Urologic Pathologies of Child at Ouagadougou

Introduction: Urologic pathologies of children are frequent. Urinary apparatus diseases occupy the third position after those of respiratory and digestive tracts in children. Objectives: The objective of this study was to investigate epidemiologic, diagnostic, and therapeutic aspects of urologic pathologies of children in our hospital. Patients and Methods: This work is a descriptive and retrospective study from January 1st 2005 to December, 31st 2012 on children from 0 to 15 years old admitted and treated in Teaching Pediatric Hospital Charles de Gaulle for a urologic pathology. Results: In total, 711 patients had been registered with 7.3 sex-ratio, an average age of 4 years old (0 15 years old). Malformative pathologies were represented by the majority (62.7%). They were mainly composed of peritoneovaginal canal pathology, posterior urethra valves (PUV), and Pyeloureteral junction anomaly (PUJA). Urolithiasis, infectious, and tumoural pathologies were second, third and fourth with 19.4%, 7.6% and 5.8% respectively. Surgical treatment was necessary for 83.2% of patients. A total nephrectomy has been realized in 5 cases for PUJA with mute kidney. Some post-operative complications have been observed in 2.6% of operated patients. The global mortality rate was 2.9% with Wilms’ tumor predominance in aetiology (58.8%). Conclusion: Urologic pathologies of children are dominated by urogenital malformations. The decreasing of their lethality is guided by a MU antenatal diagnosis and a personal qualification to improve the diagnosis and the treatment.


Introduction
Urinary apparatus diseases, among children, are in third position after respiratory ways and digestives pathologies [1].Their annual frequency had been evaluated to 1/200 living births in France and their hospitable frequency is 31.8% in Benin [1] [2].They are dominated by malformations.Their seriousness varies but the majority of these pathologies can impair the child's kidney function.Malformative disorders of the urinary tract and mainly the posterior urethra's valves are a main cause of terminal renal failure for the child [3].Considering the frequency and the potential seriousness of these uropathies, we have found appropriate to determine epidemiologic, diagnostic, and therapeutic aspects of these pathologies in order to improve their prognosis.

Patients and Methods
This work is a descriptive and retrospective study from January 1st 2005 to December 31st 2012 on children from 0 to 15 years old admitted and treated in surgical paediatric service for a urologic pathology.The catchment area spread on the whole country peopled with 17 millions inhabitants; and the under 15 years represented 48%; our pediatric hospital is the only one.
We have included all patients admitted in emergency context or normal consulting whose medical documentation possessed diagnostic information of uropathy and treatment criteria.The variables collected were pidemiologic (age, sex, type and admission mode) diagnosis (consulting delay, clinical and paraclinical information about uropathy), treatment (treatment method, results).
Was defined as a new born, children from 0 to 28 days of live, infants from 29 days to 30 month of live, pre-scholar from 31 month to 5 years old, small child from 6 years to 10 years old and big child from 11 years to 15 years old.
Data have been captured and analysed with the following software: Word and Excel 2010, Epi info 3.5.3.

Admission Mode
Patients were admitted on the direct mode in 361 cases (50.9%) and by reference in 350 cases (49.1%).Normal consultion concerned 61.9% and emergency admission 38.1%.

Age and Sex
The average age was 4 years with an interval from 0 to 15 years.The distribution by age bracket showed: 3.3% of new born, 42.3% of infants, 26% of pre-scholar, and 28.3% of big children.It was a question of 88% of boys and 12% of girls, namely a sex-ratio of 7.3.The basic characteristics of these 711 patients was summarized into Table 1.

Consultion Delay
The average delay for consultation in paediatric surgical service was about 8.43 months with some extremes of 0 to 144 months.

Nosologic Entities
The distribution of patients depending of nosology entities is given in High uropathies in 30 cases were dominated by pyelo-ureteral junction anomalies and the kidney multi-cystic dysplasia with respectively 16 and 6 cases.The other high uropathies were represented by polycystic kidney (n = 2), the kidney agenesis (n = 2), the kidney ectopia (n = 2), the horseshoe-shaped kidney (n = 1) and the bifid ureter (n = 1).

• Kidney and urinary tract tumours
The tumoural pathology was dominated by Wilms' tumour with 35 cases (83.3% of tumours).The other tumours diagnosed were bladder tumour and testicular with 9.5% and 7.1% of tumours, respectively.

• Traumatic pathology
Four (4) cases of kidney contusion, 4 cases of urethral stenosis, 1 case of glans amputation after posthectomia and 1 case of urethral section have been registered.

Surgical Treatment
The majority of patients (592 = 83.2%)have required a surgical act and took 5.5% of all surgical activity in the service during this period.The therapeutic method applied was specific to each type of uropathy.The radical nephro-ureterectomia concerned 5 cases of PUJA on the 16 registered cases.The indication was the radiologic mute kidney.

Medical Treatment
A medical treatment was applied only in 8.2% and in association with surgery in 91.8% of cases.It concerned administration of antibiotics, anti-inflammatories, analgesics, and chemotherapy drugs.

Hospitalization Length
The average hospital stay was 4.5 days with extremes of 1 and 49 days.
Considering the aetiology, dead patients repartition is specified in Table 4.

Epidemiologic Aspects
In our study, per year 88.8 cases for hospital frequency of uropathy have been found.It represented 7.4% of the whole hospitalisation.This proportion is superior to the reports of Agossou-Voyeme and Dao who respectively found 4.8% and 2.8% in their series [2] [4].This difference is relative to the context of the study.The average age of our patients was 4 years.This result is near to those of Agossou-Voyeme and Dao who found 4.4 years and 4 years 11 months respectively [2] [4].Urologic pathologies predominated on boys with 7.3 as sex-ratio.The predominance of urologic disease at boys has been reported in developed countries' literature, and this in a similar way as developing countries' one [1] [4] [5].It concerned the definition of the paediatric urology which dealt with urinary apparatus pathologies for both sexes (male and female), and particularly male genital organs [6].

Diagnosis Aspects
Considering nosologic entities, the uro-genital malformation was the most frequent pathology in our series with a proportion of 62.7%.This predominance had been observed in developed countries' literature which is similar to developing countries' literature [1] [4] [5].In our context, this frequency of the malformative pathologies would increase with the development of antenatal diagnosis.Among these MU, the PUJA was more frequent in terms of high uropathy.His frequency of 2 cases per year (15 cases in 8 years), which is close to the frequency found by Kahloul et al. [7] (15 cases in 8.5 years, namely 1.7 cases/year) is very inferior to those reported by Diarra et al. [8] (13 cases in 1.5 years namely 8.7 cases/ year).
Among low MU, PUV were the most frequent and the most serious.The increasing of creatininemia (average of 133 umol/L) was present at 45% of patients who had PUV.This kidney's function deterioration in this MU has been also reported by other African authors: Khemakhem and al. (18/38 or 47.4%) and Dami (33.33%) [9] [10].This kidney function deterioration would be function of the late in diagnosis and the seriousness of the pathology.PUV formed the first aetiology of chronic obstructive renal failure to the boy [5].Another frequent complication in PUV is the urinary infection: about 2/3 of patients in our series (64.5%) and 75% in Dami's serie [10].This frequency of urinary tract infections reported by many authors [3] [11] [12] confirms the seriousness of this pathology with the risk of septicaemia in pyelonephritis.These complications are able to strike a blow at patients' vital prognosis underlining the necessity of early diagnosis and adequate treatment.

Therapeutic Aspects
The total nephrectomy has been indicated for a muted kidney in 5 cases on 16 PUJA; it forms a high rate.In PJUA, the waited nephrectomy rate was about 10% for primary nephrectomy and inferior to 1% for secondary nephrectomy in the western series at the end of years 1980 [13]- [15].These series were composed of a majority of postnatal diagnosis, with which the primary nephrectomy decreased and secondary nephrectomy become very rare [16] [17].It's important in our context to promote the antenatal diagnosis, with obstetrical echography and at default, act to early screening of MU in order to reduce nephrectomy rate.This screening will have to concern also PUV in particular because of their seriousness.An early and adequate treatment, in particular the endoscopic resection, will contribute to the reduction of this pathology's lethality.
Postoperatives complications have been observed in 15 patients with a morbidity rate of 2.1%.It was about parietal suppuration in 6 cases and fistula in 7 cases after bladder lithotomy or after surgery of hypospadias and bladder exstrophy.
The global mortality of uropathies in our series was 2.3%.This high rate is similar to rate found by Agossou-Voyeme et al. (2.8%) [2].The principal cause of death was the Wilms' tumour with 58.8%.This high rate of lethality is explained by difficulties met in the care of cancer in developing countries, mainly the problems of accessibility to treatment and delay on diagnosis.It calls out to an early screening of cases by complete and systematic clinic exam for any child who is consulted or made medical visit, and who has a best accessibility for chemotherapy.Posterior urethra valves provided two cases of death due to renal failure after elevation of urea.The endoscopic treatment of such disease is not accessible in our context.The other causes of death were repre-sented by bladder exstrophy, strangled inguinal hernia, kidney abscess, bladder tumour, and urolithiasis.The main problems were the inadequacy of our health system which cannot provide good quality of care and the cultural considerations that urge certain parents to use traditional medicines before their admission to hospital.That situation explained the delay on diagnosis and care thus leading to drawbacks.

Conclusions
Urologic pathology of the child is frequent.It is dominated by malformations.The MU are potentially serious because in the major forms like the PUJA and PUV, the principal evolving risk is the deterioration of kidney function.
The decreasing of the infantile morbi-mortality linked to urologic pathology goes through: • A screening by a complete clinic exam during medical visit or when they are consulting; • Obstetrical echography promotion; • A physician continuing education; • An increasing in number of specialists in paediatric surgery (uro-paediatricians) and medical paediatricians (nephro-paediatricians).

Table 2 .
Distribution of patients according nosologic entities.

Table 3 .
Patients repartition according to the exit mode.