The management of posterior urethral valves by initial vesicostomy and delayed valve ablation

Role of vesicostomy in the management of posterior urethral valve in Sub-Saharan Africa

OBJECTIVE

To review the role of vesicostomy in the management of posterior urethral valve (PUV), in neonates and infants, given the limitations for endoscopic treatment in this setting.

METHODS

A review of 35 patients who presented with posterior urethral valve over a 10-year period. Demographic and clinical information were prospectively recorded on a structured pro forma, and the data extracted analysed using SPSS 11.0.

RESULTS

The 35 boys were aged 3 days to 10 years (median 3 weeks). Twenty-three (65.7%) had a vesicostomy (age range 3 days-3 years, median 3 weeks). The mode of presentation was poor urinary stream 15 (65.2%), urinary retention 4 (17.4%), and renal failure 6 (26.1%). Main findings were palpable bladder 23 (100%), hydronephrosis 4 (17.4%). Abdominal ultrasound confirmed hydronephrosis and thickened bladder wall, and voiding/expressive cystourethrogram confirmed dilated posterior urethra and vesicoureteric reflux in all 23 patients. Complications following vesicostomy were stoma stenosis 1 (4.3%), bladder mucosal prolapse 1 (4.3%), perivesicostomy abscess 1 (4.3%); there was no mortality. Following vesicostomy, 10 (43.5%) patients had excision of the valves and vesicostomy closure at age 2-8 years (median 4 years). They are well, with normal renal ultrasonographic findings, bladder capacity range 115-280 ml, and normal urea, serum electrolytes, creatinine, at 3 years of follow up. Thirteen (56.5%) are still awaiting valvotomy but have remained well and with normal ultrasonographic renal findings.

CONCLUSION

Vesicostomy is a useful temporising mode of urinary diversion in neonates and infants with posterior urethral valve (in the absence of unobstructed upper tracts) when facilities for endoscopic valve ablation are not readily available.

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.

Surgical complications of posterior urethral valve ablation: 20 years experience

PURPOSE

The aim of the study was to report the surgical complications that may occur during or after primary ablation of posterior urethral valve (PUV) in a large number of cases treated using different modalities.

MATERIALS AND METHODS

We retrospectively reviewed a database of 291 patients with PUV treated by primary valve ablation from 2 separate centers between 1987 and 2006. Primary valve ablation was performed in all patients regardless of serum creatinine level or upper tract configuration. A hot loop resectoscope was used in 122 patients, cold knife urethrotome in 108, a hook diathermy electrode in 18, a diathermy coagulation bugbee electrode in 20, whereas stripping using a Fogarty catheter was performed in 23.

RESULTS

The follow-up duration ranged from 1.5 to 20 years (median, 6.5). Early postoperative complications occurred in 22 patients (7.5%). The most common complication was urinary retention in 16 patients (5.5%). Urinary extravasations occurred in 3 cases, significant hematuria from urethral bleeding occurred in 2, and obstructive anuria developed in 1 patient. Most of cases were treated conservatively. Urethral strictures developed in 6 patients (2%) mainly after endoscopic loop resection (4/6). All were treated by visual internal urethrotomy and urethral dilatation with successful results without the need of open urethroplasty.

CONCLUSIONS

Primary valve ablation seems to be safe and is associated with low rate of postoperative complications. All the complications could be treated conservatively. Urethral stricture may occur after valve ablation in a minority of cases and can be successfully treated endoscopically. Loop resection is associated with more strictures.

Primary ablation of posterior urethral valves in low birth weight neonates by a visually guided fogarty embolectomy catheter

PURPOSE

In low birth weight neonates primary ablation of posterior urethral valves represents a particular difficulty. The tiny caliber of the urethra presents a challenge for even the smallest commercially available pediatric resectoscope. Transurethral ablation by wired electrodes is difficult due to the narrow field of neonatal scopes with slow irrigation and restricted maneuverability. A Fogarty embolectomy catheter under fluoroscopic control does not allow direct visual assessment, and can be a lengthy procedure with numerous manipulations at the radiology suite. We describe a hybrid technique for primary valve ablation in neonates using a Fogarty catheter working retrograde under direct visual guidance of a neonatal cystoscope.

MATERIALS AND METHODS

A total of 17 low birth weight newborns (median 2,100 gm, range 1,760 to 2,690) underwent primary valve ablation using a 2Fr Fogarty catheter working through a 7.5Fr neonatal cystoscope with an offset lens. Both components were withdrawn as a single unit to avulse the valve leaflets under vision. Vesicoureteral reflux was present in 13 patients (76%) involving 24 renal units. A voiding cystourethrogram was performed 8 to 10 weeks postoperatively to delineate adequate decompression of the posterior urethra and mark the end point of the study in evaluating the efficiency of the technique.

RESULTS

There were no immediate perioperative complications. Three patients died of causes unrelated to the procedure, leaving 14 boys (21 refluxing units) for evaluation. Voiding cystourethrogram revealed effective decompression of the posterior urethra with adequate drainage in all but 1 remaining patient (93%) due to a persistent left leaflet. Of 21 refluxing units reflux resolved in 6 (29%), was downgraded in 10 (48%) and remained unchanged in 5 (24%).

CONCLUSIONS

In low birth weight neonates primary valve ablation by a visually guided Fogarty catheter ensures effective disruption of the valvular obstructive mechanism. The technique maintains the transurethral visual standard and avoids the difficult manipulation of wired electrodes in a restricted field. It is devoid of radiation exposure and its simplicity enables safe performance at the neonatal intensive care unit, where the support needs of this fragile subset of patients are optimally provided for.

Posterior urethral valve: Outcome of antenatal intervention

INTRODUCTION AND AIM

Antenatal treatment of obstructive uropathy, although widely performed, remains controversial. This study evaluated the long-term outcome of managing patients with posterior urethral valves (PUV), highlighting the effect of antenatal vesicoamniotic shunt placement for patients who underwent fetal surgery.

METHODS

The medical records of 58 patients with PUV were retrospectively reviewed from June 1998 to June 2004. On the basis of prenatal assessment of sonographic findings and serial urinary electrolytes and protein measurements, patients were divided into two groups: group 1 comprised patients who had antenatal vesicoamniotic shunt placement whereas group 2 comprised patients who underwent postnatal surgical correction of PUV. Their outcomes and long-term results were evaluated.

RESULTS

Patients were followed up from 6 months to 6(1/2) years (mean 3.9 years). Group 1 included 12 patients who had vesicoamniotic shunt placement and were confirmed postnatally to have PUV. Four patients out of 12 died (33.3%); three out of the eight living patients had perinatal complications. Of the eight living patients, three (37.5%) underwent valve ablation and five (62.5%) underwent urinary diversion (three vesicostomies and two cutaneous ureterostomies). Renal function returned to normal in only four patients (50%). Radiological abnormalities (hydronephrosis and/or reflux) resolved in three (37.5%) patients, was downgraded in one (12.5%) patient and persisted in four patients (50%). Group 2 included 46 patients who were treated postnatally. Thirty-five patients (76%) underwent primary valve ablation, while 11 (24%) underwent urinary diversion (seven vesicostomies, four cutaneous ureterostomy and one pyelostomy). Renal function returned to normal in all patients who underwent valve ablation, except in three, while renal function returned to normal in only three of 11 patients who underwent urinary diversion. Radiological hydronephrosis and/or reflux resolved in 28 patients (60.9%), was downgraded in six patients (13%) and persisted in 12 patients (26.1%).

CONCLUSIONS

Antenatal vesicoamniotic shunt placement makes no difference to the outcome and long-term results of patients with PUV and debate about its efficacy on renal outcome remains. Primary valve ablation is the keystone of treatment for patients with PUV that might achieve the primary goal of nephron preservation. The lowest creatinine concentration in the first year of life is the most appropriate predictor of future renal function.

Prenatal hydronephrosis

Hydronephrosis is the most common genitourinary tract anomaly identified on prenatal ultrasound studies. Ureteropelvic junction obstruction accounts for approximately 50% of the cases of prenatally detected hydronephrosis. Postnatal evaluation allows for the identification of the cause and further management. Rarely, in utero intervention may be performed for severe oligohydramnios associated with hydronephrosis. Prenatal consultation with a pediatric urologist is useful in decreasing parental anxiety and facilitating postnatal management.

LONG-TERM FOLLOWUP OF BILATERAL HIGH (SOBER) URINARY DIVERSION IN PATIENTS WITH POSTERIOR URETHRAL VALVES AND ITS EFFECT ON BLADDER FUNCTION

PURPOSE

Although valve ablation is the treatment of choice in patients with posterior urethral valves (PUV), temporary high (ureterostomy) diversion remains controversial. In this study we evaluated the effect of bilateral Sober high urinary diversion on renal and bladder function.

MATERIALS AND METHODS

We retrospectively reviewed the records of 36 patients with PUV who underwent bilateral Sober-type diversion. Following valve ablation urodynamic studies were done in all patients after diversion and repeated after ureterostomy closure. The mean duration of diversion was 55 months. Vesicoureteral reflux (VUR), renal dysplasia, serum creatinine during followup and urodynamic parameters were recorded.

RESULTS

All patients underwent endoscopic valve ablation. Renal function impairment at the end of followup was present in 15 patients. Renal dysplasia was found in 10 patients, while VUR was present in 16 at the time of the first urodynamic studies. Urodynamic studies after ureterostomy closure showed well preserved bladder capacity or compliance in 80% and 69% of cases, respectively. About a third of patients showed increased capacity and normal compliance. Univariate analysis showed that VUR, urinary tract infection and renal dysplasia significantly correlated with impaired renal function. On multivariate analysis renal dysplasia was an independent prognostic factor for poor prognosis.

CONCLUSIONS

In patients with PUV temporary high diversion of the Sober type does not have a negative influence on bladder function. It immediately releases high intrarenal pressures but only improves renal function temporarily and may contribute to postpone the time of end stage renal failure. Renal dysplasia dictates long-term renal outcomes in this group.

Initial management of complex pediatric disorders: prunebelly syndrome, posterior urethral valves

Prunebelly syndrome and posterior urethral valves are conditions of detrusor dysfunction associated with antenatal urethral obstruction. The resultant severe hydroureteronephrosis and renal dysplasia initiate a sequence potentially leading to renal failure. This article reviews clinical features and explores neonatal evaluation and treatment for both conditions. A comprehensive approach to initial management aimed at optimal renal preservation and bladder rehabilitation is proposed.

DOES MODE OF TREATMENT AFFECT THE OUTCOME OF NEONATAL POSTERIOR URETHRAL VALVES?

PURPOSE

A prospective study on the outcome of posterior urethral valves (PUV) was performed. The data analyzed were whether the modality of treatment (fulguration vs vesicostomy) affected renal function and somatic growth, and whether the presence of vesicoureteral reflux (VUR) and abnormal serum creatinine levels affected somatic growth.

MATERIALS AND METHODS

A total of 45 consecutive neonates were diagnosed and treated for PUV with fulguration (24) or vesicostomy (21) between 1997 and 2003. Postoperative stable creatinine values, renal function and somatic growth were recorded. Well tempered renal scans using diethylenetetraminepentaacetic acid were performed during the first and second years of life at followup. Standard anthropometric techniques and statistical methods were used to compute distance statistics for body weight and crown-heel length at age intervals of 3 months for year 1 and 6 months for year 2.

RESULTS

Of the patients 9 were lost to followup and 6 died in the first year of life due to renal failure. Preoperative and postoperative mean serum creatinine was 1.6 +/- 1.5 and 0.7 +/- 0.2 mg/dl, for the fulguration group and 1.7 +/- 1.5 and 0.9 +/- 0.7 mg/dl, respectively, for the vesicostomy group. In 10 patients renal function deteriorated or there was no improvement after treatment. With the advancement of age neonates with PUV showed normal increase in body weight and crown-heel length. Those with VUR were significantly shorter compared to neonates with no VUR at the end of year 2 of life (p <0.05). Patients with creatinine less than 1 mg/dl had significantly greater increase in body weight (at 3 and 6 months) as well as crown-heel length (at 3 and 9 months), respectively (p <0.05). Physical growth of the fulguration and vesicostomy groups remained substantially lower than that of their normal healthy counterparts. Newborns treated with vesicostomy did not have any breakthrough urinary tract infections. Although patients treated with vesicostomy were lighter and smaller initially (p <0.05), they were comparable to those treated with fulguration at the end of 2 years, thus demonstrating catch-up growth.

CONCLUSIONS

Our prospective study demonstrated that transurethral fulguration and vesicostomy are equally effective for neonatal valves and achieve similar renal function. Both groups showed retarded growth compared to healthy counterparts. Somatic growth was delayed by serum creatinine greater than 1.0 mg/dl and the presence of VUR. Vesicostomy seemed to help neonates catch-up the growth deficit in the first 2 years of life.

[Vesicostomy in children. Our experience with 43 patients]

INTRODUCTION AND OBJECTIVES

Cutaneous vesicostomy (CV) is a choice temporary urinary diversion technique for patients with upper urinary tract (URT) dilation, secondary to vesical o infravesical disease. The objective of this study is to share our experience in children undergoing such diversion, analysing its efficacy to prevent urinary infections, improve or resolve the ureterectasia, and stabilise or improve renal function; in short the functional and morphological recovery of URT.

MATERIAL AND METHODS

43 children, mean age 2.5 years (range: 1 month-14 years) with ureterohydronephrosis grade IV-V, persistent urinary infection and/or renal function impairment underwent cutaneous vesicostomy (Blocksom's technique in 36 and Lapides' procedure in the rest). Thirty subjects had neuropathic bladder (26 with secondary vesicoureteral reflux), 7 massive primary vesicoureteral reflux, and 6 posterior urethral valve.

RESULTS

All children (100%) with neurogenic bladder (30 cases), showed improvement of ureteral-pyelic-calyceal ectasia after the diversion, and 90% improved renal function with disappearance of vesiculoureteral reflux in 65%. Augmentation cystoplasty with gut was performed in 12 patients during vesicostomy closure, using Mitrofanoff's type diversion in 5 of them. The same continent diversion with cecal appendix was used in another 7 children as the only procedure. The remaining 11 children still retain their vesicostomy. In 5 of the 7 children with primary vesicoureteral reflux, the reflux disappeared and so the vesicostomy was closed. Reflux correction during the same surgical procedure was required for the other 2 children. Of the 6 children with posterior urethral valves, 2 received a renal transplant, one is in waiting list and the rest (50%) maintain an acceptable renal function. In the first year of follow-up, 4 patients developed symptomatic urinary infection that later disappeared. The rest had occasional asymptomatic bacteriuria that required no treatment. Complications included vesical prolapse due to ostomy in 4 patients, lithiasis in 3 and stomal stenosis in 2.

CONCLUSIONS

We consider vesicostomy to be the choice urinary diversion technique in cases of common section obstruction and/or non-obstructive ureterohydronephrosis in new-borns who do not improve with conservative treatment.

The clinical and radiological findings in boys with endoscopically severe congenital posterior urethral obstruction

OBJECTIVE

To assess the clinical and radiological spectrum in boys with endoscopically severe posterior urethral obstruction, as there is a broad clinical spectrum which does not always correlate with the cystoscopic findings.

PATIENTS AND METHODS

Between December 1990 and July 2000, 39 boys (newborn to 12 years old) underwent cystoscopy to investigate a urethral anomaly and were found to have a severe obstructing posterior urethral membrane. Their voiding cystograms, video-recorded cystoscopy and presenting signs were reviewed.

RESULTS

Of the 39 boys assessed, a voiding cystogram and presenting signs were available in 36. Of these 36 boys, three cystograms were initially reported as normal, eight showed posterior urethral dilatation as the only feature, and the remainder had more severe bladder and upper tract changes. Fourteen were diagnosed after identifying antenatal hydronephrosis, four presented with voiding dysfunction, one with haematuria and 17 were found after investigation of a urinary tract infection.

CONCLUSIONS

This study shows that a congenital posterior urethral membrane that has only a small posterior defect endoscopically can have a wide clinical and radiological spectrum. The difference in outcome may be caused by variations in the response of the bladder to the obstruction, resulting in a different effect on the upper tracts.

Obstructive nephropathy in children: long-term progression after relief of posterior urethral valve

BACKGROUND

Approximately one third of children with end-stage renal disease have the illness because of urinary tract malformations, obstructive uropathy, and hypoplasia/dysplasia. The significant drop in infant mortality from obstructive uropathies in recent decades, attributable to prenatal diagnosis with renal ultrasonography and coordinated surgical and medical care, necessitated a reevaluation of the long-term outcome.

METHODS

To that end, we examined the long-term progression of obstructive nephropathy after neonatal relief of posterior urethral valves in our center over a span of 21 years, with diagnosis and care being provided by the same pediatric and urology team.

RESULTS

The 10 consecutive cases of posterior urethral valves represented 7% of all patients with congenital malformative uropathies seen over this period. The following procedures were performed: primary valve ablation (90%) and vesicostomy (40%). Seventy percent of patients progressed to end-stage renal disease over a (mean +/- standard error of the mean) follow-up of 11.3 +/- 2.1 years. The linear plot of the log of the inverse of serum creatinine versus time suggested unrelenting progression. The rate of progression was rapid after serum creatinine exceeded 5 mg/dL but the rate was slow and steady from serum creatinine of 1.5 to 5 mg/dL.

CONCLUSIONS

To test the effect of a therapeutic intervention to ameliorate the rate of progression, this steady and prolonged progression of 0.5 mg/dL per year between serum creatinine concentration of 1.5 to 5 mg/dL would seem the optimal study.

Applications of the KTP laser in the treatment of posterior urethral valves, ureteroceles, and urethral strictures in the pediatric patient

PURPOSE

We describes our experience using the potassium titanyl phosphate (KTP)-532 laser in treating posterior urethral valves, ureteroceles, and urethral strictures in the pediatric patient.

METHODS

A retrospective chart review was performed from 1987 to 1997 on a total of 33 pediatric patients who underwent retrograde endoscopic treatment for posterior urethral valves (PUV), ureteroceles (UC), and urethral strictures using a KTP-532 laser.

RESULTS

Overall, our success rate was excellent in the treatment of valves and ureteroceles. With a mean follow-up of three years in the PUV group, no urethral strictures of micturation abnormalities were seen. The majority of ureteroceles were decompressed and only half of our patients required and additional procedure. Our experience with urethral strictures, however, was not as promising. All of these patients ultimately required open urethral reconstruction.

CONCLUSION

The desirable thermal characteristics of the KTP laser, along with minimal complications and the availability of delicate pediatric endoscopic instruments have made this operation optimally suited for treating posterior urethral valves and ureteroceles in infants. However, the advantages for treating urethral strictures in children with the laser still remains to be established.

Comparative urodynamic findings after primary valve ablation, vesicostomy or proximal diversion

PURPOSE

There is little known about the effect of urinary diversion on the bladder of children with posterior urethral valves. There is a fear that diversion may result in contracted noncompliant bladders. We wished to compare urodynamic parameters in patients who underwent primary ablation of posterior urethral valves and in those who underwent diversion in the form of vesicostomy or pyelostomy.

MATERIALS AND METHODS

Urodynamics were done in 32 boys with a history of posterior urethral valves divided into 3 groups based on initial treatment: 1) transurethral valve ablation; 2) cutaneous vesicostomy, subsequent closure and valve ablation, and 3) proximal cutaneous pyelostomy, subsequent reconstitution and valve ablation.

RESULTS

Patients who underwent initial diversion with vesicostomy or pyelostomy had bladders with larger functional capacity, better compliance and less instability. Chronic renal failure developed in 25% of the patients who underwent primary valve ablation and 33% of those who underwent diversion. Average period of diversion in vesicostomy and pyelostomy patients was 25 months.

CONCLUSIONS

Based on our findings temporary diversion does not seem to damage bladders. On the contrary, placing a damaged bladder at rest may help to improve bladder function. Bladder function following reconstitution correlated poorly with ultimate outcome and progression to renal failure. While we do not recommend temporary diversion as the treatment of choice for patients with posterior urethral valves, we believe that when chosen as treatment, it can be safely performed with little risk of further damage to the bladder.

Urethroscopy in small neonates with posterior urethral valves and ureteroscopy in children with ureteral calculi

OBJECTIVES

To describe our recent experience using a 6.9F cytoscope in the fulguration of posterior urethral valves (PUVs) in premature neonates and distal ureteroscopy with stone extraction in children.

METHODS

Fulguration of PUVs was performed in 3 premature neonates born at 34 to 36 weeks' gestation with weights of 2480 to 2900 g. The PUVs were fulgurated during a single endoscopic procedure using a 6.9F cystoscope and a 3F bugbie electrode. In addition, 11 children (8 girls, 3 boys; mean age, 11.1 years; range 5 to 16) with symptomatic calculi underwent 15 distal ureteroscopic procedures using the 6.9F cystoscope.

RESULTS

In the neonates with fulguration of PUVs, vesicostomy, the only reasonable alternative, was avoided, and each infant now voids with an excellent stream 3 to 16 months later, without evidence of stricture or residual valves. In the children with distal ureteroscopy, the ureteral calculi were retrieved using a 3F four-wire stone basket. With one exception, distal ureteroscopy was performed without dilation of the ureteral orifice. Extracorporeal shock-wave lithotripsy (ESWL) was not recommended because of stone position and difficult radiographic visualization. Nine children were rendered stone free with one procedure. Two procedures were required in 1 child and three in another. In both cases, ureteral edema was present, and the stone was embedded in the ureteral wall. One child underwent separate procedures for bilateral calculi. In all cases general anesthesia was used, with a mean duration of 63 minutes (range 28 to 96). Temporary ureteral stenting was performed in 10 (93%) patients, and 9 (81%) were discharged home on the same day or the next morning. A mean follow-up period of 8.5 months (range, 0.5 to 22) has failed to show any problems related to ureteral stricture or injury.

CONCLUSIONS

Endoscopic fulguration of PUVs is now possible in small neonates and is minimally invasive compared with vesicostomy. Distal ureteroscopy with stone retrieval should be considered in children, especially those with calculi that are not suitable for ESWL.

Prenatally detected posterior urethral valves: is gestational age at detection a predictor of outcome?

Between 1982 and 1992, 67 boys with posterior urethral valves were managed at our hospital, including 32 (48%) in whom the condition was detected prenatally. We examined the relationship between gestational age at detection and outcome at a median followup of 3.9 years (range 4 months to 10 years). Detection at or before 24 weeks of gestation predicted a poor outcome with 9 of 17 patients (53%) dead or in chronic renal failure at followup. Of the cases detected later in pregnancy only 1 had a poor outcome (p = 0.01). All of the cases detected after 24 weeks of gestation had had normal second trimester scans. Growth parameters for boys in the early and late detection groups were not statistically different. However, there was a significant association between renal failure and growth with 67% versus 14% having heights less than the 3rd percentile (p = 0.05). Respiratory distress at birth predicted a poor outcome, while the presence of palpable abdominal abnormalities or vesicoureteral reflux failed to predict outcome.

Urethral valve incision using a modified venous valvulotome

Anterior and posterior urethral valves have been treated with a variety of methods. The gold standard for treatment of posterior urethral valves is direct vision transurethral fulguration with the patient under general anesthesia. We report a bi-institutional experience using an adapted venous valvulotome to incise the obstructing valve leaflets. During the last 4 years 15 patients were treated, 4 with anterior and 11 with posterior urethral valves. There were no complications associated with this technique, and we believe that this is a safe and simple treatment option.

Cutaneous vesicostomy in the young child: indications and results

With newer methods of managing lower urinary tract pathology in the young child, the role of cutaneous vesicostomy may be changing. This prompted a review of 50 consecutive patients treated with initial vesicostomy at our center over ten-year period. These children underwent vesicostomy diversion at a median age of 5.8 months and, of the 34 vesicostomies which have been subsequently closed, for a median duration of twenty-five months. Our indications agree with series reported previously and include patients with meningomyelocele, posterior urethral valves, or other forms of congenital or acquired lower urinary tract anomaly or dysfunction, along with complicating factors such as vesicoureteral reflux, recurrent infections, and/or renal deterioration. However, we also have identified a major group--those with primary gross vesicoureteral reflux--not previously included in detail. Follow-up averaged thirty-eight months. Improvement or stabilization of upper urinary tracts was achieved in over 90 percent of cases, and this trend continued after vesicostomy closure. As well, cutaneous vesicostomy allowed ureteral dilation to normalize, decreasing the degree of reflux and need for subsequent ureteral tapering and reimplantation at closure. Finally, though our stomal revision rate of 20 percent is high, modified techniques are being pursued.

Radiographic and serologic correlates of azotemia in patients with posterior urethral valves

A retrospective statistical analysis with a minimum followup of 10 years was done on 102 patients who presented in early childhood with posterior urethral valves. All patients were treated with initial bladder drainage. Factors correlating with the development of renal failure were evaluated. No patient with a normal kidney on 1 side had renal failure. Calculated glomerular filtration rate was significantly higher in patients who retained adequate renal function (80.7 +/- 17.8 ml. per minute per 1.73 m.2), as compared with those who had renal failure (18.6 +/- 9.6 ml. per minute per 1.73 m.2). Patients with renal failure also had a significantly higher serum creatinine level at stabilization (2.0 +/- 0.8 mg./dl.) than those who had adequate renal function (0.5 +/- 0.2 mg./dl.). The presence of bilateral high grade vesicoureteral reflux, hydronephrosis and nonfunction was significantly higher in patients with renal failure. Patient age at presentation was not a significant factor. These data represent a guideline for the prognosis and management protocols of infants with dilated upper urinary tracts and posterior urethral valves.

Influence of initial therapy on progression of renal failure and body growth in children with posterior urethral valves

Children with posterior urethral valves are at high risk for renal failure and growth retardation. It has been proposed that the type of initial surgical treatment (that is primary ablation versus high diversion) can affect the outcome of children with posterior urethral valves. We evaluated 43 children with posterior urethral valves treated and followed at our hospital from 1975 to 1990 (17 since birth and 26 referred patients). A total of 19 patients was treated by a high urinary diversion, (high urinary diversion group), 19 were treated by primary fulguration and 2 by vesicostomy (fulguration and vesicostomy group), and 3 underwent fulguration and unilateral diversion (mixed treatment group, excluded from study). The clinical outcome and body growth were compared for the high urinary diversion, and fulguration and vesicostomy groups. A normal stature (above the 25th percentile) was reached by 4 patients (21%) from the high urinary diversion group and 11 (52%) in the fulguration and vesicostomy group. This difference was not statistically significant. In contrast, renal function was predictive of body growth: 73% of the children with normal serum creatinine and 20% of the children with renal failure achieved a normal stature (p less than 0.05). One patient from the mixed treatment group died of pulmonary hypoplasia. We conclude that the type of primary surgical treatment (fulguration and vesicostomy or high urinary diversion) did not influence progression of renal failure or body growth in children with posterior urethral valves. Regardless of the surgical or medical treatment, which can greatly influence mortality, renal failure developed in almost 50% of the children with posterior urethral valves.