History Of Posterior Urethral Valves Research Articles

Renal, Bladder and Sexual Outcomes in Adult Men with History of Posterior Urethral Valves Treated in Childhood

To determine the adulthood outcomes of bladder, kidney, and sexual functions of posterior urethral valve (PUV) patients. The records of patients who were treated for PUV between 1980, and 2001 and aged ≥18 years by the end of 2019 were retrospectively reviewed. Patients with complete adulthood data were included in the study. Renal, bladder, and sexual functions were assessed. Adulthood uroflowmetry results of 22 patients were also evaluated. Thirty-nine patients with complete adulthood data out of 89 were included. The median follow-up time was 22.7 years (15-33 years). Median age at initial surgery for PUV was 36 months (1-168 months), and median age at last follow-up was 26 years (18-46 years). Lower urinary tract dysfunction was noted in 15 (38%) patients. In 22 patients (56%) with uroflowmetric analyses, median values of Qmax, voided volume, and post voiding residual urine volume were 20.5 mL/sec (7-43 mL/sec), 389 mL (154-1750 mL), and 18.5 mL (range 0-190 mL), respectively. Nineteen patients (48.7%) had normal glomerular filtration rate, 2 patients (5.1%) had chronic kidney disease, and the remaining 18 patients (46.1%) had end stage renal disease, 14 (35.9%) of whom underwent renal transplantation. Thirty-two patients (82%) had sexual function evaluation, none of which reported erectile dysfunction. However, 4 patients (12.5%) reported slow ejaculation. Five patients fathered a child whereas infertility was observed in 2 patients. After 2 decades, glomerular filtration rate was normal almost in half of the PUV patients while lower urinary tract dysfunction was detected in 38%. Furthermore, erectile dysfunction was rare.

Predicting and Modifying Risk for Development of Renal Failure in Boys with Posterior Urethral Valves.

The purpose of this review is to bring the reader up to date on the current risk factors for the development of renal deterioration in the boys with posterior urethral valves (PUV) and approaches to modify this risk. Renal bladder ultrasound (RBUS) is routinely performed in boys with PUV and recent advancements allow imaging processing that can more accurately quantify renal parenchyma and correlate this with risk for renal loss. Refinement of urine studies may improve our ability to stratify patients into renal loss categories. Use of videourodynamics (VUDS) allows refined assessment of the valve bladder to identify those who might benefit from secondary procedures and/or the addition of targeted pharmacotherapy to improve bladder emptying or dangerous storage pressures. All boys with a history of PUV are at a significant long-term risk of renal deterioration. The literature suggests that several technical advances have improved our ability to predict this risk, although there needs to be further refinement and validation before widespread use. Utilization of close follow-up, VUDS, pharmacotherapy, and bladder drainage provide the best methods to improve care to this group of patients and if more studies confirm their utility, adoption of these as part of standard of care protocols may be warranted.

Percutaneous Management of a Pyocystic Fistulizing Continent Urinary Diversion

Background: Continent diversions have since been performed with increasing frequency since the 1950s, with some providers espousing the use of orthotopic diversions as being the new gold standard. However, patients must be counseled to take great care in the maintenance of their diversions because of complications such as metabolic abnormalities, pouch stones, and mucus retention.Case Report: A 21-year-old male with a history of posterior urethral valves underwent a continent catheterizable diversion as a child. He is undocumented and without health insurance and as a result unable to follow-up with an urologist for >10 years. He subsequently develops pyocystis with cutaneous fistulization and pouch stones necessitating percutaneous management.Conclusion: Patients may benefit greatly from a continent urinary diversion, however, selection must include patients who are able to maintain their pouch and follow-up with their providers to avoid major complications that may occur up to years following the procedure.

Urinary tract infection after retrograde urethrogram in children: A multicenter study

The risk of post-procedural urinary tract infection (ppUTI) after retrograde urethrogram (RUG) has not been well quantified. Prophylactic antibiotics may reduce the risk, but must be weighed against the risks of antibiotic resistance. Prior research has shown that this risk is variable after voiding cystourethrogram (0-42% reported ppUTI rate) and appears to be low after urodynamics (0-4.8%) but this risk has not been well documented for patients undergoing RUG. We aimed to (1) describe the rate of ppUTI after RUG, and (2) examine factors associated with use of antibiotics at the time of RUG. We conducted a retrospective cohort study of children undergoing RUG at two hospitals January 1, 2004, to December 31, 2014. ppUTI within 7 days was measured. Antibiotic prophylaxis was determined. Relationships between clinical characteristics and receipt of pre-procedure antibiotics were evaluated using univariate statistics. Forty-two patients (100% male, median age 11.7 years) underwent 47 RUGs. Indications included trauma (27%), hypospadias (17%), and non-hypospadias (27%) stricture. Study indication and antibiotic administration practices are illustrated in the Figure. Three patients (6.4%) had a history of posterior urethral valves (PUV); one had neurogenic bladder (NGB) (2.4%). Two (4%) studies were performed within 30 days of a clinical UTI and 11% had a positive urinalysis or culture within 30 days pre-RUG. UTI in the 30 days before RUG was not associated with antibiotic prescription (p>0.99). One child (2.1%; 95% CI 0-6.3%) had a ppUTI: a 7-year-old, uncircumcised male with a history of PUV and voiding dysfunction who was asymptomatic at the time of RUG. Although the risk of ppUTI after RUG appears to be low, the rare occurrence of an iatrogenic UTI can lead to high cost and patient morbidity, particularly in cases similar to our patients who required inpatient admission for intravenous antibiotics. To help balance the risk of UTI with the associated healthcare costs and morbidity with the concerns about antibiotic overuse and potential exposure to drug reaction, data from this study may inform future development of evidence-based guidelines targeting only patients at highest risk for ppUTI with antibiotic prophylaxis. The risk of ppUTI after RUG is low. Antibiotic prophylaxis was unrelated pre-RUG UTI in our population. These results indicate the need for pre-procedural antibiotic prescribing guidelines, and suggest that routine antibiotics prior to RUG are not indicated unless the patient has another indication for antibiotics.

MP55-17 URINARY TRACT INFECTION AFTER RETROGRADE URETHROGRAM IN CHILDREN: A MULTICENTER STUDY

You have accessJournal of UrologyPediatrics: Urinary Tract Infection and Vesicoureteral Reflux1 Apr 2016MP55-17 URINARY TRACT INFECTION AFTER RETROGRADE URETHROGRAM IN CHILDREN: A MULTICENTER STUDY Neha Malhotra, Jared Green, Cynthia Rigsby, Jane Holl, Earl Cheng, and Emilie Johnson Neha MalhotraNeha Malhotra More articles by this author , Jared GreenJared Green More articles by this author , Cynthia RigsbyCynthia Rigsby More articles by this author , Jane HollJane Holl More articles by this author , Earl ChengEarl Cheng More articles by this author , and Emilie JohnsonEmilie Johnson More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.608AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Radiologic procedures such as retrograde urethrogram (RUG) and voiding cystourethrogram (VCUG) requiring catheterization and retrograde instillation of contrast carry an inherent risk of post-procedural urinary tract infection (ppUTI). However, the risk of ppUTI after RUG has not been well quantified. Prophylactic antibiotics may reduce the risk, but this benefit must be weighed against the risk of inducing antibiotic resistance. Our aims were to (1) describe the rate of ppUTI after RUG, and (2) examine the factors associated with use of antibiotics before, and ppUTI after, RUG. METHODS We conducted a retrospective cohort study of children <18 years old undergoing RUG at 2 pediatric hospitals from 1/04-12/14. We excluded studies with concurrent VCUG and children with no follow-up. Descriptive statistics were used for demographic and clinical characteristics. ppUTI within 7 days of RUG was measured. Antibiotic prophylaxis was determined and relationships between clinical characteristics and receipt of pre-procedure antibiotics were evaluated using Fisher exact testing. RESULTS 43 patients (98% male, median age 11.7 years) underwent 48 RUGs. The most common indications were trauma (27%), hypospadias (17%), and non-hypospadias (27%) stricture. Three patients (7%) had a history of posterior urethral valves (PUV), 1 had a neurogenic bladder (NGB); 27% had prior urethral surgery. 52% of RUGs revealed no abnormalities; the most common abnormality was stricture (31%). Two (4%) studies were performed within 30 days of a clinical UTI and 10% of children had a positive urinalysis or culture within 30 days pre-RUG. Clinical UTI in the prior 30 days was not significantly associated with pre-RUG antibiotic use (1/29 patients on antibiotics (3%); 1/19 patients not on antibiotics (5%) had a pre-RUG UTI, p = 1.0). Only 1 (2.1%; 95% CI 0 – 6.2%) child had a ppUTI. This was a 7 year-old uncircumcised male with a history of PUV, strictures and voiding dysfunction. He was asymptomatic, had a negative pre-RUG urine culture, and was not on antibiotics. RUG revealed a bulbar stricture. Seven days later, the child had a febrile E. coli UTI requiring admission. CONCLUSIONS The risk of ppUTI after RUG is very low (2.1% in our study, maximum 6.2%). We were unable to evaluate for specific predictors of ppUTI due to the low incidence. Use of antibiotics was unrelated pre-RUG UTI. Given the low incidence of ppUTI, this study suggests that routine prophylaxis with antibiotics prior to RUG is not indicated. Prophylaxis for select patients (i.e. PUV or NGB) may be warranted. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e743 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Neha Malhotra More articles by this author Jared Green More articles by this author Cynthia Rigsby More articles by this author Jane Holl More articles by this author Earl Cheng More articles by this author Emilie Johnson More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Controlled Outcomes for Achievement of Urinary Continence among Boys Treated for Posterior Urethral Valves

We evaluated the age at which boys with a history of posterior urethral valves after no or minimal anticholinergic medication achieve urinary continence and the factors contributing to continence. We reviewed the hospital records of all males treated for posterior urethral valves at a single institution between 1990 and 2008. Continence was considered to have been attained if no weekly wetting episodes occurred. We evaluated the influence of patient characteristics, including reduced kidney function and primary ring type ureteral stoma, on age at which continence was achieved. A total of 76 patients were assessed. Achievement of daytime and nighttime urinary continence was markedly delayed in patients (mean ± SD age 5.5 ± 3.3 years and 5.4 ± 3.0 years, respectively) compared to the reference population (2.3 ± 0.5 and 2.9 ± 1.2, p <0.001). Increased serum creatinine levels at age 5 years were associated with later daytime and nighttime continence (mean ± SD 6.0 ± 3.2 and 5.5 ± 2.6 years, respectively, vs 4.1 ± 2.3 and 3.7 ± 1.4 years, respectively, in patients with normal serum creatinine, p ≤0.05). Prenatal or neonatal diagnosis of posterior urethral valves was associated with significantly delayed achievement of daytime continence compared to cases diagnosed later (mean ± SD 5.9 ± 3.6 vs 4.1 ± 1.8 years, p = 0.02). Patients with high nadir serum creatinine and vesicoureteral reflux initially also were at increased risk for urinary tract infections (p = 0.003 and p <0.001, respectively). Patients with posterior urethral valves achieve daytime and nighttime urinary continence significantly later than their healthy peers. Prenatal or neonatal diagnosis and high serum creatinine are associated with later attainment of continence.

Use of Appendix for Renal Transplant Urinary Diversion After Complete Transplant Ureteral Necrosis: A 12-Year Follow-up

A 15-year-old African American male patient with a history of posterior urethral valves ablated as a newborn and who also had formation of an appendicopyelostomy at 3 years of age due to transplant ureteral necrosis subsequently underwent cadaveric renal transplant. At the time, this was a novel method for salvaging urinary diversion for the renal allograft previously reported in 2003. He most recently presented to Arkansas Children's Hospital for transplant rejection secondary to nonadherence with medications. We present an interval case report of a novel technique allowing a complicated cadaveric renal transplant to survive for 12 years.

Adult Care of Children From Pediatric Urology

In this article we highlight the difference, from established adult urology, in required approach to the care of adolescents and young adults presenting with the long-term consequences of the major congenital anomalies of the genitourinary tract. We review some abnormalities of the kidneys, progressive renal failure and disorders of bladder function from which general conclusions can be drawn. The published literature was reviewed and augmented with material from our institutional databases. For renal function the CAKUT (congenital abnormalities of the kidney and urinary tract) database at University College London Hospitals was used, which includes 101 young adult patients with CAKUT in whom the urinary tract has not been diverted or augmented. For bladder function some data are from patient records at Boston Children's Hospital. Adolescents who grow up with the burden of a major congenital anomaly have an overwhelming desire to be normal. Many achieve high levels of education and occupy a wide range of employment scenarios. Babies born with damaged kidneys will usually experience improvement in renal function in the first 3 years of life. Approximately 50% of these cases will remain stable until puberty, after which half of them will experience deterioration. Any urologist who treats such patients needs to test for proteinuria as this is a significant indicator of such deterioration. In its absence, the urologist must have a reasonable strategy for seeking a urological cause. The most effective management for nephrological renal deterioration is with angiotensin converting enzyme inhibitors, which slow but do not prevent end stage renal failure. Renal deterioration is generally slower in these patients than in those with other forms of progressive renal disease. The bladder is damaged by obstruction or by functional abnormalities such as myelomeningocele. Every effort should be made to stabilize or reconstruct the bladder in childhood. A dysfunctional bladder is associated with or causes renal damage in utero, but continued dysfunction will cause further renal damage. Bladder function often changes in puberty, especially in boys with posterior urethral valves who may experience high pressure chronic retention. Dysfunction is managed with antimuscarinic drugs, clean intermittent self-catheterization and intestinal augmentation. Adult urologists must be able to manage the long-term problems associated with these treatments. Pediatric conditions requiring management in adolescence are rare but have major, lifelong implications. Their management requires a broad knowledge of pediatric and adult urology, and could well be a specialty in its own right. Therefore, adult urologists must remain aware of the conditions, the problems that they may encounter and the special management required for these patients to live normal lives.

Long-term follow up of enteric bladder augmentations: The risk for malignancy

Objective To determine the risk of bladder cancer following enteric bladder augmentation. Materials and methods Patients followed for care after an enteric bladder augmentation have been entered into a registry; individuals followed for a minimum of 10 years were evaluated. Results The study criteria were met by 153 patients. Indications for bladder augmentation were neurogenic bladder in 97, exstrophy in 38 and posterior urethral valves in 18. There was a median follow-up interval of 27 years (range 10–53). A total of seven cases of malignancy developed. Median time to tumor development following augmentation was 32 years (range 22–52). Two patients with neurogenic bladder developed transitional cell carcinoma; both were heavy smokers (>50 pack per year history). Two patients with a history of posterior urethral valves and renal transplantation developed adenocarcinoma of the enteric augment. Three patients with bladder exstrophy developed multifocal adenocarcinoma of the augmented bladder. Two patients remain alive, 5 and 6 years following radical cystoprostatectomy; five died of cancer-specific causes. Conclusions Malignancy following enteric bladder augmentation arose in 4.5% (7/153) of our patients and was associated with coexisting carcinogenic stimuli (prolonged tobacco/chronic immunosuppressive exposure), or alternatively with the inherent risk of malignancy existing with bladder exstrophy.

Long-term follow up of enteric augmentations; the risk for malignancy

Purpose To define the risk of malignant tumours developing in enteric bladder augmentation during long-term follow up. Material and methodsS We reviewed all patients who had undergone an enteric bladder augmentation. To be included in the study, a minimum of 10 years of follow-up with a history of annual or biennial urologic follow-up evaluations were required. The patients were specifically reviewed for the development of a bladder malignancy. Results 153 patients met the study criteria; indications for bladder augmentation were neurogenic bladder in 97, exstrophy-epispadias in 38 and posterior urethral valves in 18. Median follow-up interval of 27 years range 10–53 years. A total of 7 cases of malignancy occurred. Two patients with a neurogenic bladder developed multifocal transitional cell carcinoma; both were heavy smokers (> 50 pack year history). Two patients with a history of posterior urethral valves that subsequently required renal transplantation developed invasive adenocarcinoma of the enteric augment portion of the bladder. Three patients with bladder exstrophy developed multifocal adenocarcinoma of the bladder and enteric segment. Median time to development of the tumour was 32 years range 22 – 52 years. Radical cystectomy was performed in 6/7(85%) of the patients. (One patient with wide spread metastasis at diagnosis.) Three patients remain alive, median length of time from surgery 5 yrs., range 2–6 yrs. Four patients died from their malignancy. Conclusions Malignancy following enteric augmentation frequently arose due to coexisting biologic stimuli; tobacco usage, immunosuppression or the possible inherent risk of malignancy from the native exstrophic bladder. Median lag time to tumour development was 3 decades. To define the risk of malignant tumours developing in enteric bladder augmentation during long-term follow up. We reviewed all patients who had undergone an enteric bladder augmentation. To be included in the study, a minimum of 10 years of follow-up with a history of annual or biennial urologic follow-up evaluations were required. The patients were specifically reviewed for the development of a bladder malignancy. 153 patients met the study criteria; indications for bladder augmentation were neurogenic bladder in 97, exstrophy-epispadias in 38 and posterior urethral valves in 18. Median follow-up interval of 27 years range 10–53 years. A total of 7 cases of malignancy occurred. Two patients with a neurogenic bladder developed multifocal transitional cell carcinoma; both were heavy smokers (> 50 pack year history). Two patients with a history of posterior urethral valves that subsequently required renal transplantation developed invasive adenocarcinoma of the enteric augment portion of the bladder. Three patients with bladder exstrophy developed multifocal adenocarcinoma of the bladder and enteric segment. Median time to development of the tumour was 32 years range 22 – 52 years. Radical cystectomy was performed in 6/7(85%) of the patients. (One patient with wide spread metastasis at diagnosis.) Three patients remain alive, median length of time from surgery 5 yrs., range 2–6 yrs. Four patients died from their malignancy. Malignancy following enteric augmentation frequently arose due to coexisting biologic stimuli; tobacco usage, immunosuppression or the possible inherent risk of malignancy from the native exstrophic bladder. Median lag time to tumour development was 3 decades.

Myogenic bladder decompensation in boys with a history of posterior urethral valves is caused by secondary bladder neck obstruction?

To investigate whether myogenic bladder decompensation in patients treated for congenital posterior urethral valves (PUV, the most serious cause of infravesical obstruction in male neonates and infants) may be secondary to bladder neck obstruction, as despite prompt ablation of PUV these patients can have dysfunctional voiding during later childhood or adolescence, the so-called 'valve bladder syndrome'. The study comprised 18 boys (mean age 14 years, range 6.2-18.5) who had had successful transurethral ablation of PUV between 1982 and 1996, and had completed a follow-up which included serial assessment of serum creatinine, completion of a standard voiding diary, ultrasonography with measurement of urine before and after voiding, a urodynamic examination with simultaneous multichannel recording of pressure, volume and flow relationships during the filling and voiding phases, coupled with video-cystoscopy at least twice. The mean (range) follow-up was 9.3 (6-17) years. Urodynamic investigation showed myogenic failure with inadequate bladder emptying in 10 patients; five with myogenic failure also had unstable bladder contractions. On video-cystoscopy the posterior bladder neck lip appeared elevated in all patients but in those with myogenic failure it was strongly suggestive of hypertrophy, with evidence of obstruction. At the last follow-up one patient with myogenic failure who had had bladder neck incision and four others who were being treated with alpha-adrenergic antagonists had a significant reduction of their postvoid residual urine. Despite early valve ablation, a large proportion of boys treated for PUV have gradual detrusor decompensation, which may be caused by secondary bladder neck obstruction leading to obstructive voiding and finally detrusor failure. Surgical or pharmacological intervention to improve bladder neck obstruction may possibly avert this course, but further studies are needed to validate this hypothesis.

LAPAROSCOPIC APPENDICOVESICOSTOMY (MITROFANOFF PROCEDURE) IN A CHILD USING THE DA VINCI ROBOTIC SYSTEM

The Mitrofanoff principle was originally described as a method to provide an alternative means to access the bladder.1 It creates a conduit to the bladder through which patients with a sensitive, absent or traumatized urethra can perform clean intermittent catheterization (CIC) easily. To our knowledge we report the first case of an appendicovesicostomy performed entirely laparoscopically. CASE REPORT A 7-year-old boy with a history of posterior urethral valves and resultant valve bladder syndrome was referred with persistent high post-void residuals and recurrent urinary tract infections. He had previously undergone right heminephroureterectomy as well as left ureteral reimplantation and ureteral cystoplasty. The patient had an extremely sensitive urethra, which made CIC nearly impossible. After a discussion of the treatment options with the family laparoscopic appendicovesicostomy was elected. A 4-port transperitoneal approach was used (fig. 1). A 12 mm laparoscopic camera port was placed through the umbilicus and 2, 10 mm robotic laparoscopic ports were placed in the left lower quadrant and right midaxillary line at the level of the umbilicus. A fourth port was placed in the left midaxillary line, also at the level of the umbilicus. We began by mobilizing the appendix and right hemicolon up to the hepatic flexure. The mesentery of the appendix was identified and mobilized to obtain adequate length. The appendix was divided at its base using a gastrointestinal anastomosis stapler. The bladder was filled with saline an da5c mvertical seromuscular incision was made in the right posterior wall of the bladder down to the mucosa. After incision of the mucosa the appendix was anastomosed to the bladder using 4-zero chromic interrupted sutures using the da Vinci robotic system. The seromuscular layer of the bladder was closed using interrupted 4-zero polyglactin sutures, creating a tunnel for the appendix. The appendix was then brought up to the umbilicus and a catheterizable stoma was created. Smooth catheterization through the appendix with full pneumoperitoneum and with the pneumoperitoneum released was performed (fig. 2). A 16Fr suprapubic catheter was inserted into the bladder and an 8Fr stenting catheter was left through the appendix. Overall operative time was 6 hours and operative time for the anastomosis was 25 minutes. Estimated blood loss was 10 cc. There were no intraoperative or postoperative complications. The patient was started on a clear liquid diet the following day and did not require narcotic analgesia after postoperative day 1. He was discharged on postoperative day 4 and returned to normal activity at 10 days. He currently performs CIC every 6 hours without difficulty and is dry between catheterizations. The patient has been followed for 10 months and has not had to undergo stomal revision. DISCUSSION

Management of Posterior Urethral Valves on the Basis of Urodynamic Findings

Purpose Abnormal urodynamic findings are common in boys with a history of posterior urethral valves. However, to our knowledge there are few reports on the results of treating these abnormal findings. We analyzed the treatment of abnormal urodynamic parameters and its outcome in 21 boys who underwent valve ablation. Materials and Methods After valve ablation multichannel urodynamic studies were performed in 31 boys, including 21 in whom studies were done before and after therapy was started for abnormal parameters. Detrusor instability and impaired bladder compliance were treated with anticholinergics or augmentation cystoplasty, and impaired detrusor contractility was managed with clean intermittent catheterization. Results Before therapy 17 of 21 boys had impaired compliance and detrusor instability, 2 had impaired compliance without instability and 2 had instability alone. After treatment 8 boys had impaired compliance and 4 had detrusor instability. After anticholinergics were initiated new onset myogenic failure in 2 boys necessitated clean intermittent catheterization. Of the 13 patients who presented with urinary incontinence 10 became dry and 3 had improvement with therapy. Vesicoureteral reflux in 10 boys at the time of the initial urodynamic study resolved in 7 with anticholinergic medication and in 1 after clean intermittent catheterization was begun for severely impaired compliance. All 21 boys were treated with anticholinergics and 2 were ultimately treated with augmentation cystoplasty. Clean intermittent catheterization was also instituted in 5 patients, including the 2 who required clean intermittent catheterization after myogenic failure developed. Five boys with high voiding pressures were found to have outlet obstruction due to residual valve tissue in 2, bladder neck obstruction in 2 and urethral stricture in 1 despite normal flow rates in 2. Conclusions Urodynamic studies are helpful in guiding therapy in boys after valve ablation. Anticholinergic therapy can improve compliance, decrease detrusor instability, improve continence and eliminate vesicoureteral reflux in the majority of boys, although there is an associated risk of myogenic failure. Flow rates and fluoroscopic voiding studies are often unable to detect outlet obstruction and must be obtained in conjunction with voiding pressure measurements to make this diagnosis.

Management of posterior urethral valves on the basis of urodynamic findings.

Abnormal urodynamic findings are common in boys with a history of posterior urethral valves. However, to our knowledge there are few reports on the results of treating these abnormal findings. We analyzed the treatment of abnormal urodynamic parameters and its outcome in 21 boys who underwent valve ablation. After valve ablation multichannel urodynamic studies were performed in 31 boys, including 21 in whom studies were done before and after therapy was started for abnormal parameters. Detrusor instability and impaired bladder compliance were treated with anticholinergics or augmentation cystoplasty, and impaired detrusor contractility was managed with clean intermittent catheterization. Before therapy 17 of 21 boys had impaired compliance and detrusor instability, 2 had impaired compliance without instability and 2 had instability alone. After treatment 8 boys had impaired compliance and 4 had detrusor instability. After anticholinergics were initiated new onset myogenic failure in 2 boys necessitated clean intermittent catheterization. Of the 13 patients who presented with urinary incontinence 10 became dry and 3 had improvement with therapy. Vesicoureteral reflux in 10 boys at the time of the initial urodynamic study resolved in 7 with anticholinergic medication and in 1 after clean intermittent catheterization was begun for severely impaired compliance. All 21 boys were treated with anticholinergics and 2 were ultimately treated with augmentation cystoplasty. Clean intermittent catheterization was also instituted in 5 patients, including the 2 who required clean intermittent catheterization after myogenic failure developed. Five boys with high voiding pressures were found to have outlet obstruction due to residual valve tissue in 2, bladder neck obstruction in 2 and urethral stricture in 1 despite normal flow rates in 2. Urodynamic studies are helpful in guiding therapy in boys after valve ablation. Anticholinergic therapy can improve compliance, decrease detrusor instability, improve continence and eliminate vesicoureteral reflux in the majority of boys, although there is an associated risk of myogenic failure. Flow rates and fluoroscopic voiding studies are often unable to detect outlet obstruction and must be obtained in conjunction with voiding pressure measurements to make this diagnosis.

The management of unilateral poorly functioning kidneys in patients with posterior urethral valves.

There is no uniform agreement on how to manage the unilateral nonfunctioning or poorly functioning kidney associated with posterior urethral valves. We studied the results of treatment of our patients to make recommendations regarding management of these kidneys. We reviewed the records of 13 boys with a history of posterior urethral valves and a unilateral nonfunctioning or poorly functioning kidney, defined as less than 10% of total renal function on 99mtechnetium dimercapto-succinic acid renal scans. Variables investigated included pyelonephritis, hypertension, vesicoureteral reflux, nephroureterectomy, ureteral reimplantation and spontaneous cessation of reflux. We also evaluated how the management of abnormal urodynamic parameters influenced the results of reimplantation or medically induced cessation of reflux. Three of the 6 boys with grade 5 reflux ipsilateral to the poorly functioning kidney required nephroureterectomy at a mean age of 21 months because of recurrent urinary tract infections. Another 4 boys underwent successful ureteral reimplantation, including 2 who had bilateral grade 5 reflux, and 2 who had ipsilateral grade 4 reflux, and grade 3 (1) and grade 2 (1) contralateral reflux. Of 4 boys ipsilateral grade 3 reflux in 3 and bilateral grade 5 reflux in 1 disappeared without surgery after treatment of urodynamic abnormalities. Two patients with poorly functioning kidneys and no reflux did not undergo surgery. Overall 10 of the 13 poorly functioning renal units were not removed, and these patients were free of pyelonephritis and hypertension. Ureteral reimplantation (4 ipsilateral and 3 contralateral) was performed only after urodynamic abnormalities were addressed. All reimplantations were successful. Based on our results we believed that unilateral poorly functioning kidneys in patients with posterior urethral valves can be safely preserved in select patients without hypertension and pyelonephritis. Reimplantation to correct reflux may be preferable to nephroureterectomy in specific situations, such as when contralateral function is suboptimal and the contralateral ureter needs reimplantation. When indicated, reimplantation can be performed successfully if abnormal urodynamic parameters are addressed preoperatively. In fact, treating abnormal urodynamic findings may lead to spontaneous reflux resolution.

The Management of Unilateral Poorly Functioning Kidneys in Patients With Posterior Urethral Valves

Purpose There is no uniform agreement on how to manage the unilateral nonfunctioning or poorly functioning kidney associated with posterior urethral valves. We studied the results of treatment of our patients to make recommendations regarding management of these kidneys. Materials and Methods We reviewed the records of 13 boys with a history of posterior urethral valves and a unilateral nonfunctioning or poorly functioning kidney, defined as less than 10% of total renal function on [99m] technetium dimercapto-succinic acid renal scans. Variables investigated included pyelonephritis, hypertension, vesicoureteral reflux, nephroureterectomy, ureteral reimplantation and spontaneous cessation of reflux. We also evaluated how the management of abnormal urodynamic parameters influenced the results of reimplantation or medically induced cessation of reflux. Results Three of the 6 boys with grade 5 reflux ipsilateral to the poorly functioning kidney required nephroureterectomy at a mean age of 21 months because of recurrent urinary tract infections. Another 4 boys underwent successful ureteral reimplantation, including 2 who had bilateral grade 5 reflux, and 2 who had ipsilateral grade 4 reflux, and grade 3 (1) and grade 2 (1) contralateral reflux. Of 4 boys ipsilateral grade 3 reflux in 3 and bilateral grade 5 reflux in 1 disappeared without surgery after treatment of urodynamic abnormalities. Two patients with poorly functioning kidneys and no reflux did not undergo surgery. Overall 10 of the 13 poorly functioning renal units were not removed, and these patients were free of pyelonephritis and hypertension. Ureteral reimplantation (4 ipsilateral and 3 contralateral) was performed only after urodynamic abnormalities were addressed. All reimplantations were successful. Conclusions Based on our results we believe that unilateral poorly functioning kidneys in patients with posterior urethral valves can be safely preserved in select patients without hypertension and pyelonephritis. Reimplantation to correct reflux may be preferable to nephroureterectomy in specific situations, such as when contralateral function is suboptimal and the contralateral ureter needs reimplantation. When indicated, reimplantation can be performed successfully if abnormal urodynamic parameters are addressed preoperatively. In fact, treating abnormal urodynamic findings may lead to spontaneous reflux resolution.

Comparative Urodynamic Findings After Primary Valve Ablation, Vesicostomy or Proximal Diversion

Purpose There is little known about the effect of urinary diversion on the bladder of children with posterior urethral valves. There is a fear that diversion may result in contracted noncompliant bladders. We wished to compare urodynamic parameters in patients who underwent primary ablation of posterior urethral valves and in those who underwent diversion in the form of vesicostomy or pyelostomy. Materials and Methods Urodynamics were done in 32 boys with a history of posterior urethral valves divided into 3 groups based on initial treatment: 1) transurethral valve ablation; 2) cutaneous vesicostomy, subsequent closure and valve ablation, and 3) proximal cutaneous pyelostomy, subsequent reconstitution and valve ablation. Results Patients who underwent initial diversion with vesicostomy or pyelostomy had bladders with larger functional capacity, better compliance and less instability. Chronic renal failure developed in 25 percent of the patients who underwent primary valve ablation and 33 percent of those who underwent diversion. Average period of diversion in vesicostomy and pyelostomy patients was 25 months. Conclusions Based on our findings temporary diversion does not seem to damage bladders. On the contrary, placing a damaged bladder at rest may help to improve bladder function. Bladder function following reconstitution correlated poorly with ultimate outcome and progression to renal failure. While we do not recommend temporary diversion as the treatment of choice for patients with posterior urethral valves, we believe that when chosen as treatment, it can be safely performed with little risk of further damage to the bladder.

Comparative Urodynamic Findings After Primary Valve Ablation, Vesicostomy or Proximal Diversion

There is little known about the effect of urinary diversion on the bladder of children with posterior urethral valves. There is a fear that diversion may result in contracted noncompliant bladders. We wished to compare urodynamic parameters in patients who underwent primary ablation of posterior urethral valves and in those who underwent diversion in the form of vesicostomy or pyelostomy. Urodynamics were done in 32 boys with a history of posterior urethral valves divided into 3 groups based on initial treatment: 1) transurethral valve ablation; 2) cutaneous vesicostomy, subsequent closure and valve ablation, and 3) proximal cutaneous pyelostomy, subsequent reconstitution and valve ablation. Patients who underwent initial diversion with vesicostomy or pyelostomy had bladders with larger functional capacity, better compliance and less instability. Chronic renal failure developed in 25% of the patients who underwent primary valve ablation and 33% of those who underwent diversion. Average period of diversion in vesicostomy and pyelostomy patients was 25 months. Based on our findings temporary diversion does not seem to damage bladders. On the contrary, placing a damaged bladder at rest may help to improve bladder function. Bladder function following reconstitution correlated poorly with ultimate outcome and progression to renal failure. While we do not recommend temporary diversion as the treatment of choice for patients with posterior urethral valves, we believe that when chosen as treatment, it can be safely performed with little risk of further damage to the bladder.

Long-Term Results of Renal Transplantation into the Valve Bladder

Between 1970 and 1990 renal transplantation was performed in 16 patients with a history of posterior urethral valves. While 10 patients had undergone supravesical urinary diversion before the development of end stage renal disease, all but 1 transplant were drained to the unaugmented native bladder. The 2 and 5-year graft survival rates were 70% and 59%, respectively. Of the 15 surviving patients 11 have allografts that are functioning at a mean of 86 months after transplantation with a mean serum creatinine of 2.0mg./dl. Urological complications occurred in 19% of the transplants. No detrimental effect of the valve bladder on long-term allograft survival or function was apparent. With appropriate treatment of vesical dysfunction, these patients can be expected to have graft function comparable to the general transplant population despite use of the unaugmented native bladder.

Urinary Tract Infections in Children with Posterior Urethral Valves After Kidney Transplantation

The records of 14 boys with posterior urethral valves who had renal failure and subsequently underwent renal transplantation were reviewed to determine the postoperative incidence of urinary tract infection relative to that of 29 male transplant children without valves, who served as controls. There were no significant differences between the posterior urethral valve patients and controls with regard to age, donor source, immunosuppression, followup after transplantation or mean calculated creatinine clearance. Vesicoureteral reflux was found in 1 child with posterior urethral valves and 3 of the children in the control group (p not significant). A total of 15 urinary tract infections occurred in 5 children (36%) with posterior urethral valves, for a rate of 1 per 30 patient-months of followup, and 6 urinary tract infections occurred in 2 controls (7%), for a rate of 1 per 216 patient-months of followup (p <0.05). However, only 1 of 26 controls (4%) without vesicoureteral reflux had urinary tract infection, for a rate 1 per 1,144 patient-months (p <0.01). Conversely, the rate of urinary tract infections in controls with vesicoureteral reflux was similar to that of children with posterior urethral valves. Of the 5 children with posterior urethral valves 4 had the initial urinary tract infection within 2 months of transplantation and 10 of 15 episodes occurred within the first 4 months. Antimicrobial prophylaxis did not appear to decrease the rate of infection in children with posterior urethral valves. A history of posterior urethral valves increases the frequency of urinary tract infection after renal transplantation but the usefulness of antimicrobial prophylaxis and the relationship to long-term graft function remain to be determined. Urinary tract infection rarely develops in other transplanted boys without vesicoureteral reflux.