URINARY SYSTEM BIRTH DEFECTS IN SURGICALLY TREATED INFANTS IN SARAJEVO REGION OF BOSNIA AND HERZEGOVINA

Congenital anomalies of the urinary system are relatively common anomalies. In Bosnia and Herzegovina there is no existent unique evidence of congenital anomalies and registries. Th e aim of this study was to obtain the frequency of diff erent urinary tract anomalies types and their sex distribution among cases hospitalized in the Department of Pediatric Surgery of the University of Sarajevo Clinics Centre, Bosnia and Herzegovina, during the period from January  to December . Retrospective study was carried out on the basis of clinical records. Standard methods of descriptive statistics were performed for the data analysis. Among  patients that were surgically treated , of the patients were male patients, while , were female patients. Twenty nine diff erent urinary system anomalies types were found in this study. Th ese were: vesicoureteral refl ux ( cases or ,), hypospadias ( cases or ,), pelviureteric junction obstruction ( cases or ,), megaureter ( cases or ,), duplex pelvis and ureter ( cases or ,), bladder diverticulum ( cases or ,), ureterocoele ( cases or ,), stenosis of the external urethral opening ( cases or ,), ectopic kidney, duplex kidney and pelvis (each  cases or ,), polycystic kidneys and urethral stricture (each  cases or ,), multicystic kidney ( cases or ,), kidney agenesis, ureter agenesis, urethral diverticulum, ectopic ureter, horseshoe kidney and fetal kidney (each  cases or ,), renal aplasia, urethral atresia, renal cyst, urachal cyst, epispadias, bladder exstrophy, renal hypoplasia, renal malrotation and Prune-Belly syndrome (each  case or ,). According to this study, urinary tract anomalies were more common in male than in female patients (,). Generally, the most frequent anomaly type was vesicoureteral refl ux in total number of  cases, and in females ( cases), but hypospadias was the most common anomaly in males ( cases). Th e anomalies of other systems associated with urinary system anomalies were found in ten cases. Th ese were: cryptorchidism, congenital inguinal hernia, open inner inguinal ring, uterus bicornis unicollis and one case of


Introduction
Congenital anomalies were defi ned as structural defects, chromosomal abnormalities, inborn errors of metabolism and hereditary disease diagnosed before, at, or after birth ().Congenital anomalies represent a signifi cant problem because of their frequency, unclear origin and the consequences for the society.Th e data of congenital anomalies in the diff erent parts of the world are different due to diff erences in ecological, socio-economic, geographic and other conditions of living.Th e European Economic Community's Committee on Medicinal and Public Health Research started already in ., a multicentric epidemiological study of congenital anomalies through the project called EUROCAT (European Concerted Action on Congenital Anomalies and Twins) ().Congenital anomalies are registered in almost every country all over the world on special designed questionnaires.Th e management and outcome, however, vary considerably between the developed and the developing countries.Due to the signifi cance of congenital malformation in perinatal morbidity and mortality and its various types and diverse incidences in several countries, it is important for each population, even on regional basis, to know the distribution and incidence of congenital malformations ().In Bosnia and Herzegovina there is no existent unique evidence of congenital anomalies and registries ().Congenital anomalies of urinary system are relatively common contributing  of live births ().About   of all anomalies are anomalies of the urinary system.Anomalies of kidney form a significant percentage of them ().Congenital and hereditary urinary tract abnormalities include a wide spectrum of defects ranging from gross abnormalities of morphogenesis, often incompatible with life (i.e., bilateral renal agenesis), to more subtle disorders of renal function (i.e., tubular dysfunction) frequently recognised later in life.Defects can be bilateral or unilateral, and diff erent defects often coexist in an individual child ().Because congenital anomalies of the kidney and urinary tract (CAKUT) play a causative role in  to  percent of cases of end-stage renal disease (ESRD) (), it is important to diagnose and initiate therapy to minimize renal damage, prevent or delay the onset of ESRD, and provide supportive care to avoid complications of ESRD.CAKUT are problems that often require surgical intervention or, in the worst case, lead to renal failure and the need for dialysis and/or renal transplantation ().Prenatal diagnostics allows their early detection ().One third of anomalies, which are detected in prenatal ultrasonography become urinary tract abnormalities.
Diagnostics followed by an eff ective treatment prevents the development of irreversible changes in kidneys.Urinary tract infections, especially recurrent cases, are an obligatory indication to perform urinary tract imaging ().Th e aim of this study was to obtain the frequency of diff erent urinary system anomalies types and their sex distribution among cases hospitalized in the Department of Pediatric Surgery at the University of Sarajevo Clinics Centre, Bosnia and Herzegovina, during the period from January  to December .

Patients and Methods
Retrospective study was carried out on the basis of the clinical records in the Department of Pediatric Surgery of the University of Sarajevo Clinics Centre, Bosnia and Herzegovina.From st January  to st December , a total of  patients with urinary tract malformations were hospitalized.Th e cases were divided in groups by different types of urinary tract malformations.Standard methods of descriptive statistics were performed for the data analysis.

Results
The structure of patients with urinary anomalies treated in the Department of Pediatric Surgery of the University of Sarajevo Clinics Centre according to the gender is shown in Table .A total of  cases were treated in the period from  to .Out of that number  (,) were male patients, while  (,) were female; sex ratio ,:.

Discussion
In the period from st January  to st December  a total of  cases of anomalies of the urinary system were registered, and out of that number  were males (,) and  were females (,); sex ratio ,:.Almost one third of the patients had vesicoureteral refl ux (,).VUR is followed by hypospadias ( cases or ,).According to the literature  of hypospadias are glandular hypospadias,  are penile hypospadias and  are the most severe posterior hypospadias (penoscrotal, scrotal and perineal) ().
Other authors quote that the most frequent form of hypospadias are glandular and subglandular hypospadias (almost  of all hypospadias), followed by penoscrotal and perineal with  and the penile form with  ().Th e frequency of diff erent types of hypospadias was as followed: penile hypospadias ( cases or ,), glandular hypospadias ( cases or ,), coronal hypospadias ( cases or ,) penoscrotal hypospadias ( cases or ,), scrotal hypospadias ( cases or ,), and fi nally subglandular and perineal (each  case or ,).Hypospadias was followed by pelviureteric junction obstruction ( cases or ,), megaureter ( cases or ,), duplex pelvis and ureter ( cases  Preliminary studies found that periconceptional use of a multivitamin reduced the risk for urinary tract defects ().Th ere was also noted a reduction in risk for urinary tract defects when multivitamin use was begun after the periconceptional period ().Prevention of birth defects depends on risk identifi cation and management through community and health service personnel education, population screening, genetic counselling and the availability of appropriate services ().Many of congenital anomalies can be detected prenatally which demands a larger coordination between primary and other health cares in the sense of screening and genetic testing of possible anomalies.Prenatal verification of congenital anomalies can be achieved through prenatal diagnostics that should be appropriately developed ().
It is necessary to establish a unique system of evidence and registration.Adequate prevention would decrease the percentage of congenital anomalies as well urinary anomalies as all other which would reduce the expenses of treatment and rehabilitation, and which would have an advantageous effect on the whole community ().

Conclusion
According to this study, urinary system anomalies were higher in males (,).Th e ten most frequent types were: vesicoureteral refl ux (,), hypospadias (,), pelviureteric junction obstruction (,), megaureter (,), duplex pelvis and ureter (,), bladder diverticulum (,), ureterocoele (,), stenosis of the external urethral opening (,), ectopic kidney, duplex kidney and pelvis (each ,).Vesicoureteral refl ux was the most frequent anomaly found in female patients although according to this study urinary system anomalies are more frequent in males.Th e highest number of anomalies was treated in .Th e other organ system anomalies associated with malformations of the urinary system found in this study were: cryptorchidism, congenital inguinal hernia, open inner inguinal ring, uterus bicornis unicollis and only one case of multiple anomalies.Th ey were found in ten cases, in seven male patients and three female patients.Registration of anomalies through the project EUROCAT should be set up in Bosnia and Herzegovina which would facilitate the obtaining of well documented databases.Population-based registries are a particularly powerful tool for the evaluation of health services, because they represent the experience of a whole community.Without this process there is no possible improvement of the health care.

TABLE 1 .
Total number and gender of treated urinary sytem anomalies junction obstruction ( cases or ,), vesicoureteral reflux ( cases or ,), megaureter ( cases or ,), duplex pelvis and ureter ( cases or ,), stenosis of the external urethral opening ( cases or ,), urethral stricture, bladder diverticulum, aberrant blood vessel and ureterocoele (each  cases or ,), Multiple malformations were found in ten cases (, ); in seven male patients and three female patients.Th e anomalies of other organ systems associated with