Pediatric Surgery: Pediatric Urology

Preface
Contents
About the Editor
Contributors
Part I: General
1 Embryology of the Urinary Tract
Introduction
Early Events
Renal Development
Anomalies of Ureteric Bud Development
Renal Agenesis and Dysplasia
Duplex Kidney
Anomalies of Renal Position, Rotation, and Fusion
Bladder, Trigone, and Lower Ureteric Development
Anomalies of the Urogenital Membrane and Cloacal Partitioning
Exstrophy/Epispadias
Cloacal Exstrophy
Cloacal Anomalies
Anomalies of the Trigone
Renal Agenesis
Bilateral Single Ectopic Ureters
Genital and Reproductive Tract Development
Development of the Male Internal Genitalia
Development of the Female Internal Genitalia
Development of the External Genitalia
Development of the Male External Genitalia
Development of the Female External Genitalia
Abnormalities of the External Genitalia
Hypospadias
Congenital Adrenal Hyperplasia (CAH)
Conclusion and Future Directions
References
2 Antenatal Hydronephrosis
Introduction
Prenatal Imaging
Classification: Grading Systems
Anterior Posterior Renal Pelvic Diameter (APD)
Society for Fetal Urology Grading System
Urinary Tract Dilation Grading System
Prenatal Intervention for Lower Urinary Tract Obstruction
Vesicoamniotic Shunt Placement Versus Fetal Cystoscopy
Postnatal Evaluation of AHN
Imaging
Renal Ultrasound/Resolution of Urinary Tract Dilation
Voiding Cystourethrogram (VCUG)
Renal Scintigraphy
Magnetic Resonance Urography (MRU)
Postnatal Management of AHN
P1 UTD (Low Risk)
P2 UTD (Intermediate Risk)
P3 (High Risk) UTD
Considerations for Severe Bilateral Hydroureteronephrosis
Urinary Tract Infection
Antibiotic Prophylaxis
Etiology of Antenatal Hydronephrosis
Transient or Physiologic Hydronephrosis
Ureteropelvic Junction Obstruction (UPJO-Like HN)
Vesicoureteral Reflux (VUR)
Primary Megaureter/UVJ Obstruction
LUTO (PUV, PBS, Urethral Stenosis/Atresia)
Posterior Urethral Valves
Prune Belly Syndrome
Urethral Atresia
Congenital Megacystis
Multicystic Dysplastic Kidney (MCDK)
Duplication Anomalies Ureterocele/Ectopic Ureter
Conclusion and Future Directions
References
3 Evaluation and Management of Urinary Tract Infections in Children
Introduction
Epidemiology
Etiology
Presentation
Diagnosis
Imaging
Management
Acute Management
Antibiotic Prophylaxis
Circumcision and Surgical Management
Bladder and Bowel Dysfunction
Conclusions and Future Directions
Cross-References
References
4 Imaging of the Urinary Tract
Introduction
Plain Radiographs
Ultrasound
Fluoroscopic Studies
Micturating Cystogram
CT
MRI
Angiography and Intervention
Nuclear Medicine
Introduction
Static Cortical Scintigraphy
Tracers
Acquisition
Processing and Reporting
Clinical Indications
Dynamic Radionuclide Renography
Tracers
Acquisition
Processing
The Renogram in Antenatally Diagnosed Hydronephrosis
Assessment of Pelvic-Ureteric Anomaly
Assessment of Vesico-Ureteric Junction Anomaly
Congenital Renal Anomalies
Radionuclide Cystography
Direct Isotope Cystogram
Indirect Radionuclide Cystogram
Tumor Imaging
Conclusion and Future Directions
Cross-References
References
5 Magnetic Resonance Imaging of the Urinary Tract
Introduction
Magnetic Resonance Urography Technique
Determination of Differential Renal Function and Renal Drainage
Clinical Applications
Congenital Renal Malformations
Evaluation of Ureteral Anomalies
Evaluation of Hydronephrosis
Evaluation of UPJ Obstruction
Assessment of Vascular Malformations and Anomalies
Vesicoureteral Reflux
Pyelonephritis and Renal Scarring
Renal Masses
Current Limitations
Conclusion and Future Directions
Cross-References
References
6 Urodynamic Studies of the Urinary Tract
Introduction
Evaluation Prior to Urodynamic Studies
Urodynamicist Preparation
Noninvasive UDS Testing
Four-Hour Voiding Observation
Uroflowmetry
Uroflowmetry Patterns
Invasive Urodynamics
Performing the UDS
Cystometry
Assessment of Storage Phase
Bladder Sensation
Detrusor Function
Bladder Compliance
Bladder Capacity
Urethral Function During Filling
Assessment of Voiding Phase
Pressure Flow Studies
Bladder Function During Voiding
Uroflowmetry
Conclusion and Future Directions
Cross-References
References
7 Principles of Minimally Invasive Surgery
Introduction
Anesthetic Considerations for Minimally Invasive Surgery in Children
Laparoscopic and Robotic Procedures
Background
Positioning
Retroperitoneal Versus Transperitoneal Approach
Abdominal Access and Port Placement
Complications
Current Controversies
Cost
Operative Time
Potential Benefits
Training and Human Capital Cost
Future Directions
Instrumentation
Single Port Surgery
Telesurgery
Tactile Feedback
Augmented Visualization
Conclusion and Future Directions
References
8 Chronic Kidney Disease
Introduction
Definition and Classification
Exceptions in Children
Measurement of Glomerular Filtration Rate (GFR)
Data Registries for Children with CKD
Epidemiology
Etiology of CKD
Complications of CKD
Diagnosis and Evaluation of CKD
Treatment of CKD
Hypertension
Other Antihypertensive Agents
Management of End-Stage Renal Failure
References
9 Dialysis
Introduction
Indications for the Initiation of Dialysis
Principles of Dialysis
Diffusion
Convection
Ultrafiltration
Dialysis Modalities
Modality Selection in Acute Kidney Injury
Modality Selection in Chronic Kidney Disease
Peritoneal Dialysis
Access, Technique, and Prescription
Complications
Hemodialysis
Access, Anticoagulation, and Dialyzers
Modalities
Intermittent Hemodialysis
Continuous Renal Replacement Therapy (CRRT)
Intensified Hemodialysis
Complications
Management of Comorbidities
Growth and Nutrition
Mineral and Bone Disorder (CKD-MBD)
Cardiovascular System
Anemia
Cognitive Development and Quality of Life
Long-Term Outcome
Conclusions and Future Directions
Cross-References
References
10 Renal Transplantation
Introduction
Medical Management of Children with CKD
Urological Involvement in CKD Care
Medical Preparation of Pediatric Transplant Recipients
Urological Pretransplant Interventions
Timing of Transplantation
The Transplant
Deceased Donor Management
Living Donor Management
Recipient Management
Postoperative Care
Approach to Early Graft Dysfunction and Other Complications
Surgical and Urological Complications of Transplantation
Transition to Outpatient Management
Maintenance Management Including Immunosuppression
Long-Term Aspects
Summary
Cross-References
References
Part II: Kidney
11 Congenital Renal Anomalies
Synonyms
Introduction and Classification
Embryology
Renal Anomalies in Number
Renal Agenesis
The Contralateral Kidney
Long-Term Prognosis
Bilateral Renal Agenesis/Hypoplasia/Dysplasia (BRAHD)
Supernumerary Kidney
Renal Anomalies of Rotation
Renal Anomalies in Position and Fusion
Simple Renal Ectopia
Crossed Renal Ectopia
Horseshoe Kidney
Conclusions and Future Directions
References
12 Multicystic Dysplastic Kidney Disease
Introduction
Incidence
MCDK Pathology and Pathogenesis
Classification
Associations
Presentation
Diagnostic Evaluation
Natural History
Involution
Malignant Transformation
Hypertension
Management
Conclusions and Future Directions
Cross-References
References
13 Renal Calculus Disease
Synonyms
Introduction
Epidemiology
Gender
Race/Ethnicity
Regional Differences
Clinical Features
Diagnostic Evaluation
Differential Diagnosis
Etiology
Pathogenesis
Management
Acute and Surgical Treatment
Preventive Therapy
Surveillance
Outcomes
Future Directions
References
Part III: Upper Urinary Tract
14 Ureteropelvic Junction Obstruction
Introduction
Ureteropelvic Junction Obstruction
Surgical Correction
Dismembered Pyeloplasty
Non-dismembered Pyeloplasty
Endoscopic Procedures
References
15 Ureterovesical Junction Obstruction
Definition and Classification
Pathophysiology
Diagnosis
Antenatal Ultrasound
Postnatal Ultrasound
Voiding Cystourethrogram
Diuretic Renography
Management
Prenatal Management
Antibiotic Prophylaxis
Expectant Management
Surgical Strategies
Temporizing Surgical Options
Endourology
Ureteral Reimplantation
Conclusion
References
Part IV: Vesicoureteral Reflux and Ureteral Duplication
16 Anatomical and Functional Basis of Vesicoureteral Reflux
Anatomic and Functional Basis of Vesicoureteral Reflux
Normal Anatomy of the Ureterovesical Junction and Trigone
Innervation of the Ureterovesical Junction
Anatomical Findings in VUR
Histological Findings in VUR
Bladder Function and VUR
Cross-References
References
17 The Diagnosis and Medical Management of Vesicoureteral Reflux: An Update and Current Controversies
Introduction
Diagnosis
Methods of Imaging
Ureteral Diameter Ratio (UDR)
Contrast Voiding Cystourethrogram (VCUG)
Radionuclide Cystography (RnVCUG)
Voiding Urosonography
CeVUS (Contrast Enhanced Voiding Urosonography)
Noninvasive Cystography
Renal and Bladder Ultrasound
The ``Top Down´´ Approach
Urinary and Serum Markers
Who Should Be Evaluated
Children with a History of UTI
The American Academy of Pediatrics Guidelines
The National Institute for Clinical Excellence (NICE) Guidelines
Infants with Prenatally Detected Hydronephrosis
Siblings
Medical Management
Rates of Resolution
Bowel and Bladder Dysfunction
Antibiotic Prophylaxis-Current Controversies
Discontinuing Prophylaxis
The RIVUR Trial
Conclusion and Future Directions
Cross-reference
References
18 Endoscopic Treatment of Vesicoureteral Reflux
Introduction
Indications and Contraindications
Indications
Contraindications
Instruments, Equipment, and Materials
Operative Setup
Injection Techniques
STING Procedure
Ureteric Hydrodistention and Intraluminal Submucosal Injection
Postoperative Care
Complications and Outcomes
Persistent or Recurrent Reflux
Obstruction of the Ureterovesical Junction
Conclusion and Future Directions
References
19 Surgical Treatment of Vesicoureteric Reflux
Introduction
General Principles of Surgical Treatment
Open Surgery
Intravesical Procedures
Politano-Leadbetter Technique (Fig. 1a-e)
Glenn-Anderson Technique (Fig. 2a-c for Open and 7a-k for Vesicoscopic)
Cohen Cross-Trigonal Technique (Fig. 3a-c)
Extravesical Procedures as Lich-Gregoir Technique (Fig. 4a-c)
Additional Procedures
Ureteric Remodelling/ Tapering/Tailoring (Fig. 5)
Psoas Hitch (Fig. 6)
Minimally Invasive Surgery
Laparoscopic and Robot-Assisted Intravesical (Vesicoscopic) Re-implantation. Figure 7a-k Courtesy of HS Safoury, A Aljunaibi, ...
Laparoscopic and Robotic-Assisted Laparoscopic Ureteral Reimplantation-Extravesical (RALUR-EV). Figure 8a-g Courtesy of HS Saf...
Outcome
Intravesical Approach
Extravesical Approach
Outcome of Minimally Invasive Versus Open Approach
Factors Affecting Outcome
Prior Endoscopic Management
Grade of VUR
Bilateral RALUR-EV
Age
Bladder and Bowel Dysfunction
Complications
Persistent Ipsilateral VUR
Contralateral VUR
Ipsilateral Ureteric Obstruction
Urinary Leak
Bowel Injury
Conclusions and Future Directions
References
20 Ureteral Duplication and Duplex Systems
Introduction
Embryology
Clinical Management of Duplication Anomalies
Incomplete Duplicated Systems
Complete Duplication Anomalies
Vesicoureteric Reflux
Ectopia of the Upper Pole Ureter
Investigations
Principles of Treatment
Treatment of VUR
Heminephrectomy
Alternative Surgical Approaches
Conclusion and Future Directions
Cross-References
References
21 Ureteroceles
Introduction
Embryology and Etiology
Associated Pathology
Classification
Incidence
Clinical Presentation
Diagnosis
Treatment
Conservative Management
Endoscopic Puncture or Incision
Endoscopic Treatment of VUR
Duplex System Ureteroceles
Ureterocele Excision or Marsupialization
Common Sheath Reimplantation
Heminephroureterectomy
Ureteroureterostomy
Total Reconstruction
Conclusion and Future Direction
Cross-References
References
Part V: Bladder
22 Nocturnal Enuresis
Introduction
Subdivision
Epidemiology and Natural History
Prevalence
Natural History
Long-Term Risks and Consequences
Etiology and Pathogenesis
Genetics
Nocturnal Polyuria
Detrusor Overactivity
Increased Arousal Thresholds
Possible Underlying Brainstem Mechanisms
Enuresis Due to Other Underlying Causes
Comorbidity
Psychology and Psychiatry
Bladder Dysfunction, Urinary Tract Infections
Bladder and Bowel Dysfunction
Problems Related to Sleep and Arousal
Initial Evaluation
Warning Signs
History
Voiding Charts
Physical Examination
Urine Tests, Blood Sampling
Other Examinations
First-Line Treatment
Who Shall We Treat?
The Role of Bladder Advice
Choice of First-Line Active Treatment
The Enuresis Alarm
Desmopressin
Combination Therapy
Evaluation of Therapy-Resistant Enuresis
Second-Line Therapy
Anticholinergics
Antidepressants
If Second-Line Therapy Fails
Possible Future Therapies
Enuresis in Special Situations
Enuresis and Obstructive Respiration During Sleep
Enuresis and Polyuric Conditions
Enuresis in Children with Neuropsychiatric Disturbances
Enuresis in the Child with Intellectual Disability
Conclusion and Future Directions
Cross-References
References
23 Daytime Urinary Incontinence
Introduction
Definitions
Epidemiology and Comorbidity
Etiology and Pathophysiology
Evaluation
Case History
Physical Examination
Voiding Charts
Blood or Urine Tests
Noninvasive Urodynamic Examinations
Invasive Urodynamics, Cystometry
Radiology
First-Line Treatment
Who Shall We Treat?
Treatment Overview
Urotherapy
Treatment of Concurrent Constipation
Anticholinergic Treatment
Treatment in Special Circumstances
Asymptomatic Bacteriuria (ABU)
Vaginal Reflux
Giggle Incontinence
Stress Incontinence
Second-Line Treatment
Conclusion and Future Directions
Cross-References
References
24 Injectable Bulking Agents in the Treatment of Pediatric Urinary Incontinence
Introduction
Diagnosis of Incontinence
Other Treatment Options
Endoscopic Bulking Agents and Methods of Application
Transurethral Method
Periurethral Method
Antegrade Method
Antegrade Method via a Catheterizable Conduit
Injectables
Historically Significant Injectables
Polytetrafluoroethylene (Polytef)
Cross-Linked Collagen (Contigen)
Commercially Available Injectables
Polydimethylsiloxane (Macroplastique)
Calcium Hydroxylapatite (Coaptite)
Pyrolytic Carbon-Coated Zirconinum Oxide Beads (Durasphere)
Polyacrylamide (Bulkamid)
Other Injectables
Silicone Membrane Systems
Glass (Bioglass)
Polysaccharide Microsphere (Deflux, Zuidex)
Ethylene Vinyl Copolymer (Uryx, Tegress)
Autologous Organic Therapies
Autologous Fat
Autologous Collagen, Chondrocytes, and Muscle Cells
Conclusion and Future Directions
Cross-References
References
25 Bladder Exstrophy, Epispadias, and Cloacal Exstrophy
Introduction
Incidence
Etiology and Embryology
Bladder Exstrophy
Antenatal Diagnosis
Clinical Presentation (Figs. 1 and 2)
Management
Investigations
Neonatal Closure
Pelvic Osteotomy
Complete Primary Reconstruction (CPRE)
Secondary Procedures
Continence
Outcomes
Continence
Renal Function/Scarring and End-Stage Renal Failure (ESRF)
Stone Formation
Penile Function (Sexual Activity) and Fertility
Malignancy
Quality of Life (QoL)
Cloacal Exstrophy (CEX) (Fig. 3)
Primary Epispadias (Figs. 4 and 5)
Clinical Presentation
Investigation
Surgical Management
Conclusion and Future Directions
References
26 Bladder Diverticula, Urachal Anomalies, and Other Unusual Conditions of the Bladder
Bladder Diverticula
Urachal Anomalies
Other Unusual Conditions of the Bladder
Bladder Duplication
Nonvisualization of the Bladder on Prenatal Imaging
References
27 Posterior Urethral Valves
Introduction
Presentation and Diagnosis
Surgical Management
Prenatal Intervention
Conclusion and Future Directions
Cross-References
References
28 Prune-Belly Syndrome
Introduction
Genetics
Clinical Features
Genitourinary Anomalies
Kidneys
Ureters
Bladder
Prostate and Accessory Sex Organs
Anterior Urethra and Penis
Testes
Abdominal Wall Deficiency
Other Abnormalities
Orthopedic
Pulmonary
Gastrointestinal Abnormalities
Cardiac Anomalies
Prenatal Diagnosis
Neonatal Presentation
Incomplete Presentation
Adult Presentation
Female Syndrome
Evaluation and Management
Surgical Treatment
Urinary Tract Reconstruction
Temporary Urinary Diversion
Cutaneous Vesicostomy
Cutaneous Pyelostomy
Cutaneous Ureterostomy
Ureteral Reconstruction
Reduction Cystoplasty
Internal Urethrotomy
Anterior Urethral Dilatation or Reconstruction
Orchidopexy
Abdominal Wall Reconstruction
Conclusion and Future Directions
Cross-References
References
29 Neurogenic Bladder
Synonyms
Introduction
Anatomy and Physiology
Bladder Physiology
Aetiology and Classification
Initial Assessment
Urodynamic Assessment
Management
Medical Management
Vesicoureteral Reflux
Urethral Dilation
Vesicostomy
Detrusorotomy
Bladder Augmentation
Ileum (Ileocystoplasty)
Cecum and Ileum (Ileocecoplasty)
Sigmoid (Colocystoplasty)
Stomach (Gastrocystoplasty)
General Complications of Using Segments of Bowel
Surgical Complications
Secretion of Mucus
Malignancy Risk
Metabolic Derangements
Alternatives to Augmentation with Intestinal Segments
Ureterocystoplasty
Tissue-Engineered Bladders
The Mitrofanoff Principle
Bladder Outlet Procedures
Bladder Neck Injections
Suspension of the Bladder Neck
Artificial Urinary Sphincter
Surgical Reconfiguration of the Bladder Neck
Neurogenic Bladder in the Transplanted Patient
Management of Constipation in the Neurogenic Patient
Conclusion
References
30 Continent Urinary Diversion
Introduction
Patient Evaluation and Selection
Nursing Evaluation
Pre-operative Preparation
Radiology and Laboratory Evaluation
Bowel Preparation
Continent Urinary Reservoirs
Ureterosigmoidostomy
MAINZ Pouch
Kock Pouch
Composite Gastroileal Pouch
Indiana Pouch
Ureteral Reimplantation Techniques
Continent Catheterizable Channels
Macedoileal Flap Technique
Complications of CUR
Long-Term Risks
Inadequate Reservoir
Perforation
Mucus Secretion
Stones
UTI
Metabolic Disturbances
Complications Related to Loss of Bowel Segment
Vitamin B12 Deficiency
Diarrhea
Malignancy
Bowel Obstruction
Conclusion and Future Directions
Cross-References
References
31 Augmentation Cystoplasty
Introduction
Indications and Contraindications
Basic Bladder Function
Pharmacological Treatment
Evaluation of the Patient
Patient Preparation
Technique
Gastric Tissue
Small and Large Intestine
Surgical Technique
Sigmoid Cystoplasty
Bladder Perforation
Stone Formation
Neoplasia
Alternatives to the Gastrointestinal Cystoplasty
Ureterocystoplasty
Demucosalized Enterocystoplasty
Autoaugmentation
Experimental Options
Conclusions and Future Directions
Cross-References
References
Part VI: Genital
32 Hypospadias
Introduction
Epidemiology
Embryology
The Prenatal Period
The Placenta
The Mother
The Environment
The First Day of Life and the ``Minipuberty´´
From the End of ``Minipuberty´´ to Puberty
Puberty
Etiology: Biological Errors Leading to an Underdeveloped GT
The Fetus
Chromosomal Anomalies
Genetic Anomalies
Steroidogenesis Impairments and the Dysgenetic (Dysplastic) Gonads
Target Tissue Impairments
Placental Insufficiency
Mother´s Disorders, Treatment, or Characteristics
Clinical Presentation and Classification
Classification
Presurgical Management
Preoperative Androgen Stimulation
Endocrine Screening of the Hypospadiac GT
Surgery
Postsurgical Evaluation and Long-Term Outcome
Conclusion and Future Directions
References
33 Male Epispadias, Genitourinary Implications
Introduction
History
Embryology
Genetics
Anatomic Classification
Associated Anatomic Anomalies
Surgical Management of Male Epispadias
Glanular Epispadias
Penile Epispadias
Penopubic Epispadias
Cosmetic Considerations in Reconstruction
Urinary Incontinence and Bladder Neck Reconstruction
Outcomes and Complications
Conclusion and Future Directions
Cross-References
References
34 Phimosis and Buried Penis
Introduction
Development of the Foreskin
Complications of a Normal Foreskin
Balanoposthitis
Paraphimosis
Congenital and Acquired Conditions of the Foreskin
Anomalies of Penoscrotal Fusion
Trauma
Balanitis Xerotica Obliterans (BXO)
Indications for Circumcision
Circumcision Techniques
Circumcision Complications
Conclusion and Future Directions
References
35 Cryptorchidism
Introduction
Testicular Descent
Classification
Etiology
Effects of UDT
Clinical Presentation and Diagnosis
Management
Procedures
Results
Conclusion and Future Directions
Cross-References
References
36 Varicocele
Introduction
Anatomy and Pathophysiology
Epidemiology
Diagnosis
Varicocele Grade
Testicular Volume Measurement
Testicular Atrophy/Asymmetry
Testicular Doppler Ultrasound
Hormonal Dysfunction
Semen Parameters
Natural History of Varicocele
Indications for Treatment
Treatment Options
Active Surveillance
Surgical Repair: Variocelectomy
Open Suprainguinal (Palomo) Procedure
Subinguinal/Inguinal Microscopic
Laparoscopic Varicocelectomy
Sclerotherapy
Vascular Embolization
Follow-Up
Paternity
Conclusion and Future Directions
Cross-references
References
37 Testicular Torsion
Introduction
Classification
Pathophysiology
Clinical Features
Torsion of an Undescended Testis
Intermittent Testicular Torsion
Familial Testicular Torsion
Differential Diagnosis
Torsion of the Testicular Appendages
Epididymo-Orchitis
Acute Scrotum in Henoch-Schonlein Purpura
Idiopathic Scrotal Edema
Imaging Studies
Management
Operative Technique
Testicular Prosthesis
Complications
Medicolegal Issues
Fertility
Survey of Urological Practice
Conclusion and Future Directions
Cross-References
References
38 Cloaca and Urogenital Sinus with Normal Rectum
Introduction
Clinical Diagnosis and Neonatal Management
Main Surgical Repair
Surgical Repair of Cloacae with a Common Channel Shorter than 3 Cm
Surgical Repair of Cloacae with a Common Channel Longer than 3 Cm
Surgical Technique Used to Repair Cloacae with a 1 Cm Common Channel
Surgical Repair of Cloacal Malformations with an Extremely Long Common Channel
Posterior Cloaca
Urogenital Sinus with Normal Rectum
References
39 Different Sexual Development
Introduction
Human Sexual Development
Differences/Disorders of Sex Development
Classification
Sex Chromosome DSD
46,XY DSD
46,XX DSD
Diagnostic Investigations in DSD
Anamnesis
Physical Examination
Diagnostic Investigations
Sex Assignment
Surgical Management
Management of the Gonads
Feminizing Surgery (CAH)
Management of Clitoral Enlargement
Reconstruction of the Urogenital Sinus (UGS) and Vaginoplasty
Labiaplasty
Feminizing Approach in Non-CAH Individuals
Hypospadias Repair
Management of Müllerian Structures and Prostatic Utricles
Others (Malformations Associated with DSD)
Cloacal Exstrophy
Aphallia
Timing of Surgery
Future Needs
Conclusion
Cross-Reference
References
40 Pediatric and Adolescent Gynecology
Introduction
The Pediatric Gynecologic Examination
Gynecological Problems Before Puberty
Labial Fusion
Vulvovaginitis
Prepubertal Vaginal Bleeding
Trauma
Gynecological Problems in Adolescence
Pelvic Pain
Ovarian Cysts
Benign Tumors
Malignant Tumors
Adnexal Torsion
Menstrual Obstruction
Conclusion and Future Directions
Cross-Reference
References
Index