A study of the sequelae of posterior urethral valves

Long-term bladder outcomes using a prescriber pattern scoring system for posterior urethral valves

BACKGROUND

Urinary drainage for posterior urethral valves can be achieved with valve ablation (VA) or diversion by vesicostomy (VES) or cutaneous ureterostomy (CU). The effect of these interventions on long-term bladder function remains debated, and voiding symptomatology after VES or CU reversal has been poorly characterized.

OBJECTIVE

The objective of this study was to examine the prevalence and scope of physician treatment patterns as a surrogate for retention or incontinence symptomatology among PUV patients undergoing primary VA or diversion by VES/CU and determine rates of progression to augmentation.

STUDY DESIGN

This is a single-institution retrospective cohort study. Retention Scores (R) were calculated 1 point for: retention behavior (double/timed void), alpha-blocker, intermittent catheterization, or overnight indwelling catheter. Incontinence Scores (I) were calculated 1 point for: incontinence behavior (double/timed void), oral medication, or botulinum toxin. Patients with R score above 3 or I score above 2 were deemed to have severe retention or incontinence symptomatology respectively. End stage bladder (ESB) was defined as need for bladder augmentation.

RESULTS

We identified 76 patients between 5 and 40 years old with median follow-up of 14.6 [5.0-40.4) years. There was no difference in the rates of severe retention or incontinence treatment pattern scoring between VA versus VES/CU (Figure). Rates of achieving R(1) status are similar between VA and VES/CU groups, though age of reaching R(1) was younger for those with VES/CU (4.8 years) compared to VA (6.6 years). There was no significant difference in rate of ESB by intervention category VA (9.4%) versus VES/CU (17.4%; p = 0.323).

DISCUSSION

Treatment of retention symptomatology was more common than treatment of incontinence symptomatology regardless of primary management, VA or VES/CU. This study also indicates that VES/CU patients were just as responsive as VA patients to conservative treatments (behavioral changes, pharmacotherapy) for any type of bladder symptomatology as the progression to treatment of severe symptomatology and ESB were similar between cohorts. In this cohort, bladder outcomes were not associated with type of urinary diversion (VA or VES/CU).

CONCLUSION

Long term bladder outcomes for valve patients demonstrated similar treatment patterns and progression to end-stage bladder regardless of diversion status. Patients went on to ESB approximately 4.4 years after diagnosis at similar rates between groups.

Lower urinary tract symptoms in adults treated for posterior urethral valves in childhood: matched cohort study

PURPOSE

We compared the prevalence and bother of lower urinary tract symptoms in adults treated for posterior urethral valves in childhood and population based controls.

MATERIALS AND METHODS

Questionnaires were mailed to patients 18 years and older treated at our institution for posterior urethral valves. Of the 124 patients 68 (64.2%) participated, 18 were unavailable and 38 did not participate. Age and sex matched controls were randomly identified from a population based study (response proportion 62.4%). Danish Prostatic Symptom Score was used to assess occurrence (never/rarely/often/always) and bother (none/small/moderate/major) of 12 different lower urinary tract symptoms. Chi-square test was used for the analyses stratified by patient/control status, with the 4-point ordinal scale as the outcome.

RESULTS

Median age of 68 patients with posterior urethral valves and 272 controls (ratio 1:4) was 38.5 years (range 18 to 57). Overall, at least 1 moderate or severe lower urinary tract symptom was reported by 32.4% of patients with posterior urethral valves and 15.8% of controls (p=0.002). Mild hesitancy, weak stream, incomplete emptying and straining were reported twice as often by patients with posterior urethral valves as by controls (p<0.05). Prevalence of any urgency incontinence (14.7% vs 4.8%, p=0.014) and any stress incontinence (11.8% vs 3.0%, p=0.005) was increased at least 3-fold in patients with posterior urethral valves compared to controls. Furthermore, prevalence of bother from several lower urinary tract symptoms was increased approximately 2-fold in patients with posterior urethral valves compared to controls (p<0.05). However, most patients and controls reported no or small bother.

CONCLUSIONS

In adulthood the occurrence and bother of most lower urinary tract symptoms are increased approximately 2-fold in patients with posterior urethral valves compared to the general population. However, in this cohort of young and middle-aged men most symptoms are mild.

[Posterior urethral valves: prenatal diagnosis, neonatal data and outcome]

AIM OF THE STUDY

To evaluate the impact of prenatal diagnosis on the epidemiology and outcome of children with posterior urethral valves (PUV), considering that today termination of pregnancy may be proposed in the most severe cases.

PATIENTS AND METHODS

Forty-three cases of patients with PUV were diagnosed between 1998 and 2007 in the Languedoc-Roussillon region. In this study, we detailed the prenatal data and postnatal outcome of those patients with a mean follow-up period of 7.6 years.

RESULTS

Medical interruption of pregnancy was performed in 15 severe cases. One death in utero was also observed. Twenty-seven patients were managed postnatally and one child died during the neonatal period because of lung hypoplasia. For the 26 remaining patients at the end of the follow-up period, 5 had mild renal insufficiency with a creatinine clearance calculated with the Schwartz formula of less than 80 ml/min/1.73 m2. One reached end-stage renal failure at the age of 7 years. Proteinuria and hypertension were rare.

DISCUSSION AND CONCLUSION

Today, because of the increase in medical termination of pregnancy in the most severe cases, most of the children born alive with PUV experienced a better renal prognosis when compared with previous data. Prenatal diagnosis and therapeutic progress significantly modified the epidemiology and outcome of this disease. Nevertheless, the best predictor of renal outcome remains renal function at 1 year of age.

Altered extracellular matrix expression in the diverted fetal sheep bladder

PURPOSE

It is unclear whether filling and emptying are important to bladder development. We tested this in an experimental preparation.

MATERIAL AND METHODS

Urinary diversion was performed in 7 fetal lambs at 90 days of gestation and 6 unoperated fetal lambs served as controls. Transmural sections were analyzed for changes in tissue layer thickness and/or composition after 14 days of urinary diversion. Matrix mRNA levels (collagen I and III, and FN) as well as the cytokines/growth factors IGF-1, EGR-1, WT-1 and BCL-2 were quantified by real-time polymerase chain reaction. Hydroxyproline measurements of total collagen and collagen subtype quantification were done by enzyme-linked immunosorbent assay.

RESULTS

Diverted fetal bladders showed a 27% and 57% decrease in mucosal and detrusor muscle layer thickness, respectively. In contrast, there was a 270% increase in serosal layer thickness in diverted bladders. The mRNA levels of COL1A1, COL3A1, IGF-1, EGR-1 and the anti-apoptotic gene BCL-2 were increased significantly in the serosal/detrusor layer of diverted bladders. In the mucosa levels of these mRNAs remained unchanged except for those of FN and WT-1, which were significantly decreased and increased, respectively. Total collagen, and type I and III collagen protein levels were significantly increased in diverted bladders.

CONCLUSIONS

The lack of mechanical loading in diverted bladders leads to the arrest of detrusor smooth muscle growth, and concurrent fibrosis and thickening of the serosal layer. Changes in the levels of IGF-1, BCL-2 and EGR-1 likely have regulatory roles that affect the smooth muscle phenotype in the detrusor layer.

Myogenic bladder decompensation in boys with a history of posterior urethral valves is caused by secondary bladder neck obstruction?

OBJECTIVE

To investigate whether myogenic bladder decompensation in patients treated for congenital posterior urethral valves (PUV, the most serious cause of infravesical obstruction in male neonates and infants) may be secondary to bladder neck obstruction, as despite prompt ablation of PUV these patients can have dysfunctional voiding during later childhood or adolescence, the so-called 'valve bladder syndrome'.

PATIENTS AND METHODS

The study comprised 18 boys (mean age 14 years, range 6.2-18.5) who had had successful transurethral ablation of PUV between 1982 and 1996, and had completed a follow-up which included serial assessment of serum creatinine, completion of a standard voiding diary, ultrasonography with measurement of urine before and after voiding, a urodynamic examination with simultaneous multichannel recording of pressure, volume and flow relationships during the filling and voiding phases, coupled with video-cystoscopy at least twice. The mean (range) follow-up was 9.3 (6-17) years.

RESULTS

Urodynamic investigation showed myogenic failure with inadequate bladder emptying in 10 patients; five with myogenic failure also had unstable bladder contractions. On video-cystoscopy the posterior bladder neck lip appeared elevated in all patients but in those with myogenic failure it was strongly suggestive of hypertrophy, with evidence of obstruction. At the last follow-up one patient with myogenic failure who had had bladder neck incision and four others who were being treated with alpha-adrenergic antagonists had a significant reduction of their postvoid residual urine.

CONCLUSION

Despite early valve ablation, a large proportion of boys treated for PUV have gradual detrusor decompensation, which may be caused by secondary bladder neck obstruction leading to obstructive voiding and finally detrusor failure. Surgical or pharmacological intervention to improve bladder neck obstruction may possibly avert this course, but further studies are needed to validate this hypothesis.

PEDIATRIC UROLOGICAL CAUSES OF HYPERTENSION

PURPOSE

We reviewed the association of hypertension with several common pediatric urological conditions.

MATERIALS AND METHODS

We comprehensively reviewed the published literature linking hypertension with urinary tract infection, renal scarring, vesicoureteral reflux, multicystic dysplastic kidney, ureteropelvic junction obstruction and posterior urethral valves.

RESULTS

Hypertension is a recognized sequela of several common pediatric urological conditions. It is thought to be a direct consequence of renal damage or scarring often resulting from vesicoureteral reflux and/or febrile urinary tract infection. Multicystic dysplastic kidney has rarely been shown to cause hypertension when examined in large series rather than as isolated case reports. Ureteropelvic junction obstruction and posterior urethral valves have been linked to hypertension, although to our knowledge no series to date has specifically examined this relationship and smaller retrospective reviews seldom describe associated hypertension.

CONCLUSIONS

Several pediatric urological conditions are known to cause hypertension. However, methodological flaws in the literature, including a lack of standardized blood pressure followup, highly variable patient populations and poor control of concomitant urological abnormalities, greatly limit the ability to establish a causative link between any 1 specific condition and hypertension. Early diagnosis, the prevention of infection, close clinical followup and early intervention remain the primary means of preventing pediatric urological causes of hypertension.

The valve bladder: etiology and outcome

The infravesical obstruction created by posterior urethral valves produces a series of structural, biochemical, and functional changes in these boys' bladders that begins during fetal life. Any change can be irreversible and result in the alterations in bladder function that can be found in some of these patients. Bladder instability, poor compliance, and myogenic failure are the three most common urodynamic patterns and are also responsible for some of these patients' poor long-term prognosis. Treatment of bladder dysfunction in these patients is basically directed toward improving their kidney function prognosis and also to avoid the urinary incontinence presented secondarily by some valve bladders.

The changing urodynamic pattern from infancy to adolescence in boys with posterior urethral valves

OBJECTIVE

To determine whether bladder dysfunction in boys with posterior urethral valves (PUV) changes from a uniform pattern of hypercontractility during infancy to the hypocontractility found in adolescence, by reviewing serial urodynamic studies.

PATIENTS AND METHODS

Thirty boys with PUV and no voiding symptoms underwent a total of 86 urodynamic tests (mean 2.8 each). The first urodynamic study was undertaken at 1-4 years of age in 15 boys and at 5-13 years in 15. They were re-evaluated at least 3 years later; 15 patients underwent the first and last urodynamic study, respectively, at a mean age of 2.8 and 7.7 years (group A), 10 boys at 6.2 and 8. 8 years (group B) and five at 9.4 and 15.2 years (group C). In 10 boys aged > 5 years the first and last pressure-flow studies (PFS) were analysed using an advanced analysis (PFA) to better identify hypocontractility.

RESULTS

Bladder dysfunction was found in 21 of 30 (70%) boys at the first evaluation and in 18 (60%) at the last. In 25 boys the urodynamic pattern changed. Of the 15 boys in group A, 10 of 12 who had hypercontractility changed to normal (seven), low compliance (one) or hypocontractility (two), and two remained stable; two of the remaining three with normal urodynamic studies changed to hypocontractility, while one was unchanged. Among the 10 boys in group B, six with hypercontractility changed to normal (three) or hypocontractility (three); two with normal urodynamic findings and one with low compliance changed to hypocontractility. Of the five boys in group C who showed severe hypocontractility after puberty, three had a normal pattern, one low compliance and one hypercontractility before puberty. The PFA showed a 'weak' detrusor in four of the seven boys who were considered normal on standard PFS. At the urodynamic follow-up, the PFA pattern changed to a 'weak' detrusor in four boys who had a normal (two) or strong (two) detrusor at the first evaluation.

CONCLUSIONS

Bladder dysfunction in boys with PUV changes during childhood and through adolescence. The urodynamic pattern of hypercontractility generally found soon after valve ablation gradually changes to hypocontractility in many boys and this pattern seems to be the rule after puberty. The evidence from this series supports the hypothesis that long-term detrusor hyperactivity in boys with PUV leads to detrusor failure, but a longitudinal 15-year follow-up from birth to puberty is needed to validate this concept.

[Persistent urination disorders after treatment of posterior urethral valve: incidence and semiology]

Micturition disorders were studied retrospectively in a series of 165 children over a period of 15 years. Among patients without lesions of the upper tract at the time of diagnosis (group A, n = 131), 18 (14%) had persistent nocturnal and diurnal enuresis: one urethral stenosis and six vesicoureteric reflux required surgery; three experienced persistent pollakiuria and enuresis. Among patients with upper urinary tract damage at the time of diagnosis (group B, n = 34), seven presented with recurrent urinary tract infection, five with nocturnal and diurnal enuresis and three with urolithiasis. In the long term, only 52% of them had normal renal function and two were successfully transplanted. Micturition disorders following treatment of posterior urethral valves are frequent and usually related to the so-called valve bladder syndrome. Iatrogenic complications and mortality rate have dramatically decreased during the recent years but long-term renal function impairment remains the most critical problem.

An algorithm for the management of anterior urethral valves

PURPOSE

We present our management algorithm for patients with anterior urethral valves seen in the last 2 decades with and without the benefit of prenatal sonography.

MATERIALS AND METHODS

A case series design was used to study 17 cases of anterior urethral valves. Five patients presented with prenatal hydronephrosis from 1984 to 1993 and 12 presented with predominant voiding symptoms between 1975 and 1996 at a mean age of 6 years.

RESULTS

Treatment included supravesical diversion in 1 case, vesicostomy in 5, urethroplasty in 5 and transurethral fulguration in 6. Four of the 5 patients with a prenatal diagnosis of hydronephrosis had moderate to severe hydronephrosis compared to 3 of the 12 who did not undergo prenatal sonography. All 17 patients were continent and infection-free, and had little or no hydronephrosis at a mean followup of 5 years.

CONCLUSIONS

We recommend vesicostomy in infants with high grade bilateral vesicoureteral reflux and poor emptying of the urinary tract, transurethral fulguration if the urethra has sufficient caliber and support, and urethroplasty in other patients. Based on our management algorithm patients with anterior urethral valves do not have sequelae due to distal obstruction of the urinary tract.

Endoscopic correction of vesicoureteral reflux secondary to posterior urethral valves

PURPOSE

We review our experience with children with high grade vesicoureteral reflux secondary to posterior urethral valves treated endoscopically with subureteral polytetrafluoroethylene (Teflon) injection.

MATERIALS AND METHODS

Between 1985 and 1994, 54 infants and children were diagnosed with posterior urethral valves of whom 38 (70%) had vesicoureteral reflux. In 9 patients reflux resolved after valve ablation. Seven patients underwent nephroureterectomy for nonfunctioning kidneys and in 2 reflux was treated with continuous chemoprophylaxis. The remaining 20 patients underwent an antireflux procedure, including reimplantation of the ureters in 5 and subureteral polytetrafluoroethylene injection in 15. Of the 15 patients who underwent injection 6 had unilateral and 9 had bilateral vesicoureteral reflux. According to the international classification reflux was grade IV in 6 ureters and grade V in 18. Patient age at injection ranged from 8 months to 6 years (mean 2.2 years).

RESULTS

Reflux was eliminated in 17 ureters after a single subureteral polytetrafluoroethylene injection. Five ureters required 2 injections and 2 ureters required 3 to correct reflux. Followup of the 15 patients ranges from 1 to 10 years. Followup voiding cystography in the 15 patients (24 ureters) showed no evidence of recurrence of reflux. No clinically untoward effects were noted in these children from the use of polytetrafluoroethylene as an injectable material.

CONCLUSIONS

Subureteral polytetrafluoroethylene injection is a simple and effective endoscopic alternative to open surgery for the management of high grade vesicoureteral reflux secondary to posterior urethral valves.

Evolution of upper urinary tract and renal function in patients with posterior urethral valves

From January 1972 to June 1993, 166 patients with posterior urethral valves (PUV) were treated in our surgical department, 59 with a milder form of PUV (upper urinary tract [UUT] complication rate 29%) and 107 with a severer form (UUT complication rate 96.3%). Only the latter group was studied for long-term (mean 9.3 years) evaluation of the UUT and renal function. A temporary vesicostomy was the primary treatment in 25 patients. Indications for temporary diversion were very young age and/or low birth weight, severe and bilateral UUT complications, and severe renal damage. All the other patients were treated by primary endoscopic valve fulguration. After removal of the lower urinary tract obstruction, vesicorenal reflux (VRR) resolved spontaneously or was ameliorated in 59.2% of the renal units. Spontaneous normalization or evident amelioration were found at long-term follow-up in nearly 70% of dilated, non-refluxing ureters. Ureteral reimplantation was performed on 41 of the 202 dilated or refluxing ureters (surgical rate 20.3%). The surgical failure rate requiring reoperation was 5% (2/41). The prerequisite for successful reimplantation was a large-capacity, stable, and compliant bladder. Ten nephroureterectomies were carried out for unilateral, massive VRR and renal dysplasia; 1 late nephrectomy was performed for arterial hypertension. The evolution of renal function showed statistically significant overall improvement, which was more evident in patients diagnosed and treated in the 1st month of life (P = 0.000) than in those treated between 1 and 12 months (P = 0.004) or after 1 year of age (P = 0.025). Renal function considerably improved in the vesicostomy group (P = 0.000). Thirteen patients (12.4%) are now either dead (2) or have end-stage renal disease (6) or chronic renal insufficiency evolving toward end-stage renal disease (5); 5 of these 13 were treated by vesicostomy in the first days or months of life, and at presentation the glomerular filtration rate (GFR) was less than 25 ml/min . 1.73 m(2). Determination of basic GFR and, even more, functional renal reserve is relevant in predicting the long-term evolution. In the author's opinion, vesicostomy is the procedure of choice in very ill newborns or infants. Aggressive management with early surgical reconstruction is rarely justified, because frequently UUT complications resolve spontaneously or clearly improve, and their surgical treatment has limited and very precise indications.

Congenital nephropathies and uropathies

Although congenital nephropathies and uropathies only represent a fraction of possible genitourinary diseases detected during childhood, they have serious and sometimes avoidable morbidity and mortality. Advances in genetic, molecular, and cellular biology research continue to better define embryologic insults to normal organogenesis and offer the promise that many of these conditions might be avoided in the future. For now, awareness of these entities and their varied presentations and manifestations is crucial so that prompt evaluation and aggressive multidisciplinary management assures the affected child optimal growth and development.

The urodynamic consequences of posterior urethral valves

We evaluated urodynamically 41 patients with posterior urethral valves because of signs or symptoms of incontinence (35), frequency (3), hydronephrosis (2) and infection (1). Findings included normal urodynamic evaluations in 3 patients, 2 had high voiding pressures secondary to outlet resistance and 1 had incontinence on the basis of external urethral sphincter damage. In the remainder 3 patterns of bladder dysfunction were identified. Myogenic failure with overflow incontinence occurred in 14 patients. In this group clean intermittent catheterization or Valsalva's voiding was used for emptying. Hyperreflexic bladders were seen in 10 patients. Pharmacological suppression of instability was effective in 5 of 7 patients treated; 1 required bladder augmentation. Eleven children had a small capacity bladder and poor compliance. Post-void residuals were low and these bladders were generally but not always stable. Pharmacological bladder relaxation was successful in 3 patients, 3 underwent augmentation, 1 did well with alpha-agonists and followup is unavailable on the other 4. These 3 patterns of bladder dysfunction represent an overlapping constellation of residual urodynamic abnormalities due to previous bladder outlet obstruction. Individual patients may show facets of several types of dysfunction associated with 1 predominant pattern.

Aspects concerning posterior urethral valves

Twenty-six boys were evaluated and treated for posterior urethral valves. At the time the valves were diagnosed unilateral or bilateral vesicoureteral reflux was present in 58% of the ureters and 69% of the children, while dilatation of the upper urinary tract was present in 88% and 92%, respectively. There was a variety of symptoms and signs, but the most prominent in neonates and infants were vesical urine retention, palpable kidneys and failure to thrive, whereas in the older children voiding dysfunction, incontinence and urinary infection were the most common. Twenty-four out of 26 boys were managed by primary valve ablation and in 62.5% of them this type of treatment was adequate in resolving or sufficiently improving clinical manifestations and roentgenologic findings, requiring no further management. Urinary diversion in the form of vesicostomy and cutaneous ureterostomy was preserved for those patients who did not improve with valve ablation alone. The current aspects concerning posterior urethral valves are also discussed.

Infants with posterior urethral valves: a retrospective study and consequences for therapy

This is a report on the follow-up data of 18 patients with posterior urethral valves diagnosed during the first year of life. One infant died of progressive renal failure; a slight elevation of serum creatinine levels in three children aged 4-6 years indicated a doubtful prognosis. On initial examination, ten patients showed severe unilateral or bilateral reflux. Seven of 14 refluxing units remained non-functioning and had to be removed. Following transurethral fulguration of the valves, five infants developed unilateral or bilateral reflux which was not evident on initial preoperative voiding cystograms. In contrast to those in other series, none of these refluxes ceased spontaneously. Ureteral reimplantations were done on 11 ureters of eight patients, but regression of ureteral dilatation postoperatively remained unsatisfactory in six instances, none of whom had a true mechanical obstruction. We conclude that many of these megaloureters encountered in infants with posterior urethral valves are concomitant with profound and often irreversible damage of the ureter wall. Surgery of such ureters, therefore, should be avoided whenever feasible.

Long-term outcome of boys with posterior urethral valves

One hundred and fourteen boys with posterior urethral valves were treated between 1966 and 1975. Four died during the first hospital admission, 6 died from renal failure during childhood, 1 died from other causes and 15 were lost to follow-up. Eighty-eight were reviewed 11 to 22 years after diagnosis and the renal outcome of 98 patients is therefore known. Approximately one-third of patients presented under 1 month of age, between 1 month and 1 year, and over 1 year respectively. Bilateral vesicoureteric reflux was observed in one-quarter of the boys, more frequently in those presenting in the first month of life. Half of the patients were treated by primary valve ablation and half underwent temporary upper tract diversion: the outcome was worse for the diverted group. One-third of the boys had a long-term bad outcome for renal function. This outcome was associated with early presentation, bilateral vesicoureteric reflux and day-time urinary incontinence after the age of 5 years. The association of bad outcome with incontinence points to continuing bladder dysfunction as a major determinant of long-term outcome for renal function.

Primary vesicoureteral reflux in blacks with posterior urethral valves: does it occur?

Primary vesicoureteral reflux (VUR) is thought to be largely independent of obstruction. Therefore, in patients with urethral obstruction due to posterior urethral valves (PUV) the occurrence of VUR is coincidental. In addition, primary VUR is reported to be uncommon in black children. If these two premises are correct, then primary VUR should be rare in black males with PUV. To test this hypothesis, we reviewed the medical records and radiographs of 43 males with PUV. Twenty-one of the 37 non-black males with PUV had VUR, of which 67% was primary and 33% was secondary. Three of the six blacks with PUV had VUR of which all was secondary. Thus, blacks with PUV lend credence to the theory that primary VUR is not caused by obstruction and support the observation that primary VUR is rare in black children, even those with PUV.

Percutaneous transvesical antegrade ablation of posterior urethral valves

A technique of ablation of posterior urethral valves in a neonate is described. It involves two useful modifications of antegrade suprapubic approach. These modifications include the use of a matured percutaneous suprapubic tract for antegrade fulguration of valves and the utilization of a small urethral catheter as a guide for the valve ablation. The urethral catheter also protects the urethra from fulguration injury.

Inadequate decompression of the upper tracts using a Foley catheter in the valve bladder

Catheter drainage has been advocated for initial diversion in children who present with posterior urethral valves and concomitant urinary tract infection or metabolic derangement. We report a case in which a well placed and functioning Foley catheter provided inadequate upper tract decompression. However, excellent upper tract decompression was accomplished when the catheter was replaced with a feeding tube. It appears that physiological upper tract obstruction was promoted by the Foley catheter, which may have been a manifestation of the valve bladder syndrome.

Prognostic features in infants with obstructive uropathy due to posterior urethral valves

The histories of 22 infants presenting during the first year of life with obstructive uropathy due to posterior urethral valves were analyzed to determine outcome and prognostic features. Mean patient age at the time of the initial surgical intervention was 39 days, and the mean duration of followup inclusive of renal function data was 5.8 years. One patient died (5 per cent) and one had end stage renal disease. The mean preoperative and postoperative serum creatinine concentrations during the initial hospitalization were 3.1 and 1.4 mg. per dl., respectively. Neither value was significantly predictive of the creatinine concentration at final followup. In contrast, the nadir creatinine value during the first year of life correlated significantly with final renal function. Children with nadir creatinine values less than or equal to 0.8 mg. per dl. by 12 months of age maintained creatinine levels less than or equal to 1.1 mg. per dl. at the time of final evaluation, whereas children with higher values during the first year of life were likely to have progressive renal failure. Of 19 final creatinine determinations 6 were normal and 5 exceeded 1.5 mg. per dl. Proteinuria, hypertension, renal biopsy findings, urinary infection, unilateral nephrectomy and type of surgery did not correlate significantly with functional outcome. Followup studies of longer duration are needed to determine the ultimate outcome of these patients, more than half of whom had some degree of renal insufficiency at final evaluation.

Management of congenital posterior urethral valves

A series of 46 children treated by the author since January 1972 for congenital posterior urethral valves is presented: 22% were diagnosed at birth, 28% as neonates and 52% in the first 3 months of life. Ninety-three per cent had unilateral or bilateral dilatation of the upper urinary tract at the time the valves were diagnosed and 72% had ureteric reflux. Unilateral reflux occurred into the left ureter twice as often as the right. Renal failure was present at the time of diagnosis in 72% of all of the children but in 83% of those aged less than 3 months. Surface urinary diversion was used minimally during post-operative management and contributed little to the recovery of renal function. Reflux disappeared spontaneously in one-third of the refluxing ureters. Ureteric dilatation subsided spontaneously in 57% of dilated ureters. Surgery was performed mostly for reflux. Non-refluxing ureteric dilatation was made worse by surgery in a few instances and in others the dilatation improved with time rather than as a result of surgery. Renal function returned to normal in over 60% of the children who were in renal failure at diagnosis. Measurement of glomerular filtration rate was the most accurate method of predicting recovery of renal function: a value of less than 50% of normal for age at the time of diagnosis forecast persistent chronic renal failure with all its attendant complications.

An antegrade technique for ablation of posterior urethral valves

Complications after transurethral ablation of posterior urethral valves frequently are iatrogenic because of urethral injury resulting in stricture or sphincteric incontinence. Smaller instrumentation and improved optics have made primary valve destruction safer and more reliable. The concept of early neonatal vesicostomy with delayed transurethral valve ablation allows maximal upper tract protection as well as somatic and urethral growth. This approach further reduces the possibility of urethral or sphincteric injury. We report our technique of antegrade incision of posterior urethral valves per vesicostomy, combining the advantages of early optimal neonatal vesicostomy drainage, avoidance of any anterior urethral instrumentation, and a technically easier, reliable and safe approach to posterior urethral valve destruction.

The many faces of vesico-ureteric reflux: factors contributing to renal damage

Current controversies in the pathogenesis and management of vesico-ureteric reflux (VUR) and reflux-associated nephropathy (RAN) are critically reviewed, together with the advantages and limitations of surgical correction of reflux. Special emphasis is given to pitfalls in diagnosis and ongoing reassessment, to the importance of associated urinary tract abnormalities, and to the need for continuing long term chemoprophylaxis in the presence of persisting VUR.