Anterior Urethral Valves Research Articles

Anterior Urethral Valve in an Adolescent with Nocturnal Enuresis

The anterior urethral valve (AUV) is a rare congenital urethral anomaly that can lead to variable urinary tract symptoms. We report on a 13-year-old boy with AUV who was referred from a primary care physician for nocturnal enuresis. AUV was disclosed by videourodynamic study and confirmed by simultaneous retrograde cystourethroscopy and antegrade urethroscopy. The AUV was ablated by neodymium:yttrium-aluminum-garnet contact laser at the 5-o'clock and 7-o'clock directions. A postoperative videourodynamic study depicted a patent urethra, a good maximal flow rate, and improved bladder capacity. His nocturnal enuresis had completely subsided at a follow-up period of longer than 24 months.

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 2O to 80.7 ± 9.9 cmH 2O, 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 valves in children: A possible association between anterior urethral valves and Cowper’s duct cyst

To elucidate the pathophysiology of congenital obstruction of the anterior urethra and to investigate the association between anterior urethral valves and syringocele. Three boys with congenital obstruction of the anterior urethra diagnosed at our department between 1997 and 2004 were analyzed retrospectively. All three boys had congenital obstruction in the bulbar urethra. The presenting symptoms and age of each patient were varied. Whereas continuity between Cowper's duct and the diverticulum was not demonstrated radiographically in all of the boys, it was speculated endoscopically in all. Our series has suggested a possible association between anterior urethral valves (diverticulum) and syringocele. These congenital anomalies of the anterior urethra should be considered in the differential diagnosis of obstructive lesions of the urinary tract.

Anterior urethral valves associated with hypospadias

An association of coronal hypospadias with meatal stenosis and anterior urethral valves is described in this report. A combination of double obstruction in anterior urethra may overshadow the expression of proximal one.

P06.07: Endoscopic creation of fetal urethrostomy for obstructive uropathy resulting from anterior urethral valves

Objective: Fetal megacystis in the first and second trimesters of pregnancy is an indication for diagnostic vesicocentesis. Our goal is to assess the effectiveness of early vesicocentesis as a treatment option of megacystis. Materials and Methods: From 1995 to 2005, 18 pregnancies were identified with early fetal megacystis. Fetal biometry, morphology, amniotic fluid, bladder size and volume were evaluated. Karyotype was available in 6 cases (6/18 = 33%). Vesicocentesis was performed in 8 fetuses (8/18 = 44%). Fetal urine biochemical markers were determined after each vesicocentesis. Results: Megacystis was never isolated: 6 cases (6/18 = 33%) demonstrated oligohydramnios or anhydramnios, 5 fetuses (5/18 = 28%) presented renal dysplasia, 4 had renal hyperechogenicity (4/18 = 22%), 3 had mild pyelectasis (3/18 = 17%), 1 ureteral dilatation (1/18 = 5.5%) and 1 a polymalformative syndrome with sacrococcigeal mielomeningocele (1/18 = 5.5%). Any case had chromosomal abnormalities. In 3 fetuses (3/8 = 37.5%) biochemical markers indicated a good fetal kidney function, in the remaining 5 fetuses (5/8 = 62.5%) a poor renal prognosis was suggested. In 2 cases (2/8 = 25%) pregnancy proceeded with normal amniotic fluid volume and a normal-sized urinary bladder with normal dynamics. In 3 cases (3/8 = 37.5%) megacystis recurred and a second vesicocentesis was performed. In the remaining 3 cases (3/8 = 37.5%): 2 terminations of pregnancy were performed and 1 spontaneous abortion occurred. Conclusions: Fetal vesicocentesis in the first trimester of gestation is a useful treatment option in case of megacystis. Fetal vesicocentesis is a minimally invasive procedure that can be life-saving if performed in early pregnancy.

Anterior Urethral Valves

We studied the clinical presentation and management of four patients with anterior urethral valves; a rare cause of urethral obstruction in male children. One patient presented antenatally with oligohydramnios, bilateral hydronephrosis and bladder thickening suggestive of an infravesical obstruction. Two other patients presented postnatally at 1 and 2 years of age, respectively, with poor stream of urine since birth. The fourth patient presented at 9 years with frequency and dysuria. Diagnosis was established on either micturating cystourethrogram (MCU) (in 2) or on cystoscopy (in 2). All patients had cystoscopic ablation of the valves. One patient developed a postablation stricture that was resected with an end-to-end urethroplasty. He had an associated bilateral vesicoureteric junction (VUJ) obstruction for which a bilateral ureteric reimplantation was done at the same time. On long-term follow-up, all patients demonstrated a good stream of urine. The renal function is normal. Patients are continent and free of urinary infections. Anterior urethral valves are rare obstructive lesions in male children. The degree of obstruction is variable, and so they may present with mild micturition difficulty or severe obstruction with hydroureteronephrosis and renal impairment. Hence, it is important to evaluate the anterior urethra in any male child with suspected infravesical obstruction. The diagnosis is established by MCU or cystoscopy and the treatment is always surgical, either a transurethral ablation or an open resection. The long-term prognosis is good.

Neonatal abdominal wall urinoma due to rupture of anterior urethral diverticulum

An anterior urethral valve with diverticulum is an uncommon cause of congenital urethral obstruction and urinary extravasation compared with a posterior urethral valve. We report a neonate presenting with an abdominal wall urinoma caused by rupture of an anterior urethral diverticulum. Urine drainage via urethral catheter was effective to resolve the abdominal urinoma. Voiding cystourethrogram performed 6 months after an endoscopic incision of the distal margin of the diverticulum revealed a normal urethra with smooth voiding. To our knowledge, no similar case has been reported previously.

Holmium Laser Ablation of Anterior Urethral Valves: Case Report

To report a novel method for treating anterior urethral valves in children using the holmium:YAG laser. A 2-year-old boy presented with symptoms of urinary-outflow obstruction. A micturating cystourethrogram (MCUG) revealed an abrupt narrowing of the penile urethra. At cystourethroscopy, an anterior urethral valve without a diverticulum was visible. This was ablated endoscopically using the Ho:YAG laser. The child voided successfully and was discharged the next day. Repeat MCUG 6 months later revealed a normal-caliber urethra. Holmium:YAG laser ablation of anterior valves is a minimally invasive treatment modality that provided a satisfactory result and appears to be very promising.

Anterior Urethral Valves and Diverticula in Children: A Result of Ruptured Cowper's Duct Cyst?

No AccessJournal of UrologyUrological Survey: Pediatric Urology1 Oct 2005Anterior Urethral Valves and Diverticula in Children: A Result of Ruptured Cowper's Duct Cyst? Douglas A. CanningM.D. Douglas A. CanningDouglas A. Canning More articles by this author View All Author Informationhttps://doi.org/10.1097/S0022-5347(01)68666-XAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Anterior Urethral Valves and Diverticula in Children: A Result of Ruptured Cowper's Duct Cyst?." The Journal of Urology, 174(4 Part 1), p. 1445 © 2005 by American Urological Association, Inc.FiguresReferencesRelatedDetails Volume 174Issue 4 Part 1October 2005Page: 1445 Advertisement Copyright & Permissions© 2005 by American Urological Association, Inc.MetricsAuthor Information Douglas A. Canning More articles by this author Expand All Advertisement PDF downloadLoading ...

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.

Antenatal sonographic findings of congenital anterior urethral diverticulum

Although there are approximately 100 case reports in the English literature of congenital anterior urethral diverticula (AUD) in neonates, children and adults1, 2, we report the first case describing antenatal findings of AUD. Antenatal urethral obstruction leading to urinary ascites, bilateral urinomas and dysplastic kidneys secondary to AUD has previously been reported3. A 32-year-old woman, gravida 2 para 1, presented initially at 19 weeks' gestation for a routine fetal anomaly scan. Her previous pregnancy was uncomplicated and she had no significant medical history. The initial ultrasound examination demonstrated a fetus appropriate in size for gestational age with an 8-mm simple cyst in the region of the external genitalia. The kidneys, bladder and anterior abdominal wall appeared normal. Subsequent serial ultrasound examinations revealed a male fetus with otherwise normal-appearing penis and scrotum. The cyst (Figures 1 and 2) appeared contiguous with the penis and scrotum. The cyst contained clear fluid, had no associated solid components and was avascular. It was not associated with the umbilical cord. Cyst wall thickness and cyst diameter varied during the pregnancy. The latter varied between 11 and 18 mm but remained constant during each ultrasound examination. The renal pelvis anteroposterior diameter measured 6 mm at 37 weeks' gestation, with no evidence of caliectasis or changes in the appearance of the renal parenchyma. Ultrasound image showing a sagittal view of the penis (P), scrotum (SC) and anterior urethral diverticulum (CYST). Ultrasound image showing a transverse view of the scrotum and anterior urethral diverticulum (arrow). A healthy male was delivered at term. A ventral penile swelling (Figures 3 and 4) and urinary dribble were noted. Neonatal ultrasound demonstrated an AUD. There was no significant urinary tract obstruction. Diagnosis was confirmed on micturating cystourethrography, which demonstrated a large, wide-mouthed AUD, in addition to right Grade 1–2 vesicoureteric reflux. Primary open repair of a large diverticulum, including urethroplasty, was performed at the age of 4 months, with good functional and cosmetic results. Neonatal scrotum and penis with distended anterior urethral diverticulum. Neonatal scrotum and penis with non-distended anterior urethral diverticulum (following manual decompression). AUD usually present as a ventral compressible penile swelling, associated with poor stream or urinary dribble. They may cause lower urinary tract obstruction with secondary renal dysfunction. They can cause urinary tract infections. Sometimes small AUD are asymptomatic until adult life. Occasionally, stones can form in the diverticulum. Urethral diverticula are predominantly in the anterior urethra, distal to the urogenital diaphragm, occurring in all segments of the anterior urethra4. AUD form saccular (wide-mouth diverticulum) or globular (narrow-mouth diverticulum) types. The embryology remains uncertain, as does the relationship of AUD to anterior urethral valves (AUV). AUD can predispose to the development of AUV, although some believe that they remain distinct entities4. Theories of the embryology of AUD include incomplete duplication of the urethra, periurethral gland dilation and a segmental defect in the corpus spongiosum. These theories are linked by the idea of a deficiency in the supporting corpus spongiosum5. Diagnostic modalities include retrograde urethrography, voiding cystourethrography and cystourethroscopy. Ultrasound can also be useful, particularly if the ostium of the diverticulum is very small—it may then be difficult to visualize either on contrast radiographic studies or with direct vision during urethroscopy. Sonourethrography has been used successfully (distension of the urethra with sterile saline introduced through a Foley's catheter), in addition to color Doppler assessment6, 7. The upper urinary tract should be imaged to exclude renal involvement. Renal function may need assessment if there is obstructive uropathy. Treatment depends on the size of the diverticulum and associated complications. Large or symptomatic AUD require surgical repair. Some advocate transurethral resection8; however, this does not always eliminate urinary stasis or the bulging of a large diverticulum. Open primary reconstruction allows complete exposure of the diverticulum and may be the treatment of choice1, 5. In conclusion, we present a case of AUD diagnosed at 19 weeks' gestation. Early diagnosis and prompt surgical intervention will limit potential complications such as urinary tract infection and renal dysfunction. D. Ladwig [email protected]*, G. McNally*, P. Warren*, R. H. Farnsworth , * Department of Medical Imaging, Royal Hospital for Women, Barker Street, Randwick, NSW 2031, Australia, Prince of Wales Private Hospital, Randwick, NSW, Australia

Congenital urethral anomalies in boys. Part II.

In the second part of this article, congenital urethral anomalies other than posterior urethral valve were reviewed. The anomalies considered in the current review were anterior urethral valve, lacuna magna, syringocele, Cobb's collar, duplication of urethra, megalourethra, and prostatic urethral polyps. The literature was extensively reviewed concerning the presentations, diagnosis, different types of treatment modalities, morbidity, mortality, and new concepts for the above disorders. Anterior urethral valves or diverticula are the most prevalent congenital anomalies of anterior urethra. The lacuna magna is the largest depression in the dorsal aspect of the fossa navicularis. It is demonstrable on a well-performed voiding cystourethrography of the distal urethra. The dilated Cowper's gland duct is the other missed diagnosed anomaly of the urethra in boys. The congenital narrowing of the bulbar urethra with a variable clinical presentation and obstruction grade and different types of anterior urethral obstruction are the most common presentation of these anomalies. However, other symptoms or signs including, hematuria, bloody spotting on underwear, discomfort or sever pain in the vicinity of the glance, interrupted voiding, infection, bulging of anterior urethra, enuresis, and postvoiding dribbling are the only nonspecific manifestations of these disorders. All of these disorders are demonstrable on a well-performed voiding cystourethrography of the distal urethra. The urologist must be aware about these uncommon congenital anomalies and the anterior urethra should be carefully evaluated for such anomalies. Diagnosis of these entities is elusive unless the physician is looking for them. Nonspecific symptoms mentioned here besides radiographic findings can be a valuable clue for diagnosis.

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.

Anterior urethral valves and diverticula in children: a result of ruptured Cowper's duct cyst?

To review a series of children with anterior urethral valves and diverticula, to elucidate the pathophysiology and optimal management of this entity. Nine cases (all boys; 1963 to 2003) were reviewed retrospectively. Seven of nine boys had bulbar diverticula. Continuity between Cowper's duct and the diverticulum was noted endoscopically in two and confirmed radiographically in one. Initially, open surgery was curative but more recently endoscopic management has been the procedure of choice. This series indicates that the distal lip of a ruptured syringocele may function as a flap-valve, leading to anterior urethral obstruction. Advances in imaging and endoscopic instruments have altered the mode of presentation and management of this entity.

Fetal bladder rupture due to anteriorurethral valves

A rupture of the fetal bladder that resulted in urinary ascites has rarely been reported in published studies. We present the first case of a spontaneous rupture of the fetal bladder, due to an anterior urethral valve, in which the diagnosis was suspected prenatally by means of Doppler ultrasonography and was confirmed postnatally.

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.

Válvula de uretra anterior

Objetivo: apresentar os aspectos clínicos, diagnósticos e terapêuticos de pacientes portadores de válvula da uretra anterior. Descrição: em dois neonatos, o diagnóstico presuntivo de patologia obstrutiva do trato urinário foi sugerido pela ultra-sonografia realizada no período pré-natal, confirmando-se o diagnóstico de válvula de uretra anterior pela avaliação pós-natal. Os pacientes foram submetidos a tratamento cirúrgico paliativo, com vesicostomia temporária e, posteriormente, definitivo, pela fulguração endoscópica das válvulas. Ambos evoluíram com função renal normal. Comentários: a válvula da uretra anterior é anomalia rara que deve ser considerada em meninos com quadro radiológico pré-natal sugestivo de obstrução infravesical, secundariamente à hipótese mais comum de válvula da uretra posterior. Ressaltamos a utilização da vesicostomia como derivação urinária temporária nestes casos, prevenindo potenciais complicações pela manipulação da uretra do recém-nascido.

In utero release of constricting limb bands: successful timing of operation with Doppler flow assessments

Background: Constricting limb bands in utero can lead to vascular compromise, resulting in limb amputations and/or significant neural compression sequele. In utero release has been described to improve outcome. When constriction bands were identified early in pregnancy, the question as to when operation should be performed remains controversial.Purpose: We report two cases, where the vascular status of the limbs was serially assessed and operation performed when Doppler flow assessment showed significant compromise.Methods: Case 1 had insertion of fetal vesico‐amniotic shunt performed at 17 weeks for bladder outlet obstruction. While the urinary bypass was successful, the free end of the shunt was found to have wrapped round the left fetal thigh. With advancing gestation, the shunt was shown to progressively indent on the thigh, and Doppler flow assessment showed 37% reduction in flow below the constriction by 29 weeks. Case 2 was found to have constricting amniotic bands to the left fetal thigh and right leg at 19 weeks. Serial assessments showed no evidence of worsening until 29 weeks, when Doppler flow showed reduction in flow by 50 and 34%, respectively, on the left and right legs. After extensive counseling, fetoscopic release of the constrictions were performed for the two cases at 30 and 32 weeks, respectively.Results: Both operations were performed with two port uterine accesses (3 mm) under general anaesthesia. The constrictions were identified and divided under direct vision. In case 1, the cut end of the shunt retracted into the fetal bladder. Recurrence of bladder outlet obstruction with hydronephrosis and anhydramnios necessitated delivery at 32 weeks. Anterior and posterior urethral valves were resected at 6 months. Follow up at 2 years of age showed no renal impairment. Case 2 delivered at 36 weeks. Significant limb indentations could be identified at the constriction sites for both fetuses after birth. Case 1 has no neurological deficit of the limbs while case 2 need further surgery for talipes and has minor functional impairments.Conclusions: In utero release of constricting limb bands may reduce long‐term sequele. Serial Doppler flow assessments can assist in the appropriate timing of such procedures.

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. J Pediatr Surg 35:556-558. Copyright © 2000 by W.B. Saunders Company.

An Algorithm for the Management of Anterior Urethral Valves

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. 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. 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. 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.