The Effects of Bladder Neck Incision on Urodynamic Abnormalities of Children With Posterior Urethral Valves

Simultaneous primary posterior urethral valves ablation and bladder neck incision may decrease kidney and bladder failure in long-term follow-up in patients with bladder neck hypertrophy and poor bladder function at presentation: report of 301 cases

OBJECTIVES

To investigate the effects of bladder neck incision (BNI) and primary valves ablation on long-term kidney and bladder function in children with posterior urethral valves (PUV) and bladder neck hypertrophy (BNH).

PATIENTS AND METHODS

From 1997 to 2016, a total of 1381 children with PUV were referred to our tertiary hospital. Of these patients, 301 PUV patients with bladder neck hypertrophy need concurrent BNI and valve ablation. All patients were followed up every 3-6 months on regular basis in first 2 post-surgical years and annually then after. The paired t-test and chi-square test were used to perform statistical analysis with p value < 0.05 defined as the level of significance.

RESULTS

Mean age at diagnosis was 7.22 ± 2.45 months (ranging from 7 days to 15 months) with a mean follow-up of 5.12 ± 2.80 years. The incidence of hydronephrosis was decreased from 266 (88.3%) at the baseline to 73 (24.3%) patients in long-term follow-up. At baseline, 188 (62.5%) patients were diagnosed with VUR, which decreased to 20 (6.6%) individuals at the end of follow-up. Bladder and renal function were improved in follow-ups following concomitant PUV ablation and BNI. No Myogenic failure was depicted in all patients with BNH. No ureteric reimplantation was needed during the two decades follow-up.

CONCLUSION

Simultaneous valve ablation with BNI may present further profits in children with PUV and BNH particularly cases of BNH with poor bladder function at the time of presentation. This method can improve the results of urodynamic and imaging studies after the surgery. We hypothesize every child with PUV presentation who has concurrent vesicoureteral reflux, CKD or persistent hydrourethronephrosis may suffer from secondary bladder neck obstruction. This secondary bladder outlet obstruction must be managed through BNI as the surgical relief.

Can Concomitant Bladder Neck Incision and Primary Valve Ablation Reduce Early Re-admission Rate and Secondary Intervention?

Objective:

To assess the effect of bladder neck morphology and its incision (BNI) in patients with posterior urethral valve (PUV) on early reintervention rate.

Patients and methods:

Infants undergoing PUV ablation (PVA) before 24 months of age and had at least 18 months of follow-up, were categorized into three groups according to the bladder neck appearance on baseline radiological and endoscopic examination: group 1; normal bladder neck underwent PVA, group 2; high bladder neck underwent PVA plus BNI, group 3; high bladder neck underwent PVA only. Early reintervention was defined as the need for check cystoscopy because of persistent renal function deterioration, worsening hydronephrosis and/or unsatisfactory VCUG improvement during the 1st six months post primary PVA.

Results:

Between 2000 and 2017, a total of 114 patients underwent PVA and met the study criteria with a median follow-up of 58 (18-230) months. For group 1, 16 (22.9%) patients needed readmission. Check cystoscopy was free and no further intervention was performed in 5(7.5%) and re-ablation was performed in 11(15.7%) patients. For group 2, 3(14.3%) patients needed reintervention. Re-ablation and re-ablation plus BNI were performed in 1(4.8%) and 2(9.5%), respectively. For group 3, cystoscopy was free in 1(4.3%), re-ablation and re-ablation plus BNI were performed 2(8.7%) and 1(4.3%), respectively. There were no significant differences in the re-admission and re-intervention rates among the three study groups (p=0.65 and p=0.50, respectively).

Conclusion:

In morphologically high bladder neck associated PUV, concomitant BNI with PVA doesn’t reduce early re-intervention rate.

Urodynamic assessment in the management of the child's posterior urethral valves

BACKGROUND

Bladder dysfunction may be associated with valves of the posterior urethra. Their evaluation by urodynamic assessment is an important parameter for the therapeutic management. The objective of our study was to study the contribution of urodynamic assessment in the management of valves of the posterior urethra of the child.

METHODS

Our study was descriptive, retrospective, involving 43 children with posterior urethral valves (PUV), followed at the pediatric ward at Charles Nicolle Hospital in Tunis from January 1995 to December 2015. All the children had an urodynamic assessment after valves of the posterior urethra treatment.

RESULTS

The mean age was 15.8 months. Preoperatively, creatinine clearance was below 60 ml / min in 32 patients (74%). The worsening of renal function was noted in 32 (74%). A significant post-voiding residue proved in 34 patients (79%). Cystometry revealed a hypo compliant bladder in 24 (56%), low bladder capacity in 42% of cases; a hypertonic detrusor in 37% of cases. Bladder sphincter dyssynergia was diagnosed in 6 patients. Like urodynamic assessment data, bladder enlargement associated with a Mitrofanoff-type shunt was indicated and performed in 3 patients (7%).

CONCLUSION

Through our study, the urodynamic profile made it possible to specify the type of vesico-sphincter dysfunctions persistent in patients operated for PUV, and subsequently to adapt the therapeutic conduct in these patients. Given the lack of management and the consequences on the health of the child as well as on his quality of life, reflections on the preventive and therapeutic approach after PUV treatment are necessary.

Posterior urethral valves: Role of prenatal diagnosis and long-term management of bladder function; a single center point of view and review of literature

Posterior Urethral Valves (PUV) are the most common cause of lower urinary tract obstruction. More severe forms are detected early in pregnancy (mainly type I), while other forms are usually discovered later in childhood when investigating lower urinary tract symptoms. Bladder dysfunction is common and is associated with urinary incontinence in about 55% (0%-72%). Despite the removal of the obstruction by urethral valve ablation, pathological changes of the urinary tract can occur with progressive bladder dysfunction, which can cause deterioration of the upper urinary tract as well. For this reason, all children with PUV require long-term follow-up, always until puberty, and in many cases life-long. Therefore, management of PUV is not only limited to obstruction relief, but prevention and treatment of bladder dysfunction, based on urodynamic observations, is paramount. During time, urodynamic patterns may change from detrusor overactivity to decreased compliance/small capacity bladder, to myogenic failure (valve bladder). In the past, an aggressive surgical approach was performed in all patients, and valve resection was considered an emergency procedure. With the development of fetal surgery, vesico-amniotic shunting has been performed as well. Due to improvements of prenatal ultrasound, the presence of PUV is usually already suspected during pregnancy, and subsequent treatment should be performed in high-volume centers, with a multidisciplinary, more conservative approach. This is considered to be more effective and safer. Primary valve ablation is performed after clinical stability and is no longer considered an emergency procedure after birth. During childhood, a multidisciplinary approach (pediatric urologist, nephrologist, urotherapist) is recommended as well in all patients, to improve toilet training, using an advanced urotherapy program with medical treatments and urodynamic evaluations. The aim of this paper is to present our single center experience over 30 years.

Antenatal and postnatal management of posterior urethral valves: where do we stand?

Introduction

Posterior urethral valve (PUV) is the leading etiology of lower urinary tract obstruction (LUTO) in boys and is an important cause of end-stage renal disease (ESRD) in children. The aim of this article is to review the current status on antenatal intervention for PUV as well as postnatal medical and surgical management.

Main body

MEDLINE, EMBASE, Pubmed and Google Scholar search was conducted throughout December 2020 using the keywords: posterior urethral valves, congenital urinary obstruction, antenatal, valve bladder syndrome, medical, anticholinergics, alpha blocker, antibiotics, biofeedback, diversion, augmentation cystoplasty and renal transplantation. Only papers written in English were included. The relevant literature was summarized. Despite advances in antenatal intervention for fetal LUTO, it remains associated with considerable fetal and maternal morbidity. Patient selection criteria for antenatal intervention are greatly debated. Fetal intervention has resulted in improved perinatal survival in properly selected cases, with a questionable benefit to postnatal renal function. There is decent evidence supporting the use of anticholinergics in infants and young children following valve ablation, with less robust evidence advocating alpha blockers, overnight catheter drainage and biofeedback. The role of urinary diversion remains contentious. Optimizing bladder dynamics is crucial for successful renal transplantation outcomes.

Conclusion

While antenatal intervention has failed to improve renal function outcomes of PUV, patient-centered medical and sometimes surgical interventions can help delay the progression of chronic kidney disease. Lifelong monitoring and management of the associated bladder dysfunction is indispensable even after successful renal transplantation.

Urodynamics in Posterior Urethral Valve: Pursuit of prognostication or optimisation

INTRODUCTION

Detrusor dysfunction is known to persist in several patients of Posterior Urethral Valve (PUV) after successful fulguration leading to progressive deterioration of renal function. Persistent bladder outlet obstruction (BOO) in the form of bladder neck hypertrophy, residual valves or strictures may contribute to progressive detrusor dysfunction. These are assessed radiologically or cystoscopically and are managed variedly by anticholinergics, alpha-adrenergic blockers or even bladder neck incision. Unfortunately, currently we do not have any objective measures to evaluate the degree of BOO in children or follow treatment outcome of any such measures.

OBJECTIVE

To assess the feasibility of pressure flow studies in children and proposition of an age independent index to quantify outflow parameters.

STUDY DESIGN

We retrospectively studied the urodynamic data of the follow up cases of PUV who had been referred to us for urodynamic evaluation. Free flow uroflowmetries and filling and voiding cystometrogram were performed as per recommended protocol. Parameters like Adjusted Bladder Capacity (ABC = Voided volume + post void residue; expressed as percentage of expected bladder capacity {EBC}), overactivity, compliance, Qmax and P _{det at Qmax} were taken into consideration. Indices like Bladder Outlet Obstruction Index (BOOI) and Bladder Contractility Index (BCI) were calculated. Multivariate analysis was run to assess correlation of ABC with other parameters. Receiver Operating Characteristics (ROC) curve analysis was performed to assess predictive values of BOOI for ABC.

RESULTS

We did not find the ABC to change with age as has been classically described. Qmax and BCI were found to correlate with age. Values obtained for P _{det at Qmax} and BOOI were not dependent on age and were in similar range as observed in adults. On multivariate analysis, small bladder was found to positively correlate with presence of overactivity, high BOOI and low BCI. ROC curve analysis showed a BOOI >29 could predict ABC to be <100% EBC with moderate sensitivity and specificity.

DISCUSSION

Pressure flow studies are the only objective means of quantifying outlet resistance, hitherto they have been considered to be unrepresentative in children. Documentation and correction of high outflow pressures may arrest the cycle of detrusor hypertrophy and dysfunction.

CONCLUSION

Quality pressure flow studies are feasible in children. Values of P _{det at Qmax} and BOOI in children are age independent and similar to those observed in adults. BOOI can be potentially used in children to assess degree of BOO.

Insight into Posterior Urethral Valve from Our Experience: Paradigm Appended to Abate Renal Failure

Objective:

The objective of the study was to share our experience of management of posterior urethral valve (PUV) and to suggest a paradigm to impede upstaging of chronic kidney disease (CKD) and prevent end-stage renal failure (ESRF).

Patients and Methods:

We have treated 332 patient of PUV from March 2005 to April 2016, Of which 272 case records had adequate data to be analyzed. The mean age was 2.48 years (range: 1 day–18 years). We did primary fulguration in 231 patients, of which five patients needed bilateral ureterostomy for obstinate high creatinine level. The remaining 36 patients had primary fulguration done elsewhere.

Results:

The mean duration of follow-up was 7.8 years (range 3–14 years). In the end of this study, 10 patients had down staging in CKD, 36 patients had up staging in CKD, and 9 patients ended in ESRF (3.8%).

Conclusions:

Detection of deterioration of renal function with creatinine clearance along with identifying the causes of deterioration and necessary interventions would help to arrest upstaging of CKD otherwise that might end in ESRF. From this study and reviewing the literature, we presume that the rhabdosphincter spasm underneath actually renders bladder outlet obstruction, and cusps of PUV, particularly in neonates, amplify the obstruction, following that bladder outlet obstruction cascades detrusor hypertrophy, bladder neck hypertrophy/obstructions, and ureterovesical junction obstruction/reflux, causing gradual damage to the bladder and upper tract and deterioration of renal function as a consequence.

Is there a need for endoscopic evaluation in symptomatic boys with an unsuspicious urethra on VCUG? A consideration of secondary radiologic signs of posterior urethral valves

INTRODUCTION

A significant proportion of PUV becomes symptomatic after the perinatal period. Voiding cystourethrography (VCUG) often fails to identify PUVs. This study evaluates the relationship between the radiological appearance of the posterior urethra, potential secondary radiological signs and endoscopically documented PUV in boys with febrile UTIs, VUR, refractory symptoms of bladder overactivity or suggestive sonography findings.

PATIENTS AND METHODS

Data on VCUG findings and endoscopy from 92 boys (mean age 27 months) who underwent endoscopic PUV incision between 2012 and 2017 following a VCUG were reviewed. 24 boys with endoscopically unsuspicious urethras were included as control group (mean age 27.5 months). Statistical analysis was performed using Fisher's exact test.

RESULTS

In patients with PUV, the urethra was suspicious on a preoperative VCUG in 45.7%, whereas it appeared normal in 54.3%. Abortive forms of PUV were more frequently found in patients with a radiologically unsuspicious urethra (30%vs.16.7%, p = 0.15). Bladder neck hypertrophy on VCUG (16.7%vs.60.9%, OR 7.5, p < 0.001), a trabeculated bladder on VCUG (72%vs.37.5%, OR 4.3, p < 0.001) and a hypertrophied musculus interuretericus (38%vs.4.2%, OR 11.7, p < 0.001) were more common in patients with PUV and urethras appearing normal on VCUG as compared to controls.

CONCLUSION

Unsuspicious findings of the urethra on VCUG cannot exclude a relevant PUV and implicate a risk of disregarding abortive forms. The presence of secondary radiologic signs of infravesical obstruction on a VCUG despite an unsuspicious posterior urethra in boys with recurrent UTI's as well as refractory symptoms of bladder overactivity or suggestive signs on sonography must be further clarified endoscopically.

Consensus on the Management of Posterior Urethral Valves from Antenatal Period to Puberty

The need for successful management of posterior urethral valves always captivates the minds of pediatric surgeons. Its success, however, depends on several factors ranging from prenatal preservation of upper tracts to postoperative pharmacological compliance. Regardless of measures available, some cases do not respond and progress to end stage. The management depends on several issues ranging from age and severity at presentation to long-term follow-up and prevention of secondary renal damage and managing valve bladder syndrome. This article is based on a consensus to the set of questionnaires, prepared by research section of Indian Association of Paediatric Surgeons and discussed by experienced pediatric surgeons based in different institutions in the country. Standard operating procedures for conducting a voiding cystourethrogram and cystoscopy were formulated. Age-wise contrast dosage was calculated for ready reference. Current evidence from literature was also reviewed and included to complete the topic.

Refractory Urinary Incontinence in Girls: The Role of the Bladder Neck

BACKGROUND

Prevalence of lower urinary tract dysfunction (LUTD) in children is between 6 and 9% with urinary incontinence (UI) being one of the most common symptom.

VARIOUS ASPECTS OF LOWER URINARY TRACT SYMPTOMS LUTS

Anatomical anomalies of the urinary tract as well as neurogenic underlying pathology can results in LUTS. Comorbidities and long-term consequences of the LUTD for the female patients as well as genetic issues are also briefly discussed.

THE ROLE OF THE BLADDER NECK

Thanks to urodynamics, we have learnt a lot about the lower urinary tract function, but the role of the bladder neck in the pathophysiology of LUTS in children is not clear. Secondary bladder neck hypertrophy is a well-described pathology, but there is no standardized treatment for this phenomenon. Primary bladder neck dysfunction has already been defined by the International Children's Continence Society.

REFRACTORY UI IN GIRLS

Uniform diagnostic protocols are used in these girls with UI. Treatment consists of standard urotherapy, additional interventions, and pharmacotherapy in selected cases. Those with refractory UI require careful reassessment to look for the unrecognized disorders. Invasive urodynamics should be done in those patients. Ultrasound of the bladder neck region and the pelvic floor can be helpful, but its interpretation is very subjective. In a small group bladder neck insufficiency can be found and those might benefit from a surgical intervention.

FUTURE PERSPECTIVE

Strict criteria of the bladder neck insufficiency in children must be defined. Early surgical intervention in girls with bladder neck insufficiency might reduce the long period of intensive conservative treatment.

The Long-term Effect of Superficial Bladder Neck Incision on Ejaculation and Incontinence in Boys with Primary and Secondary Bladder Neck Obstruction

OBJECTIVE

Superficial bladder neck incision (SBNI) is controversial at young age, with retrograde ejaculation after puberty as main concern. The aim of the study is to investigate the long-term effect of SBNI on ejaculation and incontinence in boys with primary and secondary bladder neck obstruction (BNO).

MATERIALS AND METHODS

In boys with infravesical obstruction, SBNI was performed in case of a persistent BNO after earlier desobstruction or in case of primary severely obstructive bladder neck. SBNI was performed with a diathermy hook, always superficially (2-3 mm) and unilaterally at 7 O'clock. Males that had SBNI during childhood after posterior urethral valve incision or relief of other obstruction between 1986 and 2003 were included. Evaluation was done by International Continence Society male sex questionnaire, International Prostate Symptom Score, developmental International Consultation Modular Questionnaire on Urinary Incontinence, frequency volume chart, and uroflowmetry.

RESULTS

Of 79 traceable patients, 40 (50.6%) participated. Of these, 37 (92.5%) completed all questionnaires and 28 (70%) performed uroflowmetry. Median age at SBNI was 4.7 years [interquartile range (IQR) 0.6-8.5] and was 19.6 years (IQR 17.3-20.9) at follow-up. All men had antegrade ejaculation, 4/37 (10.8%) reported possibly reduced ejaculatory volume. Eight (22%) had moderate lower urinary tract symptoms and two (5.4%) had moderate incontinence. Median maximum flow rate was 30.1 mL/s (IQR 24.4-42.6).

CONCLUSION

SBNI in boys with severe infravesical obstruction can be done safely with preservation of antegrade ejaculation and no additional lower urinary tract dysfunction.

Long-term Impacts of Concurrent Posterior Urethral Valve Ablation and Bladder Neck Incision on Urinary Continence and Ejaculation

OBJECTIVE

To assess the long-term impacts of bladder neck incision (BNI) on continence and ejaculatory function of adults who underwent concurrent posterior urethral valve (PUV) ablation and BNI during childhood.

MATERIALS AND METHODS

A retrospective chart review was performed to find all adult patients with relevant history. All patients had undergone BNI at 6 o'clock proximal to the verumontanum with caution to leave the adventitia and verumontanum untouched. Charts were reviewed and attempts were made to contact those ≥18 years old for follow-up. Patients were specifically evaluated for lower urinary tract symptoms and ejaculatory condition.

RESULTS

Among patients treated for PUV between 1998 and 2015 in our center, 21 were ≥18 years old at the time of assessment. Until February 2016, we were able to contact 18 patients, all of whom agreed to participate. Mean age was 21.1 ± 2.9 years with a mean follow-up of 12.5 ± 4.8 years. None of those contacted had incontinence or dry ejaculations. All considered their ejaculations normal and only one complained of weak ejaculations. Four of 5 patients who consented to perform a semen analysis had normal tests and 1 had low sperm count with abnormal motility.

CONCLUSION

BNI is not associated with additional risk of incontinence and dry ejaculation in early adulthood and preserves antegrade ejaculation. Concomitant valve ablation with BNI may provide additional benefits in care of PUV children, especially those with prominent bladder neck and poor bladder function at presentation.

Effect of Botox injection at the bladder neck in boys with bladder dysfunction after valve ablation

OBJECTIVE

After posterior urethral valve ablation, some boys are still have a hostile bladder. We conducted a prospective randomized study to determine if Botox injection at the bladder neck will help improve vesical dysfunction in this subgroup of boys or not.

PATIENTS AND METHODS

Twenty boys with history of posterior urethral valve ablation and severe bladder dysfunction with a mean age of 16 months were studied. Cases were further randomized into two groups. Group I (study group) had endoscopic injection of a single dose of 100 IU of Botox into the hypertrophied bladder neck at 3, 6, and 9 o'clock. Group II (control group) patients with the same parameters had urethroscopy to exclude residual valves. Both groups had the standard conservative treatment. Cases were followed after 6 months of initiating the management protocol. This includes laboratory studies (urine culture and sensitivity, blood urea nitrogen, serum creatinine), ultrasound of the urinary tract. Voiding cysto-urethrogram and urodynamic study (pressure flow study).

RESULTS

There was no statistical difference in both groups regarding rate of urinary tract infection, improvement of hydronephrosis, resolution of vesico-ureteral reflux, creatinine level at the start or at the end of the study. Urodynamic parameters revealed an increase in cystometric capacity in both groups at the end of the study but without statistical difference. The mean voiding pressure reduced significantly in both groups but without statistical difference.

CONCLUSIONS

Temporarily abolishing the effect of bladder neck by Botox injection does not seem to improve the outcome of those boys who had a severe voiding dysfunction after valve ablation.

Best practice in the assessment of bladder function in infants

The purpose of this article is to review normal developmental bladder physiology in infants and bladder dysfunction in conditions such as neurogenic bladder, posterior urethral valves and high grade vesicoureteric reflux. We contrast the classical concept that bladder function in nontoilet-trained children is thought to be 'reflexive' or 'uninhibited', with the results of more recent research showing that infants most commonly have a stable detrusor. The infant bladder is physiologically distinct from the state seen in older children or adults. The voiding pattern of the infant is characterized by an interrupted voiding stream due to lack of proper urinary sphincter relaxation during voiding. This is called physiologic detrusor sphincter dyscoordination and is different from the pathologic 'detrusor sphincter dyssynergy' seen in patients with neurogenic bladder. Urodynamic abnormalities in neonates born with spina bifida are common and depend on the level and severity of the spinal cord malformation. Upper neuron lesions most commonly lead to an overactive bladder with or without detrusor sphincter dyssynergy while a lower neuron lesion is associated with an acontractile detrusor with possible denervation of the external urinary sphincter. In infants with neurogenic bladder, the role of 'early prophylactic treatment (clean intermittent catheterization and anticholinergics)' versus initial 'watchful waiting and treatment as needed' is still controversial and needs more research. Many urodynamic-based interventions have been suggested in patients with posterior urethral valves and are currently under scrutiny, but their impact on the long-term outcome of the upper and lower urinary tract is still unknown. Cumulative data suggest that there is no benefit to early intervention regarding bladder function in infants with high-grade vesicoureteric reflux.

Long-term consequences of posterior urethral valves

Posterior urethral valves (PUV) are the most common congenital cause of bladder outlet obstruction in infancy, and it is the effect of this obstruction on the bladder and the kidneys that will decide a patient's prognosis. With the improvements in diagnosis and treatments, what was previously a poor prognosis for boys with PUV has improved, and more patients will encounter the long-term sequelae of PUV during puberty and adulthood. In these patients the long-term prognosis in terms of renal and bladder function and fertility, as well as the risk of malignancy in those whose bladders were augmented with gastrointestinal segments, is still a matter of great concern and all of these topics will be discussed in this article.

Efficacy of bladder neck incision on urodynamic abnormalities in patients with posterior urethral valves

PURPOSE

This study aims to study the efficacy of simultaneous endoscopic bladder neck incision (BNI) and primary endoscopic valve incision (PEVI) in patients with posterior urethral valves (PUV).

MATERIALS AND METHODS

Nine PUV patients underwent PEVI and BNI over a year. They were compared to nine comparable historical controls that had undergone only PEVI. Trends in renal function tests, urodynamics and changes in the upper urinary tracts were evaluated after 3 months during which no pharmacotherapy was given.

RESULTS

The incidence of bladder dysfunction in the two groups was similar-55.5 % in case group and 66.6 % in control group. Hypocompliant, high-pressure bladder was the predominant cystometric finding in both groups. Three patients in the case group and two patients in the control group had high end infusion pressure (EIP) with poor compliance. Detrusor overactivity (DOA) was seen in 23.1 % patients in the case group as compared to 55.5 % patients in the control group (P = 0.3348). Five patients in both groups were later started on anticholinergics due to raised EIP, small capacity bladder and/or DOA.

CONCLUSION

Although BNI should theoretically improve the outcome of PUV patients, the current pilot study failed to demonstrate any significant difference. A larger sample size and longer follow-up are required to prove or disprove its efficacy.

[Is there an outcome difference between posterior urethral valves diagnosed prenatally and postnatally at the time of antenatal screening?]

PURPOSE

Posterior urethral valves (PUV) diagnosed during childhood have classically been associated with a better outcome than antenatally diagnosed PUV. The aim of our study was to compare long-term outcome of these two patients' groups.

MATERIAL AND METHODS

We retrospectively reviewed the medical records of boys with PUV managed between 1990 and 2010. Patient demographics, clinical background, radiographic data (including prenatal ultrasonography data when available), renal and bladder functional outcomes, surgical procedures and urinary tract infections (UTI) were abstracted. Impaired renal function (IRF) was defined as glomerular filtration rate less than 90 mL/min/1.73 m(2) at last follow-up.

RESULTS

We identified 69 patients with confirmed PUV. Thirty-eight were diagnosed prenatally (group 1) at 30.5 weeks of gestation and 31 had a delayed diagnosis (group 2) at a median age of 6.31 years. At diagnosis, 20 patients in group 1 had renal insufficiency versus two in group 2 (P<0.05). At the end of mean follow-up of 7.2 ± 0.5 years, in group 1, 26.3% developed IRF versus 6.3% in group 2 (mean follow-up 2.3 years). Mean age at last follow-up was 7.3 years in group 1 versus 8.3 in group 2 (P>0.05). In group 1, 27% had voiding dysfunction versus 30% in group 2 (NS). In group 1, 35% had UTI during follow-up versus 10% (P=0.01).

CONCLUSION

During the follow-up, the patients with delayed diagnosis VUP have developed fewer complications related to the initial obstruction than the population who was detected antenatally and managed from the early hours of life. However, the rate of IRF and voiding disorders in our study, associated with the data of the literature, highlights the potential persistence and worsening of these conditions. That is why, whatever the age at diagnosis, VUP patients require a close monitoring.

A systematic review on renal and bladder dysfunction after endoscopic treatment of infravesical obstruction in boys

Background

Posterior urethral valves (PUV) may cause subtle to severe obstruction of the urethra, resulting in a broad clinical spectrum. PUV are the most common cause of chronic renal disease in boys. Our purpose was to report the incidences of kidney and bladder dysfunction in boys treated with endoscopic valve resection for PUV.

Methodology

We searched MEDLINE and EMBASE databases until 1st of July 2011, to identify original papers that described outcome of endoscopic valve resection (EVR) in boys. We extracted information on (1) patient characteristics and clinical presentation of PUV related to outcomes and (2) the post-treatment absolute risks for kidney and bladder dysfunction.

Principal findings

Thirty-four studies describing renal function, vesicoureteral reflux (VUR), incontinence, and urodynamic bladder function after EVR in 1474 patients were retrieved. Patients treated for PUV show high percentages of chronic kidney disease (CKD) or end stage renal disease (ESRD), 22% (0–32%) and 11% (0–20%), respectively. Elevated nadir serum creatinine was the only independent factor associated with renal failure. Before treatment, VUR was present in 43% of boys and after EVR, VUR was present in 22%. Post treatment, 19% (0–70%) was reported to suffer from urinary incontinence. Urodynamic bladder dysfunction was seen in many patients (55%, 0–72%) after treatment of PUV.

Conclusions

The reported cumulative incidence of renal and bladder dysfunction in patients with PUV after endoscopic PUV treatment varies widely. This may reflect a broad clinical spectrum, which relates to the lack of a standardised quantification of obstruction and its severity. Moreover, the risk of bias is rather high, and therefore we put little confidence in the reported estimates of effect. We found elevated nadir serum creatinine as a predictor for renal dysfunction. In order to be able to predict outcomes for patients with PUV, an objective classification of severity of obstruction is mandatory.

Posterior urethral valves and adult sexual function

OBJECTIVES

To evaluate sexual function and fertility in adult patients treated for posterior urethral valves (PUV) in childhood and to compare these patients with the normal population. To examine if patient characteristics such as chronic renal failure (CRF), history of cryptorchidism and bladder neck incision in childhood have an impact on sexual function.

PATIENTS AND METHODS

Information on sexual function was assessed using questions from the International Index of Erectile Function (IIEF). In addition, the patients were asked if they had had children or been treated for CRF. Out of 108 adult patients with PUV, 67 (62%) returned the questionnaires. Sexual function in these patients was compared with 201 controls and paternity rates were compared with a national database.

RESULTS

The mean (sd) age of the patients and controls was 38 (9) and 38 (7) years, respectively. Six percent of the patients and 9% of the controls reported problems in achieving erection during sexual stimulation and 9% of the patients and 10% of the controls reported problems with the hardness of erection (P = nonsignificant). Ejaculation was absent in 1/61 sexually active patients (2%). The only significant risk factor in patients for erectile dysfunction (ED) was increasing age. Thirty-three (49%) of all 67 patients and four (57%) of the seven patients with kidney transplantation had had children. The paternity rates were similar to those in corresponding age groups of the general Finnish population. Eight patients (12%) had attempted to have children without success.

CONCLUSIONS

Men treated for PUV have a similar prevalence of ED and similar paternity rates to men without PUV. Erectile function and paternity rates can be satisfactory in spite of CRF.

Management of recurrent epididymitis in children: application of neurovascular sparing vas clipping in refractory cases

PURPOSE

To investigate the efficacy of therapeutic methods for recurrent epididymitis and neurovascular sparing vas clipping in refractory cases.

MATERIALS AND METHODS

Fifteen boys with recurrent epididymitis were enrolled: the first group (9) with primary structural anomalies and the second group (6) with voiding dysfunction without structural anomalies. Median age was 4 (29 months to 7 years) and 4.5 (6 months to 11 years) years, respectively. Mean follow up was 7.5 (2-11) and 5.2 (3.5-8) years, respectively.

RESULTS

Urethrovasal reflux was detected in all patients of the first group except one. Endoscopic injection of bulking agent was successfully applied in three patients with no recurrent epididymitis. No further episodes of epididymitis were reported after valve ablation or clean intermittent catheterization. In four non-responders, vas clipping was successfully undertaken. Voiding dysfunction was the possible etiology of epididymitis but with no obvious urethrovasal reflux in the second group. No further episodes of epididymitis occurred using bladder retraining and medications for detrusor and sphincter relaxation.

CONCLUSIONS

The results suggest that neurovascular sparing vas clipping can be used effectively in children with structural anomalies and urethrovasal reflux who have developed intractable epididymitis.

Posterior urethral valves: long-term outcome

Posterior urethral valves represent the most common cause of bladder outlet obstruction in infancy that impairs renal and bladder function. Long-term outcome of patients with previous PUV is evaluated. Patients over 18 years of age, treated from 1982 to 1995 before the age of 3 years were considered. Previous surgery, renal function, bladder activity, urinary incontinence, and fertility/sexual activity were evaluated. Clinical interview, creatinine clearance, uroflowmetry with ultrasound post-void urine residue, and self-administered questionnaire were recorded. Out of 45 identified records, 24 patients (53.3%) accepted to be enrolled (age 18-34 years, mean 23 years). The mean follow-up was 19.5 years (16-30 years). Out of the 21 excluded patients, 20 did not reply to the clinical interview and 1 died at age of 6 years. All the 24 patients had early endoscopic section of PUV; nine also received transient ureterocutaneostomy or vesicostomy. Ureteroneocystostomy was performed in five patients and ureterocystoplasty with unilateral nephrectomy in two. At follow-up chronic renal failure was detected in 13 patients (54.1%) and 9 (37.5%) had arterial hypertension. End-stage renal disease developed in five patients (20.8%): three had successful renal transplantation and two were in dialysis. Lower urinary tract symptoms were present in seven patients (29.1%). No significant fertility deficit and sexual dysfunction were observed in 23 patients, while 1 patient was azoospermic. No paternity was reported so far. Long-term outcome of patients with previously treated PUV is mandatory. Kidney, bladder, and sexual functions should be monitored till adulthood to verify any modified behaviour.

Urodynamic testing in children: indications, technique, interpretation and significance

PURPOSE

Urodynamic studies in children have been performed with increasing frequency as the techniques, reproducibility and reliability of the testing have been refined in the last quarter century. Children of all ages and with a variety of comorbidities are now often referred for urodynamic testing to evaluate and understand the causes of incontinence and/or persistence of lower urinary tract symptoms, as well as to appropriately define and evaluate treatment regimens.

MATERIALS AND METHODS

We performed a MEDLINE® search for relevant articles on urinary tract dysfunction, neurogenic bladder and urodynamic studies in the pediatric population. We also included 3 major textbooks that addressed the subject matter.

RESULTS

We review the current indications for urodynamic studies in children with nonneurogenic and neurogenic bladder dysfunction. We summarize the components and techniques of the current practice of urodynamic studies in the pediatric population, and explain how to identify abnormal results.

CONCLUSIONS

The use of urodynamic studies in pediatrics has become almost mandatory for the effective management of severe or therapy resistant urinary tract abnormalities. This review may be used as a guideline for the appropriate application of urodynamics in this patient population.

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.

CONGENITAL URINARY BLADDER OUTLET OBSTRUCTION

The term congenital ‘bladder outlet obstruction (BOO)’ describes the collection of conditions in which the normal, urethral egress of urine from the fetal bladder is impaired. The term is interchangeable with fetal ‘lower urinary tract obstruction’, as used by other authors. After considering normal urinary tract embryology, we describe the epidemiology of congenital BOO and the primary anatomical disorders associated with it. We then proceed to describe its fetal and postnatal clinical manifestations and then consider therapies and interventions which have been used to manage the condition. We not only focus on urethral and bladder disease with constitutes BOO itself, but also describe associated kidney disorders which, via chronic renal excretory failure, are important causes of morbidity. Rather than provide an exhaustive review, we emphasise studies published in the last decade, and therefore readers are referred to other reviews citing numerous earlier references.

Cold knife valvulotomy for posterior urethral valves using novel optical urethrotome

OBJECTIVES

To present our results after valve ablation using a novel cold knife urethrotome.

METHODS

Eleven consecutive male patients with posterior urethral valves underwent cold knife valvulotomy using a modified optical pediatric urethrotome. Patients were assessed both pre- and postoperatively using serum creatinine, voiding cystourethrography, and renal/bladder ultrasonography.

RESULTS

From August 2003 to August 2005, 11 patients underwent cold knife valvulotomy, of whom 7 returned for postoperative follow-up (mean follow-up 17.4 months). At surgery, the patients ranged in age from 5 days to 9 years. At presentation, 5 of the 7 patients had an elevated serum creatinine (mean 2.5 mg/dL, range 0.3-6.5), all had bilateral hydronephrosis of at least grade 3, and 6 of 7 had at least grade 3 reflux on 1 side. Intraoperatively, 1 complication (minor urethral laceration) occurred. Postoperatively, all 6 patients with serum creatinine levels measured showed improvement in renal function (mean creatinine 0.47 mg/dL, range 0.2-0.9). For the 6 patients who underwent postoperative ultrasonography, 4 had either complete resolution or significant improvement in their hydronephrosis, and none showed worsening. Six patients underwent postoperative voiding cystourethrography, with 5 showing either marked improvement or complete resolution of their reflux and 1 showing stable, unilateral reflux.

CONCLUSIONS

Valvulotomy using our modified urethrotome is a safe and effective technique for valve ablation.