Anterior Urethral Valves Research Articles

A new spectrum of neonatal urethral pathologies in the era of early vesicoamniotic shunting?

Intrauterine vesicoamniotic shunting (VAS) was shown to affect survival of male fetuses with megacystis in suspected lower urinary tract obstruction (LUTO). Data on postnatal management are largely lacking. We aim to describe the pathologies diagnosed in children born after vesicoamniotic shunt placement in early pregnancy for megacystis. All newborns with previous intrauterine VAS treated in our institution were analyzed retrospectively. We evaluated the clinical spectrum of urethral pathologies. We also compared patients who received a shunt before the 17th gestational week with those who received it later. Between 2014 and 2023, 26 patients (all male) with a history of VAS for suspected LUTO were treated in our institution postnatally. Five fetuses with dislocated shunts underwent re-implantation in utero. Overall, premature birth before the 38th week of gestation was observed in 14 patients. Seven patients received a Harrison® shunt whereas 19 received a Somatex® shunt. Twelve patients required surgical shunt removal under general anesthesia due to shunt migration/embedding. Posterior urethral valves were found in 10/26 patients, 10/26 patients showed a urethral hypoplasia [Fig.1] and two patients had urethral duplications. In two patients, we identified a prune belly syndrome. One patient had posterior and anterior urethral valves. One patient had a high grade bilateral vesicoureteral reflux without LUTO. The 11 patients shunted early (before 17GW) showed a trend towards a higher proportion of urethral hypoplasia in the early shunt group (54% vs. 26%) without statistical significance. In our observation, patients treated with VAS had a noticeable high proportion of complex urethral pathologies such as urethral hypoplasia. These data should be taken into consideration for prenatal counselling of parents and planning of postnatal management.

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

ObjectivesTo 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). MethodsWe 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). ResultsThe 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). ConclusionAUV 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.

Assessment of clinical prognosis improvement in children with concomitant anterior and posterior urethral valves: A case series report.

Concomitant anterior urethral valves (AUVs) and posterior urethral valves (PUVs) is an extremely rare congenital urologic anomaly, which may be easily overlooked in the clinic. This study assessed the prognosis of children with concomitant PUVs and AUVs. The clinical data of inpatients with concomitant AUVs and PUVs in our hospital were collected from January 1983 to June 2022. The clinical manifestations, auxiliary inspection, and treatment were described in detail. In total, 6 cases of concomitant AUVs and PUVs in boys were found in our hospital, with ages ranging from 3 months to 9 years; the main clinical manifestation was abnormal urination. Four patients exhibited concomitant AUVs and PUVs preoperatively and underwent simultaneous anterior and posterior urethral valvotomy. Follow-up studies showed that 3 patients' clinical symptoms substantially improved with well-maintained renal function. One patient died of renal failure. In the other 2 patients, PUVs were initially identified and excised, but their clinical symptoms did not show substantial improvement. Following voiding cystourethrography (VCUG), the AUVs were found and obstructions were then completely relieved. However, 2 patients died of renal failure. If urinary symptoms cannot be substantially relieved after posterior urethral valvotomy, VCUG and cystoscopy should be repeated to shorten the interval between anterior and posterior urethral valvotomies to improve patient prognosis.

SUCCESSFUL TRANSURETHRAL RESECTION OF ANTERIOR URETHRAL VALVE IN CHILDREN : A CASE REPORT

Objective: This case report will present transurethral resection of double anterior urethral valves in tertiary hospital. Case(s) Presentation: A three-year-old boy who complained of a poor stream of urine and discomfort during micturition. From the radiological examination, the main finding was found on ultrasound (USG), with thickening of the bladder wall without upper tract abnormality. On panendoscopy, we found double anterior urethral valves at bulbar part and trabeculation in bladder. Discussion: The resection of the valves was performed and achieved an excellent result included normal stream of urine and there was no discomfort during micturition. Conclusion: Anterior Urethral Valve is a rare case that can be caused a lower urinary tract obstruction. A good understanding of AUV’s radiological and endoscopic anatomy is required to differentiate it from other diseases, essential to prevent further injury, and also to decide for appropriate management.
 Keywords: Anterior Urethral Valve, Congenital Anomaly, Urinary Obstruction

Anterior urethral valve with diverticulum in an adolescent

Abstract The anterior urethral valve (AUV) is a rare cause of obstructive uropathy in children; they are much rarer than posterior urethral valves. A 13-year-old male presented with obstructive and irritative lower urinary tract symptoms (LUTS). On urethrocystoscopy, an AUV with a diverticulum was noted in the ventral surface of the urethra. It was ablated endoscopically using the holmium laser. Postoperatively, the patient voided successfully without any immediate complications. AUV with diverticulum may occur in adolescents. Endoscopic holmium laser ablation of the valve and the diverticulum is associated with good outcome.

Congenital anterior urethral diverticulum in children: case series and review of the literature

BackgroundCongenital anterior urethral diverticulum (CAUD) is a rare condition in children. This condition can present at any age; however, it is more commonly identified in infants and older children. The patient may present with difficulty in micturition, dribbling of urine, poor urinary stream, or urinary tract infection. Children with large anterior urethral diverticulum with poor spongiosal support may also complain of cystic ventral penile swelling during micturition.MethodsIn this series, we report seven such cases of congenital anterior urethral diverticulum treated over a period of 12 years (2008–2020). All cases presented to the Pediatric Surgery Department with dysuria, dribbling of urine, recurrent urinary tract infection, and/or fluctuant ventral penile swelling. They were further evaluated with retrograde urethrography with micturating cysto-urethrogram and cysto-urethroscopy.ResultsThree cases had anterior urethral valves that were managed by cystoscopic fulguration of valves. Surprisingly, all these three cases had concomitant posterior urethral valves, while the other four cases presented with relatively larger and saccular anterior urethral diverticulum required excision of the diverticulum and primary urethral reconstruction.ConclusionsThe cases with congenital anterior urethral diverticulum secondary to anterior urethral valves may also be associated with posterior urethral valves as seen in our case series. Surgeons should be aware of this association, and both valves should be fulgurated in the same sitting. A larger and saccular anterior urethral diverticulum requires excision and urethroplasty as a definitive procedure.

Congenital diverticulum of the anterior urethra of non-obstructive genesisS

Congenital diverticulum of the distal urethra is extremely rare in urological practice, there are isolated descriptions of it in the literature, as a result every clinical observation is of interest. The aim of this study is demonstration of a rare clinical observation congenital diverticula of the distal urethra without infravesical obstruction (meatostenosis) in a teenager.
 The article describes a clinical case of treatment of congenital diverticula of the anterior urethra without signs of infravesical obstruction in a 13-year-old teenager.
 A case of surgical treatment of congenital urethral diverticulum without infravesical obstruction in a 13-year-old teenager is presented. Diverticulectomy with suture of the urethra was performed with good anatomical and functional results.
 A distal urethral diverticulum of a congenital nature is extremely rarely noted as an isolated condition without an anterior urethral valve or another variant of infravesical obstruction. The method of choice is to perform diverticulectomy with suturing of the urethra.

A Case Report with a Late Dıagnosis of Anterior Urethral Valves

Congenital anomalies are the leading pathologies that cause obstructive uropathy by causing stenosis in the lower urinary tract. Among these disorders, anterior urethral valves (AUV) are rarely seen and diagnosed based on the clinician’s suspicion. Ultrasound findings, voiding cystourethrography (VCUG), and urethroscopy are used for diagnosis. AUV can lead to serious clinical consequences, including end-stage renal disease due to late diagnosis and treatment. In our case, unilateral kidney loss occurred due to recurrent urinary infections and nephrolithiasis. Our patient, who could not be diagnosed until the period of nephrectomy necessity, was found to have an AUV as a result of cystoscopy.

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

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. Presentation, investigations, management, concomitant posterior urethral valves (PUV) and pre-operative characteristics predisposing to long-term poor renal outcome were assessed. 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 > 1mg/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 (>1mg/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 60ml/kg/min. 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 60ml/kg/min was associated with pre-operative elevated serum creatinine, trabeculated bladder, non-dilated posterior urethra, and bilateral impaired renal function on scans.

Lack of consensus in atypical congenital obstructive urethral lesions in children: Snapshot of the web-based ObsCUre (obstruction to the child urethra) study.

Atypical Congenital Obstructive Urethral Lesions (ACOUL) are uncommon causes of urethral obstruction in children. They include Cobb's collar or Moorman's ring, Type III posterior urethral valve (PUV), congenital urethral narrowing and anterior urethral valves. This study is aimed to evaluate the knowledge and current practice amongst clinicians attending to ACOUL. An international online case based questionnaire was performed. A survey was administered to members of international urological societies. It included 22 clinical questions on cases with ACOUL (14 questions suitable for statistical analysis) using cases of Type I PUV as controls. Two sets of paired questions evaluated change in opinion(s) after additional information was provided. One hundred twenty-one participants responded with 71% reporting exposure of less than 5 cases per annum. In questions regarding diagnosis between 11.6% (14/121) and 21.5% (26/121) of participants identified the ACOUL as PUV. Among them, 66% of respondents agreed on ACOUL's causative role in urethral obstruction. Gini coefficient was consistently lower for ACOUL compared to PUV: diagnosis (mean 0.33 vs. 0.44) and prognosis (0.23 vs. 0.43). High intra-rater concordance (kappa 0.420.57) was observed for paired questions-a mean of 5.79% (7.44% and 4.13% for questions 10 and 12, 16 and 17, respectively) of participants changed their answers from an alternate diagnosis to the correct diagnosis of ACOUL after viewing endoscopic images. High variation in management of ACOUL was noted (Gini 0.51). This global snapshot survey identified substantial inconsistency among clinicians dealing with ACOUL. Although rarely encountered in clinical practice, better overall education of ACOUL is warranted.

Case Report: Neonatal Urinary Ascites Without Hydronephrosis: A Rare Case of Anterior Urethral Valve and Diverticulum in Preterm Newborn

The deformation of congenital obstruction of the anterior urethra is rare in male infants. The anterior urethral valve (AUV) and diverticulum are not common causes of distal urethral obstruction, which may be significant but difficult to diagnose in time. We describe a premature infant who was diagnosed with AUV as part of a diverticulum in the anterior urethra and was presented as massive urinary ascites without hydroureters and hydronephrosis. After indwelling abdominal tube and urinary catheterization, the infant’s massive ascites were resolved, while urethral obstruction had successful treatment by Holmium laser. We suggest that the presence of urinary ascites in fetuses and neonates should be considered as a warning against urinary malformations.

Outcome of boys with posterior urethral valves from a single tertiary hospital in Singapore.

Posterior urethral valve (PUV) is the most common congenital cause of bladder outflow obstruction in male infants. Despite timely treatment, renal damage can still occur in the long-term leading to chronic kidney disease (CKD). A retrospective review of all PUV patients in a single tertiary institution between April 1998 and July 2019 was conducted to analyze their presentations, management and outcomes. Long-term renal function, radiologic scans and somatic growth were evaluated. A total of 16 patients were included in this study. Two patients who defaulted all follow-ups were excluded. Seven patients (43.7%) presented in the antenatal period; four patients (25%) presented in the neonatal period and five patients (31.3%) presented in the post-neonatal period. Primary transurethral fulguration of valves was done in 13 patients, while three had vesicostomies as the primary procedure. Three patients had associated anterior urethral valves (AUV), which were treated endoscopically. Nine boys had additional procedures for diversion and undiversion, VUR, non-functioning kidney and clean intermittent catheterization. Ten patients had urodynamic studies performed, of which eight patients received anticholinergic therapy. Eleven patients had DMSA scans, of which three patients had a normal study and eight patients showed unilateral reduced function. Four patients were diagnosed with CKD on long-term follow-up duration over 5 years. All patients were shown to have good somatic growth. Patients with PUV can suffer from complications despite primary treatment. In our small cohort, a quarter of our patients developed CKD on follow-up. Thus, patients need long-term follow-up to optimize bladder and renal function.

Fetal urinary ascites and spontaneous bladder rupture—A rare case of anterior urethral valves: A case report

Fetal urinary ascites and spontaneous bladder rupture—A rare case of anterior urethral valves: A case report

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

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

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. This study is a retrospective review of cases diagnosed with anterior urethral obstruction and correlation of radiological and endoscopic anatomy of AUV and AUD. 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. 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. 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. Based on our experience, AUV and AUD should be differentiated and should be considered as two separate entities.

A new born with anterior urethral diverticulum and posterior urethral valve

A new born with anterior urethral diverticulum and posterior urethral valve

Anterior urethral valves – A rare but challenging congenital pathology

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

Anterior Urethral Valve – A Commonly Misdiagnosed Entity in Adolescent Boys

Anterior urethral valves are a rare cause of obstructed voiding in adolescent children and are often unheard by adult urologists. In this case report, we discuss the management of two adolescent patients who were referred to us with obstructive voiding symptoms with a diagnosis of neurogenic bladder and posterior urethral valves respectively but on evaluation were found to have anterior urethral valves. This article highlights the need for considering anterior urethral valve as an important differential diagnosis in children and adolescents presenting with obstructive voiding symptoms so as to avoid delay in diagnosis and management in young boys.

Comparison of clinical course of patients with both posterior and anterior urethral valves vs those with anterior urethral valve alone

To compare the clinical course of patients with concomitant posterior urethral valve (PUV) and anterior urethral valve (AUV) vs those with AUV alone, to know if associated PUV increases morbidity. Retrospective review of 24 AUV patients (2002-2018). Results were compared between boys with both PUV and AUV (Group A) vs AUV alone (Group B). Symptoms started from birth (n=6)/2 mths age (n=1) [group A]; birth (n=10)/2 mths–9 yr age (median 1 yr 3 mo) (n=7) [group B]. Most common symptom: poor urinary stream, dribbling. Age at presentation to us: 11dy-12yrs with blood Urea (mg/dL) A: 17-194 (median 23), B: 11-108 (median 23) Creatinine (mg/dL): A: 0.38-13.6 (median 0.7), B: 0.2 – 2.2 (median 0.65). Previously undergone circumcision (n=1), urethral dilatation (n=2), internal urethrotomy (n=1), PUV fulguration (n=2). Urethral diverticulum present in A: 4 (57.1%), B: 9 (52.9%). Valve location: between Bulbar/proximal penile urethra junction, Proximal/mid-penile urethra junction & Distal penile urethra: A: 4 (57.1%),3 (42.9%), 0 and B: 9 (52.9%), 1 (5.9%), 7 (41.2%) respectively. Renal function [nuclear scan] showed bilateral normal, bilateral impaired, unilateral non/ poorly functioning A: 4 (57.1% with bil slow drainage in 2), 2 (28.6%), 1 (14.3%) and B: 10 [58.9% with bil VUR (1),L II VUR(1)], 0, 7 (41.2%) respectively. Patients underwent fulguration and/or urethroplasty/diverticulum excision. Follow up: 6 mo-15 years. Total procedures specifically for valves 31 (average 1.4/patient) and overall 47 interventions (average 1.95/patient) including nephroureterectomy etc. Follow up: Although stream normalized in all, 3 required urinary diversion (A: n=2; B: n=1). Renal failure: A: 2 (28.6%), B: 1 (5.9%) (with associated urethral duplication) Bladder instability: A: 3 (42.9%), B: 6 (35.3%). Unless there is a visible swelling, there is a delay in diagnosis and referral to pediatric urologists in boys with AUV in spite of a majority being symptomatic since birth. Valve location in distal urethra is more common in isolated AUV. Patients with associated PUV presented earlier and had higher morbidity. All AUV patients need long term follow up.

Anterior Urethral Valves-An Unusual Cause of Hydrops Fetalis

Anterior Urethral Valves (AUV) are a less common cause of lower urinary tract obstruction than Posterior Urethral Valves (PUV). AUV may present with symptoms of mild to severe obstruction and renal impairment at any age. Here we report possibly the first case of AUV presenting as hydrops fetalis. This late preterm infant presented with postnatal presentation of hydrops leading to respiratory failure. There was marked ascites, a left-sided inguinal hernia and hypospadias. Immune and most non-immune causes of hydrops were ruled out. Mild hydronephrosis with poor renal function and dependency on bladder catheterization for urinary output remained. While the ascites gradually improved, the bladder outlet obstruction persisted without evidence for PUV. Voiding cystourethrogram (VCUG) led to suspicion of AUV which was confirmed and managed with cystoscopic valve ablation. We review the physiology, clinical presentations, treatment and outcomes of AUV in the context of a differential diagnosis based on neonatal ascites values.