EDITORIAL: POSTERIOR URETHRAL VALVES AND THE 11th COMMANDMENT

Prolonged Indwelling Urethral Catheterization as Minimally Invasive Approach for Definitive Treatment of Posterior Urethral Valves in Unstable Premature Babies

Premature newborns with posterior urethral valves (PUV) may present with medical conditions taking priority over definitive surgical care. We encountered three of such cases who underwent initial bladder decompression via transurethral catheterization and waited 2-3 weeks until they were fit enough for voiding cysto-urethrography to confirm PUV. An unexpected good urinary flow and negligible residual urine volume were documented during micturition, suggestive of valve disruption induced by insertion and prolonged duration of indwelling urethral catheter drainage. Cystoscopy documented non-obstructing remnant leaflets. Non-operative treatment may be considered as a viable alternative therapeutic option for PUV in tiny babies facing prolonged intensive care unit stay.

Posterior urethral valve

BACKGROUND

Posterior urethral valve (PUV) is a significant cause of morbidity, mortality and ongoing renal damage in children. It accounts for end-stage renal disease in a proportion of children. This article aims at highlighting the current trend in the management of boys with posterior urethral valve.

DATA SOURCES

PubMed/Medline and bibliographic search for posterior urethral valve was done. Relevant literatures on presentation, pathology, evaluation, management and outcomes of PUV were reviewed.

RESULTS

PUV which is increasingly diagnosed prenatally presents a spectrum of severity. The varied severity and degree of obstruction caused by this abnormality depend on the configuration of the obstructive membrane within the urethra. The decision to intervene prenatally is dependent on gestational age, amniotic volume, and renal function of fetal urine aspiration. Identification of the patients who may benefit from early intervention remains inconclusive. Endoscopic ablation of the valve is the gold standard of treatment but use of Mohan's valvotome and other modalities are invaluable in developing countries where endoscopic facilities are limited. Proximal urinary diversion may result in poor bladder compliance and should be reserved for patients with persisting or increasing upper urinary tract dilatation, increasing serum creatinine or inappropriate instruments. The behavior of the bladder and its subsequent management after valve ablation may influence the long-term renal outcome in PUV patients.

CONCLUSIONS

The care of children with PUV continues to improve as a result of earlier diagnosis by ultrasound, developments in surgical technique and meticulous attention to neonatal care. The ultimate goal of management should be to maximize renal function, maintain normal bladder function, minimize morbidity and prevent iatrogenic problems.

Role of alpha adrenergic blocker in the management of posterior urethral valves

PURPOSE

To evaluate the effect of Terazosin (alpha1 adrenergic blocker) on bladder emptying in children with posterior urethral valves.

MATERIALS AND METHODS

Forty-two children with significant post void residual urine after valves ablation were placed on Terazosin ranging from 0.25 to 2 mg. Post void urine at the commencement and at follow up was monitored with abdominal ultrasound.

RESULTS

Post void residual urine significantly reduced in 40 patients (95%) who were put on Terazosin. Mean pretreatment PVR was 15.7 ml and mean PVR at the last follow up was 2.4 ml (P = 0.000). This was a reduction of 85% in the pretreatment post void residual urine volume. All the patients had improvement in urinary stream. One patient reacted to Terazosin with hypotension necessitating its withdrawal. Mean follow up was 17 months.

CONCLUSION

Terazosin has proved to be safe and results in significant improvement in bladder emptying in our patients with posterior urethral valves. Randomized controlled trial and long-term follow up are necessary to further define the role of alpha1 adrenergic blocker therapy in children with posterior urethral valves. This study will become the justification for such a study.

Posterior urethral valves: a single center experience over 7 years

PURPOSE

To evaluate the outcome of management of 65 consecutive children with posterior urethral valves (PUV) using two techniques of valves ablation.

METHODS

Retrospective review of 65 consecutive children with PUV managed over 7 years. There were two groups based on the methods of valves ablation: either Mohan's urethral valvotome for primary cases or electrocautery fulguration for patient with previous intervention. Serum electrolyte and serial post-void residue (PVR) were monitored in outpatient clinic. Alpha-blockers were started in all cases with high PVR. Management outcome of patient who had valves ablation with Mohan's valvotome were compared with those who had endoscopy fulguration.

RESULTS

Sixty-one patients were regular on follow-up with a median age at presentation of 45 days. Nineteen (31%) patients were diagnosed antenatally. There were 32 refluxing ureters in 26 patients; 58 (95%) underwent primary valve ablation (37 with Mohan's urethral valvotome, 21 fulguration). Reflux disappeared in 10 (36%) refluxing ureters. There were five (8.2%) urethral strictures (all five in fulguration group), eight residual valves (four in each group), and three recurrent urinary tract infections. Three patients had nephrectomy and one patient had renal transplantation. There was no death. The mean serum creatinine for all the patients at presentation and at the last follow-up were 1.2 and 0.5 mg/dl, respectively (P = 0.031). At follow-up, mean PVR of valvotome group was 2.5 ml and fulguration group was 2 ml (P = 0.282). The median follow-up period was 24 months.

CONCLUSIONS

Early ablation of PUV and detailed attention to bladder management gives a better outcome. With Mohan's valvotome incidence of stricture is less and incidence of residual valves is comparable to endoscopic ablation of PUV.