Obstructing anterior urethral valves in children

Isolated Posterior Urethral Valves and Anterior Urethral Valves With and Without Concomitant PUV: Matched Cohort Study at a High-risk Pediatric Center

OBJECTIVE

To compare postnatal outcomes of anterior urethral valves (AUV) and posterior urethral valves (PUV) patients to evaluate for potential differences between these conditions, given that AUV with or without concomitant 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 >.05). Only 15.4% of AUV cases presented prenatally compared to 72.0% of PUV cases (P = .0016), leading to delayed postnatal management in AUV patients (P = .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 = .0120 and P = .0302) than the AUV ± PUV group, with only 1 patient requiring RRT (P >.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 = .0331) which also demonstrated more patients with persistent HN (P = .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 suggest potential differences in presentation and less severe postnatal outcomes in AUV compared to PUV patients.

Congenital anterior urethral valves and diverticula

AIMS OF STUDY

Anterior urethral valves (AUVs) are rare congenital anomalies causing lower urinary tract obstruction in children. The present study highlights the clinical approach in identifying the condition and its treatment options.

METHOD

Single centre, retrospective study of children.

RESULT

Over a 16 year duration, 14 children were diagnosed with AUVs and diverticula with a mean age of 15 months. Clinical features included straining at micturation and a palpable penile swelling. Diagnosis was confirmed with voiding cystourethrogram and cystoscopy. An open surgical procedure was performed in 12 cases and endoscopic intervention done in one. On follow up 13 patients showed restoration of a normal voiding stream and normal renal function. One child died of chronic renal failure due to a delayed presentation, severe back-pressure changes, urinary ascites, and urosepsis. One patient developed a small urethrocutaneous fistula that healed spontaneously.

CONCLUSION

AUV, though rare, should be recognizable due to the combination of a poor urinary stream and visible swelling in the ventral aspect of penis. Open surgical excision is the method of choice, and the outcome is excellent.

LEVEL OF EVIDENCE

Level IV.

Congenital anterior urethral valves and diverticulum: A case series and association with posterior urethral valves

INTRODUCTION

There is limited data regarding long-term results and associated complications in patients with anterior urethral valve (AUV) and diverticulum (AUD). We retrospectively reviewed AUV/AUD cases managed by us between the year 2002-2020.

MATERIAL AND METHODS

Presentation, investigations, management, concomitant posterior urethral valves (PUV) and pre-operative characteristics predisposing to long-term poor renal outcome were assessed.

RESULTS

There were 27 patients [AUV (n = 11); AUD (n = 16)] with 5 having concomitant PUV. All presented with poor urinary stream and dribbling at a median age of 1-year (5 days-12 years). More patients with AUD (9 of 16, 56.3%) especially with concomitant PUV presented at ≤1-year-age as compared to those with AUV (4 of 11, 36.4%). Concomitant PUV and AUD cases (n = 3) had characteristic micturating cystourethrography (MCUG) features. (Fig. 1A) Retrograde urethrography delineated the valve and distal urethra dimensions better (Fig. 1B, C). Urethral hypoplasia distal to the valve (n = 4) urethral duplication (n = 1) were associated (Fig. 1D). Syringocele was ruled out in proximal AUD by absence of filling defect on MCUG and appearance of urethral walls on urethrocystoscopy. Serum creatinine > 1 mg/dL (n = 5), trabeculated bladder (n = 12), and vesicoureteral reflux (VUR) (n = 12) was noted at presentation. Diverticulum/valve excision (n = 13, 48.2%), fulguration alone (n = 12, 44.4%) and primary urinary diversion (n = 2, 7.4%) were performed. Follow up (range:3 mo-19 years), showed deranged renal function tests (n = 6), VUR (n = 4), impaired renal function on scans (n = 8), and lower urinary tract dysfunction (n = 7). Outcome with and without associated PUV was similar. Long term results were better in AUV compared to AUD. Pre-operative raised serum creatinine (>1 mg/dL), trabeculated bladder, non-dilated posterior urethra on MCUG and bilateral impaired renal function on scans had significant association with follow up eGFR less than 60 ml/kg/min.

CONCLUSIONS

Co-existing PUV and AUD present earlier and have specific imaging findings. In proximal AUD, possibility of syringocele should be kept in mind, as they have similar presentation and imaging. Concomitant PUV did not alter prognosis. Secondary effects on bladder and renal function were more with AUD. Follow up eGFR less than 60 ml/kg/min was associated with pre-operative elevated serum creatinine, trabeculated bladder, non-dilated posterior urethra, and bilateral impaired renal function on scans.

A Large Congenital Anterior Urethral Diverticulum in a 14-Month-Old Boy

Congenital anterior urethral diverticulum is a rare condition causing lower urinary tract obstruction in children. It usually arises from the ventral aspect of the anterior urethra, mostly located at the penoscrotal junction. We report a case of a 14-month-old baby boy who presented with a soft ventral swelling over the distal penile urethra, difficulty in passing urine, and a history of recurrent febrile urinary tract infections. A retrograde urethrogram revealed a large distal anterior urethral diverticulum. He underwent diverticulectomy and primary repair with no post-operative complications. The treatment of these depends on the size of the diverticulum and the degree of obstruction. In cases of a large anterior urethral diverticulum, open diverticulectomy and primary repair are recommended.

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.

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.

Congenital anterior urethral diverticulum presenting as a scrotal mass in a two-year-old child

Here, we describe a case of congenital anterior urethral diverticulum (CAUD) in a two-year-old boy, who presented with right inguinoscrotal swelling that mimicked a spermatic cord cyst or hydrocele. Accurate diagnosis was made intraoperatively by retrograde urethrography. Open diverticulectomy and primary urethroplasty were performed for its management. The clinical presentation, diagnosis, and the management of this rare condition is discussed.

Anterior urethral valves without diverticulae: a report of two cases and a review of the literature

Two unusual cases of anterior urethral valves (AUV) without diverticulae are presented. The first case is a male child born with prenatal diagnosis of bilateral hydronephrosis. On cystoscopy, iris-like diaphragm valves were encountered about 3 mm distal to the skeletal sphincter. In the second case, an 18-month-old male child was investigated for recurrent febrile urinary tract infections and obstructed urinary symptoms. Cystoscopy confirmed the presence of slit-like valves 5 mm distal to the skeletal sphincter. Fulguration of the AUVs was performed in both cases. It may be worthwhile to review all cases of anterior urethral obstruction collectively and re-categorize them appropriately to include the unusual AUVs without diverticulum in that classification.

Congenital anterior urethral valve with or without diverticulum: a single-centre experience

INTRODUCTION

Congenital anterior urethral valves (AUV) are rare and can occur as an isolated entity or in association with proximal diverticula. Diagnosis may be overlooked and ideal treatment is not standardized when both the valve and diverticulum are simultaneously present. We present our experience of congenital AUV.

MATERIAL & METHODS

From January 2007 to June 2012 a retrospective review of the medical records of 7 cases of AUV was performed.

RESULTS

Three patients were diagnosed as isolated AUV while four presented with associated diverticula. The age of presentation ranged from 10 months to 6 years. Weak voiding stream and dribbling were the most common symptoms. Renal function was found to be deranged in two patients (28%). Hydro-ureteronephrosis was present in three boys (42%) and reflux was present in one patient. Post-void residual volume was >20 ml (mean 55 ml) in all children. Transurethral holmium laser fulguration was carried out on isolated AUV or AUV with small diverticula. Open resection and reconstruction or plication was performed in patients with AUV and proximal large (>3 cm) diverticula. Surgical outcome was successful in all patients except for occurrence of urethrocutaneous fistula in one patient.

CONCLUSIONS

In isolated AUV or valve with associated small diverticulum, transurethral holmium:YAG laser ablation is the treatment of choice. Primary excision and repair or plication are preferred if a large diverticula has formed. Eventual outcomes of AUV are good if irreversible changes have not been established.

Anterior urethral valve and diverticulum in a neonate with febrile urinary tract infection

Anterior urethral valve is a rare congenital anomaly that can cause obstructive uropathy. Herein, we report a case of an anterior urethral valve that led to the development of febrile urinary tract infection in a neonate.

Anterior urethral valves and diverticulum

Anterior urethral valves with associated urethral diverticulum is a rare but important cause of infravesical obstructive uropathy in children. This condition can be a cause of significant morbidity and can even lead to end-stage renal disease. This rare condition should be included in the differential diagnosis while evaluating male infants with infravesical obstructive uropathy.

Anterior urethral valves in children: an uncommon multipathogenic cause of obstructive uropathy

INTRODUCTION

Anterior urethral valves (AUVs) are uncommon congenital anomalies causing urethral obstruction in boys.

PATIENTS AND METHODS

Medical records of 13 children were reviewed retrospectively. Each patient (pt) was evaluated with voiding cysto-urethrogram (VCUG) and renal ultrasonography. Pts older than 5 years performed an uroflowmetry. Serum creatine was determined in all children.

RESULTS

All pts had difficulty in voiding and eight had recurrent urinary tract infection. Renal function was normal in all pts. VCUG showed filling of Cowper's duct in a pt. In a case, a vesicoureteral reflux was discovered. Uroflowmetry showed a flat trace in all cases. Transurethral endoscopic resection of the valves was carried out in 11 children while open resection was necessary in two children. At serial follow-up, all pts remain symptom-free and uroflowmetry documented regular pattern.

DISCUSSION

Anterior urethral valves are rare lesions that may create problems at different stages. Some AUVs may result from the obstruction distal lip of a ruptured syringocele. Improvements in endoscopic equipment allow for minimally invasive transurethral resection. Large diverticula are best managed with open diverticulectomy and reconstruction. In newborns with severe altered urinary tract drainage, particularly in low birth-weight infant, a vesicostomy may be necessary.

Anterior and posterior urethral valves with subcoronal hypospadias: a rare association

Association of the anterior and posterior urethral valve is a rare congenital anomaly which can lead to various urinary tract symptoms. An 8-year-old boy was referred by his primary care physician for urinary dribbling, straining at micturition, and recurrent febrile urinary tract infection since the age of 2 years. Clinically, the bladder was palpable; both testes were normal, and, in addition, he had a subcoronal hypospadias. Diagnosis was confirmed by retrograde urethrogram and voiding cystourethrogram (micturating cystourethrogram) and urethroscopy. Cystoscopic ablation of both valves was done by electrocautery hook using low current at 5 o'clock and 7 o'clock directions. He voided with good flow and to completion. Urinary dribbling had completely subsided and renal function was normal at a follow-up period of 36 months with freedom from recurrent urinary tract infection. Both the anterior and posterior urethral valves develop from different embryological sources; thus, this association is rare. A case with this association has not been reported previously in the literature.

Anterior urethral valves: an uncommon cause of obstructive uropathy in children

PURPOSE

Anterior urethral valves (AUV) are rare entities generally described in case reports. They are an uncommon cause of lower urinary tract obstruction in children and can be difficult to diagnose. In the present study, we present our experience in four children with AUV along with a literature review.

MATERIALS AND METHODS

We retrospectively identified four children with AUV presented between 1998 and 2005 at age 4-9 years.

RESULTS

Hematuria, urinary tract infection and weak voiding stream were the most common symptoms. Voiding cystourethrography (VCUG) confirmed the diagnosis of AUV. On cystourethroscopy, cusp-like valves in the anterior urethra were seen in all children. Transurethral endoscopic resection of the valves was carried out in three children using a pediatric resectoscope. In one child with a massive anterior urethral diverticulum, open resection of the valve, diverticulectomy and urethroplasty were performed. All patients were cured, none had complications as a result of surgery, and all reported a normal urinary stream at follow-up.

CONCLUSIONS

Children with poor stream and recurrent infections should be evaluated carefully and anterior urethral valves should be considered in differential diagnosis of obstructive lesions.

Urodynamic changes in patients with anterior urethral valves: before and after endoscopic valve ablation

PURPOSE

To retrospectively review a series of children with anterior urethral valves (AUV), with emphasis on patterns of urodynamic change and long-term outcome of endoscopic treatment.

PATIENTS AND METHODS

We reviewed the medical records of eight patients who had undergone thorough radiological and urodynamic exams before and after treatment. The diagnosis of AUV was based on radiological imaging and confirmed by urethrocystoscopy. The valves were ablated through either transurethral fulguration or resection. The upper urinary tracts were studied by renal scan and ultrasonography before and after the procedure. Bladder function was assessed urodynamically 3 months after surgery. Uroflowmetry was performed as soon as the children were toilet trained.

RESULTS

Endoscopic ablation of AUV was successful in all cases and no surgical complications occurred. The initial symptoms resolved in all boys. VUR disappeared in two out of three patients, and five children had bladder trabeculation that was resolved after surgery. The final outcome was successful in seven patients (88%). The major urodynamic dysfunction was bladder hypercontractility that resolved following valve ablation. The mean maximum voiding detrusor pressure (P(detmax)) decreased from 213.2+/-17.9 cmH(2)O to 80.7+/-9.9 cmH(2)O, 6 months after treatment (P<0.001). None of the patients had low-compliant bladder, detrusor instability or myogenic failure. The voiding pattern in all toilet-trained patients was staccato and of an interrupted shape prior to surgery, but changed to a normal bell-shaped voiding pattern following valve ablation.

CONCLUSION

AUV should be considered in the differential diagnosis of patients presenting with infravesical obstruction. We recommend endoscopic valve ablation as the treatment of choice.

Anterior urethral valve associated with posterior urethral valves

The association of anterior urethral valve (AUV) with posterior urethral valve (PUV) is rare. A 7-month-old infant was presented at a district hospital with episodes of acute pyelonephritis. He was treated medically and a voiding cystourethrogram (VCUG) confirmed bilateral vesico-urethral reflux. The presence of concomitant AUV and PUV was not recognized. He underwent several surgical procedures, which failed. He had reflux recurrence following two antireflux procedures. He had urinary retention after each operation, which was managed by vesicostomy and perineal urethrostomy. At the age of 3.5 years, he was referred to our paediatric urology clinic. Noticing the AUV and PUV in the past VCUG, the valves were fulgurated. Urodynamic study before and 3 months after valve ablation showed a high voiding pressure. VCUG 6 months following ablation showed no reflux, but several uroflowmetric studies showed a staccato and interrupted pattern. Empirical treatment with an alpha-blocker was started. One year after treatment, a repeat VCUG showed no reflux. Uroflowmetry and urodynamic studies returned to normal. The perineal urethrostomy was closed. The child was asymptomatic after 9 months of follow up.

Spontaneous resolution of prenatal megalourethra

Urethral obstruction in the fetus is rare. Whereas proximal obstruction most often is caused by posterior urethral valves, causes of distal obstruction are less well recognized and can include urethral atresia, urethral webs, and anterior urethral valves. These latter abnormalities can lead to urinary retention, incontinence, enuresis, spontaneous bladder rupture, and megacystis. The authors present 3 fetuses (gestational age range, 18 to 20 weeks) in whom distal urethral obstruction was suspected by prenatal ultrasonography in the absence of a demonstrable lesion. All 3 experienced spontaneous resolution of the presumed obstruction. On follow-up, all are alive and well with no adverse genitourinary tract sequelae. No postpartum intervention was required.

Congenital anterior urethral diverticulum with stone: a unique presentation

We report the case of an 18-month-old boy with a congenital anterior urethral diverticulum containing an elliptical stone at the penoscrotal junction, with urinary retention and extravasation of urine. Initial management consisted of an open suprapubic cystostomy. Three weeks after resolution of extravasation, diverticulectomy with removal of the stone by urethroplasty was done after ruling out associated obstructing anterior urethral valves.

Anterior urethral valves and diverticula

Obstructive lesions of the anterior urethra (valves, diverticula) are rare and can be difficult to diagnose. One recent case led us to review existing international reports; there are case histories for 260 patients over a 20-year period. The anatomical interpretation of these lesions is far from being unequivocal but many authors clearly distinguish between valves and diverticula, the basic difference being in the contiguity between the anomaly and the corpus spongiosum. Where the clinical presentation depends on age, the diagnosis depends essentially on voiding cysto-urethrography, which must image the whole urethra. Generally, the treatment for valves is simple, consisting of endoscopic resection. For diverticula it is not always necessary or desirable to remove the diverticulum; if there is a well-formed distal obstructing lip, removing it may be enough to cure the obstruction.

Megalourethra and urethral diverticula

Megalourethra and urethral diverticula encompass a diverse group of congenital and acquired urethral defects. The appropriate management of these anomalies relies on a keen appreciation of phallic anatomy and an understanding of urethral embryology. A thorough history and physical examination--including a careful evaluation of the urinary tract--is necessary to identify associated congenital anomalies. Finally, satisfactory surgical management demands meticulous attention to surgical technique.

Anterior urethral valve as a cause of end-stage renal disease

Although posterior urethral valves are predominant as a cause of obstructive uropathy in children, anterior urethral valves may also appear as the underlying etiologic factor in end-stage renal disease that results from obstruction. Two cases are presented of anterior urethral valve patients that were admitted with end-stage renal disease. The first case was successfully treated with diverticulectomy and urethral reconstruction in preparation for renal transplantation. The second case, however, had been on cystostomy drainage for 6 years and also had a contracted bladder. A more extensive lower urinary tract reconstruction was delayed. Children with poor stream and recurrent infections should be evaluated carefully and anterior urethral valve or diverticula should be considered in differential diagnosis of obstructive lesions.

Anterior urethral valves: a rare cause of infravesical obstruction in children

PURPOSE

The aim of this study was to report the clinical presentation, mode of diagnosis, and treatment of patients with anterior urethral valves (AUV), a rare congenital anomaly causing infravesical obstruction in children.

METHODS

Three patients with anterior urethral valves were admitted in the Pediatric Urology Unit at The Children's Hospital, Lahore, Pakistan, during the period 1997 through 1998. Main clinical features included difficulty in voiding, dribbling of urine, incontinence, poor urinary stream, hematuria, and urinary tract infections. The diagnosis was confirmed by voiding cysto-urethrogram (VCUG) in 2 patients and retrograde urethrogram in 1 patient. A total of 4 valves were found; 1 patient had 2 valves. Two patients had associated vesico-ureteric reflux. Endoscopic resection was performed in all patients.

RESULTS

Postoperatively, all patients were able to pass urine with good stream. At 9 to 24 months' follow-up, all patients remain well and asymptomatic.

CONCLUSIONS

Although rare, AUV must be considered in the differential diagnosis of lower urinary tract obstruction. They present with all degrees of severity depending on the age of patient and the degree of obstruction. A properly performed and carefully interpreted VCUG is essential for diagnosis. Transurethral resection is the treatment of choice.

An algorithm for the management of anterior urethral valves

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Anterior urethral valves. A case report

Anterior urethral valves are rare anomalies which cause obstructive uropathy in the lower urinary tract of young men. We discuss our illustrative case and review the English medical literature in order to analyze the clinicopathologic spectrum. We propose a hypothesis of embryology of this lesion and present guidelines for its management.

Anterior urethral valves in the fossa navicularis in children

Anterior urethral valves are an uncommon cause of lower urinary tract obstruction in children. They have been noted in the bulbous (40 per cent) and penile (30 per cent) urethra, and at the penoscrotal junction (30 per cent). None has been reported in the fossa navicularis. We encountered 3 cases in which anterior valves were located in the glanular urethra. This entity may be misdiagnosed as meatal stenosis and without a high index of suspicion it might be overlooked. The combination of distal obstruction and a normal urethral meatus should lead one to suspect this entity. Observation of the voided stream is extremely helpful in the diagnosis, since voiding urethrography often fails to include the penile tip and urethroscopy of the distal urethra often is unsatisfactory. Treatment can be performed either transurethrally or by excision through the meatus.

The role of vesicostomy in the management of anterior urethral valves in neonates and infants

We performed vesicostomy as the initial form of management in 2 male newborns and 1 infant with anterior urethral valves associated with proximal urethral diverticula and bilateral hydronephrosis. Prompt improvement in the degree of hydronephrosis was noted after vesicostomy in all 3 patients along with improvement in renal function in 2 who had presented with renal insufficiency. Subsequently, 2 patients have undergone vesicostomy closure and transurethral valve fulguration, and 1 also required ureteral reimplantation for persistent vesicoureteral reflux. The use of vesicostomy in the newborn period rather than transurethral fulguration prevented the potential complications of urethral stricture and inadequate valve resection that can occur owing to the small size of the neonatal urethra. Furthermore, a period of vesicostomy drainage before eventual ureteral reimplantation for severe vesicoureteral reflux obviated the need for ureteral tailoring.

Urethral stricture

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Voiding dysfunction in children

Superficially, the causes of voiding difficulties in children may seem quite simple, but a thorough understanding of the anatomy physiology and neurology of normal and abnormal lower urinary tract function is necessary in uncovering the etiology of often seemingly siple complaints. An ectopic ureter, neurogenic bladder, urinary tract obstruction, or simple urinary tract immaturity, for example, can all cause a child to present with the complaint of "wetting." A familiarity with all the possible causes of voiding dysfunction is required to distinguish significant from insignificant symptoms. While a "wait and see" attitude often results in the spontaneous resolution of a problem such as simple nocturnal enuresis, the misdiagnosis of a severe disorder, such as urinary outflow obstruction, may permit the insidious development of irreversible renal failure. Our purpose in writing this monograph was not to provide a comprehensive guide to the diagnosis of voiding dysfunction in children, but rather to enhance the clinician's appreciation of the complexity of these problems. Our hope is that the perspective that we have provided will obviate the diagnostic and therapeutic exaggeration of insignificant voiding complaints, while assuring that the presence of significant lesions is not overlooked.