Concomitant Anterior and Posterior Urethral Valves: A Comprehensive Review of Literature

Isolated posterior urethral valves (PUV) and anterior urethral valves (AUV) with and without concomitant PUV: Matched cohort study at a high-risk pediatric center

OBJECTIVES

To compare postnatal outcomes of AUV and PUV patients to evaluate for potential differences between these conditions, given that anterior urethral valves (AUV) with or without concomitant posterior urethral valves (PUV) is a rare congenital anomaly leading to lower urinary tract obstruction (LUTO).

METHODS

We reviewed our LUTO database and included patients with AUV or concomitant AUV+PUV, managed at our institution between 2003 and 2023 matching them to comparable PUV cases. Assessed variables included prenatal diagnosis, gestational age (GA) at birth, initial management, kidney function, presence and degree of hydronephrosis (HN), and need for renal replacement therapy (RRT).

RESULTS

The AUV ± PUV group (AUV: n=11, concomitant PUV: n=2) and PUV group (n=26) had similar presenting ages and follow-up times (p>0.05). Only 15.4% of AUV cases presented prenatally compared to 72.0% of PUV cases (p=0.0016), leading to delayed postnatal management in AUV patients (p=0.0260). Findings at presentation included UTI, weak stream or a palpable penile mass. PUV patients demonstrated significantly higher creatinine levels at the initial visit and at last follow-up (p=0.0120 and p=0.0302) than the AUV ± PUV group, with only one patient requiring RRT (p>0.05). At the last follow-up, no patient in the AUV ± PUV group required clean intermittent catheterization compared to 37.5% in the PUV group (p=0.0331) which also demonstrated more patients with persistent HN (p=0.0039).

CONCLUSION

AUV with or without concomitant PUV is a rare finding that should be considered in patients presenting with weak stream, UTI, and penile swelling. Our data suggests potential differences in presentation and less severe postnatal outcomes in AUV compared to PUV patients.

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.

Check cystoscopy in the management of anterior urethral valves in a cohort of pediatric patients

INTRODUCTION

Anterior urethral valves (AUV) are a rare cause of lower urinary tract obstruction which could progress to renal damage, Clinical presentation varies according with patient's age and severity of obstruction, but, in most cases, diagnosis is based on voiding cysto-urethrogram (VCUG). To date, the treatment of choice is endoscopic ablation even if approved guidelines about the overall management of AUVs, including the recognition and treatment of residual valves, are not available.

OBJECTIVE

We describe our protocol for AUV treatment based on primary endoscopic valve ablation followed by check cystoscopy 15 days later.

STUDY DESIGN

Medical records of 5 patients with AUVs admitted from 2008 to 2018 to our Pediatric Urology Unit were retrospectively reviewed. Blood tests, urinalysis, renal US and VCUG were performed in all children, while urodynamic evaluation was performed in the 3/5 patients who could void spontaneously. All patients underwent endoscopic valves ablation and after 15 days after a second look cystoscopy was performed. Follow up was based on clinical and radiological evaluation with US, urinalysis and blood tests. Postoperative non-invasive urodynamic studies were performed in the 3/5 patient toilet-trained patients and VCUG was performed in 1/5 patient.

RESULTS

and Discussion: At primary endoscopic ablation cystoscopy revealed AUVs in the penile urethra in three patients, in the penoscrotal urethra in one case, in the bulbar urethra in another case. In 3/5 patients check cystoscopy found residual valves and a second endoscopic ablation was performed. All patients achieved symptoms release and improved urodynamic parameters. No intra or post-operative complication were reported. The assessment of residual valves is variable in literature and it is usually described for posterior urethral valves (PUVs). Few series report the use of VCUG within the first week after valve ablation, our experience instead suggests that performing a second look cystoscopy, is very effective to evaluate the presence of residual AUVs and eventually proceed with further ablation.

CONCLUSION

Endoscopic ablation is the gold standard treatment for AUV, but residual valves management is not clearly defined. According to our experience, a check cystoscopy 15 days after primary ablation allows to identify and treat possible residual valves showing good results in terms of safety and efficacy.

Are anterior urethral valve and anterior urethral diverticulum two separate entities: A radiological and endoscopic review

BACKGROUND

Anterior urethral valve (AUV) and anterior urethral diverticulum (AUD) are two rare causes of anterior urethral obstruction with variable presentation and anatomy. Their existence as the same or different entity is still debatable, and management has not yet been standardized.

OBJECTIVE

This study is a retrospective review of cases diagnosed with anterior urethral obstruction and correlation of radiological and endoscopic anatomy of AUV and AUD.

STUDY DESIGN

A retrospective review of cases diagnosed with AUV and AUD, between May 2013 and February 2020 is presented. The presentation, laboratory, radiological and endoscopic anatomy along with the management required was reviewed. A special emphasis has been given on the correlation of radiological and endoscopic anatomy and an attempt has been made to standardize the management.

RESULTS

A total of 8 patients with age ranging from 2 months to 9 years were reviewed. Poor urinary stream and recurrent UTI was the commonest presentation. The anatomy of the anterior urethra on VCUG (voiding cystourethrogram) and Urethrocystoscopy was correlated. Two sets of patients were identified. In the first set, five cases on endoscopy had findings of the classical valve-like fold in the anterior urethra with immediate proximal dilation of the urethra giving the appearance of a 'pseudodiverticula' without any definite opening. In three of these cases, endoscopic findings correlated well with radiological findings of 'pseudodiverticula' in which dilated proximal urethra formed an obtuse angle with the ventral floor of the urethra. The other set of four patients had a 'true diverticula' on endoscopy with a well-defined mouth and prominent distal lip, correlating well with radiological findings of a 'true diverticula' forming an acute angle with the ventral floor of the urethra. One case on endoscopy had both an anterior urethral valve with a proximal 'pseudodiverticula and a large wide-mouthed bulbar 'true diverticula'. All the patients with classical valves were successfully treated using a resectoscope while two patients with 'true diverticula' were successfully managed by incising the distal lip. One of the patients previously managed for the posterior urethral valve (PUV) had both classical valves in the anterior urethra with proximal 'pseudodiverticula' and a bulbar 'true diverticula'. The AUV was ablated with a resectoscope while 'true diverticula' required diverticulectomy. All the patients after follow up of 3 months-8 years, were asymptomatic except the one with 'true diverticulum' who remained symptomatic after TUR (Trans-urethral resection) and required vesicostomy.

DISCUSSION

AUV and AUD both can cause obstructive uropathy. The proximal dilatation related to AUV cannot be labeled as a 'true diverticula', which lacks a classical orifice. The distal obstructing lip of 'true diverticula' should not be confused with a classical mucosal valve-like fold seen in AUV. While AUV and small AUD can be treated with endoscopic ablation, large diverticula as a result of wide spongiosal defects require surgical excision. A good understanding of their radiological and endoscopic anatomy is required to differentiate them and decide for appropriate management.

CONCLUSION

Based on our experience, AUV and AUD should be differentiated and should be considered as two separate entities.

A Rare Association of Posterior Urethral Valve with Anterior Urethral Valve, Large Anterior Urethral Diverticula, and Glanular Hypospadias

Background: Multiple urethral anomalies are rare with its own challenges in diagnosis and management. The double urethral obstructions are often missed as proximal obstruction can mask the early diagnosis of distal obstruction. We present a rare case of concomitant posterior urethral valve (PUV) and anterior urethral valve (AUV) with a large anterior urethral diverticula (AUD) and hypospadias. Case Presentation: An 11-month-old male child after fulguration of PUVs continued to have urinary symptoms. He was subsequently found to have distal urethral obstruction because of AUV and large anterior urethral bulbar diverticula. He also had associated glanular hypospadias. He was managed with endoscopic ablation of AUV and diverticulectomy. Conclusion: Concomitant PUV, AUV, AUD, and hypospadias is a rare occurrence. The diagnosis and management can be challenging in such cases with multiple anomalies. To avoid a misdiagnosis, a high index of suspicion, proper assessment of urethrogram, and detailed cystourethroscopy is required.

Anterior urethral valves - A rare but challenging congenital pathology

BACKGROUND

Anterior urethral valves (AUV) and associated anterior urethral diverticula (AUD) are a rare cause of congenital lower urinary tract obstruction. They occur 25-30 times less frequently than posterior urethral valves (PUV) and historically tend to have a less aggressive presentation and outcome. However, due to the low incidence, little is known about management and long-term prognosis.

OBJECTIVE

We aim to evaluate the outcomes after AUV valve ablation and compare this group to a previously studied PUV cohort.

STUDY DESIGN

In this IRB-approved study, we retrospectively identified all patients from 2002 to 2017 undergoing valve ablation using CPT code 52400. Charts were manually reviewed to identify AUV patients, their presenting symptoms, timing of diagnosis, pre and postnatal imaging findings, age at presentation and valve ablation, creatinine, recurrences, additional surgeries and follow-up. The AUV group was then compared to a previously studied PUV cohort of 104 patients from our institution.

RESULTS

Nine AUV patients were identified. Only four (44%) patients were diagnosed prenatally. Three (33%) patients were diagnosed neonatally, one for weak stream/dribbling and two for febrile UTIs. The remaining two patients were diagnosed at ages 3 and 4 due to dysuria and penile swelling with micturition. Patients presenting later in life had no evidence of renal dysfunction or VUR. All patients underwent primary TUR-AUV (1 laser, 4 cold knife, 4 cautery), but 55% had residual valves and/or diverticula identified on routine postoperative imaging in two patients and due to development of clinic symptoms in three patients. All five patients with recurrences underwent repeat endoscopic evaluation, and thereafter two patients required urethral reconstruction. In contrast, only 15% (16/104) of PUV patients required re-TUR (p = 0.01). At an average follow-up time of 4.24 years (range 0.6-11.4 years), 44% of patients had no evidence of CKD, and two patients (22%) had progressed to CKD of at least stage IIIA, compared to 21.4% in the PUV cohort at a mean follow-up of 2.3 years.

DISCUSSION

The overall incidence of AUV is low, making it difficult to characterize these patients definitively. However, despite a milder phenotype and later presentation in most AUV patients, they do require more aggressive surgical treatment for complete resolution of the AUV. Furthermore, the long-term renal outcomes appear more severe than previously reported.

CONCLUSIONS

The poorer outcomes of AUV patients both with respect to recurrence and long-term CKD indicate that close urologic follow-up is essential in this group.

PUVs are more common in boys with hypospadias

INTRODUCTION

The association between posterior urethral valves (PUVs) and hypospadias has previously been reported in case reports. After the identification of this twin pathology in a number of patients, a national retrospective review of all patients with this dual diagnosis was performed.

PATIENTS AND METHODS

All patients were identified in each centre from surgical databases of prospectively collated information on all surgical procedures. The medical notes were reviewed to ascertain demographics, the type of hypospadias, the mode of presentation of the valves and the outcome.

RESULTS

Twenty-eight patients who had the dual diagnosis of hypospadias and PUV between 2002 and 2017 in the four tertiary paediatric centres where specialist paediatric urology is undertaken in our country were identified. Most patients (n = 24) had the valves diagnosed after hypospadias surgery. The median age at the time of hypospadias surgery was 1.4 years (range 1-4 years). There were 12 proximal and 16 mid or distal hypospadias. The commonest presentation was with problems voiding after surgery in 14 cases with a further seven boys who had urinary tract infections. Four patients had a urethro-cutaneous fistula after repair that initiated further assessment. Two boys had distal dehiscence of their repair. There was one boy presented with new onset daytime incontinence. The median time of follow-up after valve incision surgery was 4.9 years (range 0.1-12.3 years). Twenty-two patients (three pre toilet training) had no ongoing urinary symptoms. Twenty-one boys have normal renal function with one patient in stage 3b chronic kidney disease. The incidence of this dual diagnosis in Scotland is estimated at one in 100 cases of hypospadias in the paediatric population.

CONCLUSION

The incidence of PUV in boys with hypospadias is estimated at 1% patients.

The preventive effect of a free radical scavenger on oxidative stress after the relief of partial bladder outlet obstruction in a rat model

Aims

To investigate the effect of a free radical scavenger (tempol) after relief of partial bladder outlet obstruction (pBOO) on bladder function in a rat model.

Methods

pBOO was induced in 50 eight-week-old female Sprague-Dawley rats and relieved 3 weeks later. The rats were divided randomly into 5 groups: sham-operated, tempol-treated for 1 week (Treat-1w) or 3 weeks (Treat-3w), and no treatment for 1 week (nonTreat-1w) or 3 weeks (nonTreat-3w). Awaken cystometrograms were obtained 1 or 3 weeks after relief according to the grouping. The bladders were isolated and weighed. H&E, Masson’s trichrome and TUNEL staining were used to analyze histological changes. The oxidative stress assessed using malondialdehyde. The expression of beta-3 adrenoreceptor was examined by Western blotting.

Results

The tempol-treated groups exhibited a significant decrease in the number of non-voiding contractions per voiding cycle (nonTreat-1w vs. Treat-1w, 1.18±0.82 vs. 0.36±0.40, P = 0.010; nonTreat-3w vs. Treat-3w, 1.51±0.69 vs. 0.23±0.25, P = 0.002). The thickness and collagen fiber deposition of the detrusor muscle layer was significantly decreased in the treated groups. Apoptosis detected was mainly observed in the urothelial cell layer, although the rate of apoptosis was significantly decreased in the treated groups (48.9±3.36% vs. 32.7±11.10%, P = 0.024; 25.8±4.67% vs. 15.7±9.83%, P = 0.314). The tempol-treated groups showed significant decreases in the MDA concentrations at both 1 and 3 weeks after relief. The expression of the beta-3 adrenoreceptor was increased in the tempol-treated rats.

Conclusions

Ischemic reperfusion injury after relief of pBOO caused histological and functional changes in the bladder. Free radical scavenger treatment prevented this oxidative stress.

Anterior Urethral Valve: A Rare But an Important Cause of Infravesical Urinary Tract Obstruction

Background

Urethral valves are infravesical congenital anomalies, with the posterior urethral valve (PUV) being the most prevalent one. Anterior urethral valve (AUV) is a rare but a well-known congenital anomaly. AUV and diverticula can cause severe obstruction, whose repercussions on the proximal urinary system can be important. Few cases have been described; both separately and in association with urethral diverticulum. The presentation of such a rare but important case led us to a report with highlighting its classic imaging features.

Case Report

We present a case report of AUV with lower urinary tract symptoms in a 6-year-old boy with complaints of a poor stream of urine and strain to void. Unique findings were seen on Retrograde Urethrography (RGU) and Voiding Cysto-Urethrography (VCUG), i.e. linear incomplete filling defect in the penile urethra and associated mild dilatation of the anterior urethra ending in a smooth bulge. On cysto-urethroscopy the anterior urethral valve was confirmed and fulguration was done.

Conclusions

Congenital anterior urethral valve is an uncommon but important cause of infravesical lower urinary tract obstruction that is more common in male urethra. It can occur as an isolated AUV or in association with diverticulum and VATER anomalies. Early diagnosis and management of this rare condition is very important to prevent further damage, infection and vesicoureteral reflux. AUV may be associated with other congenital anomalies of the urinary system; therefore a full evaluation of the urinary system is essential.