catheterisation, operative and excision of operative, including ureterocele and indications for and ureteric timing of surgery, reimplantation, procedural options, vesicostomy, long term follow-up heminephrectomy, endoscopic incision of the role of involvement of tertiary level paediatric urologist and other members of multidisciplinary team in family counselling and support. controversies in operative the role of involvement of tertiary level paediatric ureterocele. Hypospadias repair, orchidopexy, gonadectomy. Vaginal reconstruction, urogenital sinus repair. Closure bladder and anterior abdominal wall repair.

5 Bladder Exstrophy and Epispadias Cont. Hypospadias Acute scrotum to the anatomical abnormalities of bladder exstrophy and epispadias including associated orthopaedic anomalies. Describe the embryology of the penis and urethra in relation to the development of hypospadias. Classify testicular torsion and relate to the predisposing anatomical configurations. Explain embryology of testis and renal tract and its relationship to torsion and other causes of acute scrotum. pathphysiological and anatomical basis for non-surgical causes of acute scrotum presentation with regards to surgical and medical causes and Know clinical features that require further investigation : imaging and endocrinological investigations in those situations. Indicate clinical scenarios when investigations are. timing, interpretation and limitations of these urologist and other Bladder neck members of reconstruction, multidisciplinary artificial urinary team in sphincter, continent diversion, epispadias repair. family counselling and support. Describe and complications including early closure of bladder. options including timing of surgery, including postoperative and complications. the role of involvement of tertiary level paediatric urologist options, both non surgical and surgical, including Erection test, MAGPI, Distal hypospadias repair, Correction of chordee, repair of postoperative urethral fistula. Exploration of scrotal contents with fixation of the testes. Proximal hypospadias repair, buccal mucosa graft, two stage urethroplasty.

6 Varicocele Labial adhesions Renal failure and transplantation Preputial conditions Hydrometrocolpos Describe the embryological theory of development of the testis, inferior vena cava and gonadal veins as it relates to development of varicocele. post-natal pathological causes of varicocele. Describe the aetiology of labial adhesions. Describe the causes of obstructive and reflux uropathy. Describe the embryology and natural history of prepuce. Describe embryology and anatomy of female genital tract relating to uterine and vaginal anomalies causing hydrometrocolpos List associated urinary and G.I.T. abnormalities. the modes of note Describe symptoms and signs particularly the features that differentiate labial adhesions from malformations of external genitalia. the modes of presentation of renal failure and the presentation of preputial disorders and the modes of findings related to different anatomical causes and age of presentation. investigations as affected by age and mode of presentation investigations and prevent in non Correction of Radiological surgical and varicocele embolization of surgical laparoscopic high varicocele, ligation. correction of including varicocele indications, timing, inguinal approach. options for renal impairment and renal failure, including dialysis and transplantation, providing procedural details and complications. options for preputial conditions, both non surgical and surgical, and complications. options, including, complications and long term follow-up. Insertion of peritoneal dialysis catheter. Circumcision, hemi circumcision, dorsal slit, reduction of paraphimosis. Division of membranous vaginal atresia (imperforate hymen). Vaginoscopy. Renal transplantation, creation of A-V fistula. Preputioplasty. Correction of cloacal anomaly, correction of vaginal atresia.

7 Urinary incontinence Neuropathic / neurogenic bladder Vesicoureteric reflux and UTI Ovarian pathology Describe the embryology and anatomy of the urogenital tract and the normal development of urinary continence. Describe the anatomy and innervation of the bladder and sphincter and list the causes of neurogenic bladder. Classify neurogenic bladder with reference to pressure, outcome, continence, infection and potential for renal damage (uropathy) Describe the embryology and anatomy of the urinary tract related to the condition of vesicoureteric reflux and the associated theories of natural progression. the ovarian pathologies that occur antenatally, during childhood the modes of note Perform and discuss history and particularly in identifying differentiating features between benign dysfunctional voiding and neurogenic bladder disorders.) Describe modes of the varieties of presentation of role of cytoscopy Describe performance of urodynamics. Select indications for use of urodynamics. Use select and interpret Use of the bed Urodynamics, alarm, operations for options, both non pharmacotherapy, duplex renal surgical and cystoscopy. anomalies. surgical, including Outline the options, both non operative and operative, including follow up, the role of involvement of tertiary level paediatric urologist and other members of multidisciplinary team in options, both non surgical and surgical, including timing of surgery, preoperative investigations and treatment, procedural options, long term follow up procedural options, long term follow up and Clean intermittent catheterisation, vesicostomy, ureteric reimplantation Ureteric reimplantation, circumcision. Laparoscopic and Open Ovarian cystectomy and Continent and noncontinent urinary diversion, bladder augmentation artificial urinary sphincter, subureteric injection of bulking agent. Sub ureteric injection of bulking agent, vesicostomy.

8 Ovarian pathology See also Gonadal tumours in Childhood Tumours module cont. Ovarian Torsion and adolescence including neoplasms, chromosomal anomalies and cystic conditions. embryological development of ovaries and internal genital tract with regard anomalies including antenatal torsion. Classify ovarian cysts. predisposing conditions for ovarian torsion ovarian torsion in normal ovary. ovarian pathology. List differential diagnosis of abdominal masses in females. Know clinical presentation of ovarian torsion and explain relationship of timing of diagnosis to outcome role and timing of Laparoscopy, ultrasonography and endocrine. the significance of findings on including single vs multiple cysts and solid ovarian masses Use emergency investigation discuss limitations of ultrasonography in diagnosis complications. oophrectomy. principles Ultrasound guided of ovarian and laparoscopic preservation. guided cyst Elucidate plan of aspiration of Laparoscopic antenatally oophoropexy diagnosed ovarian pathology procedural options, follow up principles of ovarian preservation. Laparoscopic and Open Ovarian cystectomy and oophrectomy. Ultrasound guided and laparoscopic cyst guided aspiration Laparoscopic and open detorsion.