Management Of Posterior Urethral Valves Research Articles

Post-obstructive diuresis after posterior urethral valve treatment in neonates: a retrospective cohort study.

The management of posterior urethral valve (PUV) in neonates requires close monitoring in the intensive care unit because of the risk of post-obstructive diuresis (POD). Our aim was to describe the incidence and factors associated with POD in newborns treated for PUV. Retrospective analysis of the medical records of all neonates who underwent surgical intervention for PUV in our neonatal intensive care unit between January 2014 and April 2021. Of the 40 patients included, 15 (37.5%) had POD defined by urine output > 6ml.kg-1.h-1 during the first 24h following urinary tract obstruction relief. At prenatal ultrasound examinations, oligohydramnios was more common in the group with POD than in the group without (53.3% vs. 8%, p = 0.002). Preterm birth was more frequent in neonates with POD (66.7% vs. 8%; p < 0.001). Median serum creatinine (212 [137-246] vs. 95 [77-125] µmol.l-1; p < 0.001) and urea (8.5 [5.2-12.2] vs. 4.1 [3.5-4.7] mmol.l-1; p < 0.001) concentrations on the day of obstruction relief were significantly higher in the group with POD than in the group without. After adjustment for prematurity, logistic regression models confirmed correlation between the occurrence of POD and the severity of the consequences of urethral obstruction (i.e., oligohydramnios and serum creatinine levels; ß = 2.90 [0.88; 5.36], p = 0.013 and ß = 0.014 [0.003; 0.031], p = 0.034, respectively). In neonates, POD is common after the relief of PUV-related obstruction. Our findings may help to identify patients at highest risk. A higher resolution version of the Graphical abstract is available as Supplementary information.

The Outcome of Management of Posterior Urethral Valves

The Outcome of Management of Posterior Urethral Valves

Posterior urethral valves: Role of prenatal diagnosis and long-term management of bladder function; a single center point of view and review of literature.

Posterior Urethral Valves (PUV) are the most common cause of lower urinary tract obstruction. More severe forms are detected early in pregnancy (mainly type I), while other forms are usually discovered later in childhood when investigating lower urinary tract symptoms. Bladder dysfunction is common and is associated with urinary incontinence in about 55% (0%-72%). Despite the removal of the obstruction by urethral valve ablation, pathological changes of the urinary tract can occur with progressive bladder dysfunction, which can cause deterioration of the upper urinary tract as well. For this reason, all children with PUV require long-term follow-up, always until puberty, and in many cases life-long. Therefore, management of PUV is not only limited to obstruction relief, but prevention and treatment of bladder dysfunction, based on urodynamic observations, is paramount. During time, urodynamic patterns may change from detrusor overactivity to decreased compliance/small capacity bladder, to myogenic failure (valve bladder). In the past, an aggressive surgical approach was performed in all patients, and valve resection was considered an emergency procedure. With the development of fetal surgery, vesico-amniotic shunting has been performed as well. Due to improvements of prenatal ultrasound, the presence of PUV is usually already suspected during pregnancy, and subsequent treatment should be performed in high-volume centers, with a multidisciplinary, more conservative approach. This is considered to be more effective and safer. Primary valve ablation is performed after clinical stability and is no longer considered an emergency procedure after birth. During childhood, a multidisciplinary approach (pediatric urologist, nephrologist, urotherapist) is recommended as well in all patients, to improve toilet training, using an advanced urotherapy program with medical treatments and urodynamic evaluations. The aim of this paper is to present our single center experience over 30 years.

Role of a Preoperative Catheter Regimen in Achieving Early Primary Endoscopic Valve Ablation in Neonates with Posterior Urethral Valves.

Primary valve ablation is preferred to vesicostomy in the initial management of posterior urethral valves. However, some neonates have a prohibitively small urethra. We describe our experience with a preoperative urethral catheter regimen to enhance the likelihood of neonatal valve ablation. We performed a retrospective review of 126 neonates with posterior urethral valves treated between 2003 and 2019 with valve ablation prior to 10 weeks of age. The preoperative indwelling catheter either was gradually upsized to an 8Fr (progressive urethral dilation), was not upsized (nondilated) or was initially larger bore (8Fr only). The primary outcome was the ability to perform primary ablation by neonatal resectoscope. The secondary objective was to establish the parameters for considering progressive urethral dilation as well as its associated risks. Overall 97% could be ablated. The progressive urethral dilation group had the lowest mean weight (p <0.001). Only a larger catheter at the time of ablation was significantly associated with feasible ablation (p <0.001) and not urethral dilation, the infant's weight or his gestational age. Progressive urethral dilation was associated with a longer duration of catheterization as well as double the rate of febrile urinary tract infections (8.5%) over the nondilated group (3.6%). A much higher rate of primary ablation is feasible (97%) than previously reported (82%). More important than the infant's weight is whether a 6Fr to 8Fr catheter is in place at ablation. If an initial 6Fr to 8Fr catheter cannot be placed, urethral dilation to 8Fr should be performed before attempting ablation. This is both a technique and preoperative assessment that is useful for operative planning.

Management of Posterior Urethral Valves about 26 Cases

Aim: To improve management of the posterior urethral valve (PUV) in children in a hospital environment. Patients and Methods: This was a retrospective descriptive study that covered a sixteen (16) years period, from January 1, 2002 to December 31, 2017, In pediatric surgery and urology departments of our teaching hospital, 26 cases of posterior urethral valve (PUV) were involved. The diagnosis was made by retrograde urethrocystography and micturition, supplemented by ultrasound. Results: During this period, 26 patients (1.7%) had a PUV. The mean age of the patients was 73, 2 months with extremes ranging from 6 to 180 months. Fifteen patients consulted for dysuria, 8 for complete retention of urine. Only one patient had a history of rolling the valves to the benign ones. The main complications found were urinary tract infection in 15 children, urolithiasis in 3 children and renal failure in 2 children. Two children had serum creatinine values of 50 and 58 mg/L. The lamination of the posterior urethral valves was performed in all patients. In our series, we had one death from chronic renal failure in a 6-year-old child with a bilateral mute kidney at IVU. Conclusion: The valve diagnosis of the posterior urethra is made late because the diagnosis is still postnatal.

Outcome of Cold Knife Incision Compared to Diathermy Fulguration in Posterior Urethral Valve

Background: Posterior urethral valves are the most common cause of congenital obstructive lesion in the newborns and infant male child, occurring at the distal portion of the prostatic urethra. Diathermy fulguration of valve is one of the commonest modalities which has been practiced by Pediatric Urologist since decades where success rate ranging from 50-70%. Despite high success rate, post-operative complications like hematuria, urinary tract infections, urinary incontinence, retention of urine, residual valve and urethral stricture may develop in significant number of patients. Incision of the posterior urethral valve by cold knife is one of the modalities in the recent years with insignificant complications and good outcome with success rate ranging from 70-90%.&#x0D; Objective: To compare the efficacy of the cold knife with the diathermy fulguration in the management of the posterior urethral valve.&#x0D; Materials and Methods: This study was conducted in Urology Department of Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh from 1st January 2017 till 1st September 2018. A total 48 patients, diagnosed as a case of PUV and who fulfill the selection criteria were divided randomly by simple lottery method into 2 groups consisting of 24 patients in each group. Valve ablation was performed under standard aseptic condition according to groups. Patients were followed up at 3 and 6 months of initial intervention. They were re-evaluated during the follow up with history, clinical examination and investigation findings. Their subjective outcome and objective findings were assessed and compared in between the two groups.&#x0D; Results: There was no significant difference in the age distribution in between the groups (p= 0.083). Within the group, all the variable parameters were significantly improved prior and after the intervention. But, in between the groups, after 6 months of intervention, there was no difference in improvement of urinary flow(p=0.695). Incontinence of urine was not significant (p=1.000). The drop of mean serum creatinine level was not significant (p=0.530). Decrease in Mean PVR was not significant (p=0.684). Maximum flow rate was not significantly improved (p= 0.255). Peri catheter bleeding and residual valve were not significant. Stricture urethra was not found in any patient in both groups.&#x0D; Conclusion: Comparing the findings of the present study, it can be concluded that cold knife incision is equally effective in comparison to diathermy fulguration in the management of posterior urethral valve.&#x0D; Bangladesh Journal of Urology, Vol. 22, No. 2, July 2019 p.118-127

The posterior urethral valves revisited: embryological correlation, clinical classification, and risk stratification of the spectrum

BackgroundThe diagnosis of posterior urethral valves (PUV) encompasses a vast spectrum of disease with variable severity and clinical features. It is vital to understand the extent of developmental insult and to define the different distinct entities grouped together under the diagnostic umbrella of PUV. This would help to determine the severity of the disease, enable better prognostication, and optimize therapy. The objective of this study is to analyze the variable features of PUV and correlate the different manifestations with the embryological development of the urinary system. The possible developmental basis of anomalies in PUV is analyzed, as recognition of the underlying defect would help to determine the severity of the disease. A clinical classification and a risk stratification approach encompassing the spectrum of PUV is proposed, to help define diagnosis and guide prognosis. A combined retrospective and prospective analysis of cases diagnosed as PUV at the tertiary teaching institute over a 5-year period from July 2014 to July 2019 was done. The outcome of selected cases was analyzed, based on the risk group stratification.ResultsThe incidence of major complications during follow-up in each risk group was assessed individually and found to be highest in the high-risk group (92%), which was significantly higher than the other groups. The intermediate risk group was found to have a complication rate of 38%, while the low-risk group had only 12.5% complication rate. The three key concepts addressed in this study pertain to the embryological basis of PUV, the necessity of a clinical subdivision of patients, and the possibility of risk stratification based on clinical criteria. The limited review of institutional series is added to highlight the method of risk stratification and its probable utility.ConclusionsThe most critical factors to be accounted for in the diagnosis and management of PUV are the definition of disease severity, recognition of systemic complications, and identification of children at risk of progression to ESRD. The proposed developmental defect analysis, description of PUV sequence, clinical classification, and risk stratification approach are only the means to this end of segregating patient groups within the diagnostic spectrum.

Valve Bladder Syndrome Associated with Posterior Urethral Valves: Natural History, Work-up, and Management

This review focuses on the diagnosis, evaluation, and management of valve bladder syndrome (VBS) following initial treatment of posterior urethral valves (PUV). Based on current literature, we discuss the effect of PUV management in VBS and investigate the role of medications, catherization, surgery, and novel interventions. The current initial management of PUV involves valve ablation. Cutaneous urinary diversions are secondary options based on patient characteristics, PUV severity, and response to catheter drainage. VBS can independently occur as a consequence of PUV due to reduced nephron endowment leading to renal tubular dysfunction and polyuria, high bladder filling pressures secondary to a non-compliant bladder, and poor bladder emptying due to bladder neck hypertrophy. Options to mitigate the risk of upper tract deterioration include behavioral modifications and medical therapy (anticholinergics or alpha-blockers), bladder neck incision, clean intermittent catheterization and overnight catheter drainage, or more invasive approaches such as botulinum toxin injections and creation of a Mitrofanoff channel. Several experimental therapies to attenuate bladder fibrosis are currently under investigation. The management of VBS starts with initial management of PUV and is subsequently dependent on the evolving bladder filling dynamics and bladder neck hypertrophy affecting bladder filling and emptying. This requires a pre-emptive management protocol to identify VBS in boys with PUV to prevent renal damage using various therapeutic interventions. The lack of prospective studies to investigate effectiveness of available therapeutic options to treat VBS limits the development of an evidence-based approach for severity-based management of PUV-associated VBS.

Insight into Posterior Urethral Valve from Our Experience: Paradigm Appended to Abate Renal Failure.

Objective:The objective of the study was to share our experience of management of posterior urethral valve (PUV) and to suggest a paradigm to impede upstaging of chronic kidney disease (CKD) and prevent end-stage renal failure (ESRF).Patients and Methods:We have treated 332 patient of PUV from March 2005 to April 2016, Of which 272 case records had adequate data to be analyzed. The mean age was 2.48 years (range: 1 day–18 years). We did primary fulguration in 231 patients, of which five patients needed bilateral ureterostomy for obstinate high creatinine level. The remaining 36 patients had primary fulguration done elsewhere.Results:The mean duration of follow-up was 7.8 years (range 3–14 years). In the end of this study, 10 patients had down staging in CKD, 36 patients had up staging in CKD, and 9 patients ended in ESRF (3.8%).Conclusions:Detection of deterioration of renal function with creatinine clearance along with identifying the causes of deterioration and necessary interventions would help to arrest upstaging of CKD otherwise that might end in ESRF. From this study and reviewing the literature, we presume that the rhabdosphincter spasm underneath actually renders bladder outlet obstruction, and cusps of PUV, particularly in neonates, amplify the obstruction, following that bladder outlet obstruction cascades detrusor hypertrophy, bladder neck hypertrophy/obstructions, and ureterovesical junction obstruction/reflux, causing gradual damage to the bladder and upper tract and deterioration of renal function as a consequence.

MON-310 POSTERIOR URETHRAL VALVE AT A PAEDIATRIC NEPHROLOGY UNIT IN SOUTH WESTERN NIGERIA

Posterior urethral valve (PUV) is the most severe form of obstructive uropathies in the paediatric population occurring exclusively in boys. Management of posterior urethral valves is challenging in many parts of sub-Saharan Africa. To provide data on Posterior urethral valves in sub-Saharan Africa, we reviewed the cases of PUVs seen over a 21 month period. Retrospective study- information was obtained from the paediatric nephrology unit data base of children admitted with a diagnosis of posterior urethral valve between March 2016 and December 2017 Twenty-five cases were seen during the study period. Their ages ranged from 3days to 13 years with the median age been 24 months. The mean age and standard deviation was 42.1 (SD ±57.1). Eight (32%) presented during the first year of life and of this number, one (12.5%) presented in neonatal period. The commonest cause of hospital admission was urosepsis, 37.5% of the urine cultures however yielded no growth, and half of the cases were due to Pseudomonas aeroginosa. 9(32.1%) had surgical intervention (Mohan’s valve ablation or Endoscopic Valve ablation). Thirteen (%) had renal failure Three of the subjects received dialysis and of this number, two had haemodialysis. The in-hospital mortality rate is (12.0%) Posterior urethral valves are not uncommon and remain an important cause of urosepsis and chronic kidney disease in the paediatric population in sub-Saharan Africa. Efforts to further improve outcomes are needed.

698 - Management of posterior urethral valve in infants: What is the role of vesicostomy?

698 - Management of posterior urethral valve in infants: What is the role of vesicostomy?

Consensus on the Management of Posterior Urethral Valves from Antenatal Period to Puberty.

The need for successful management of posterior urethral valves always captivates the minds of pediatric surgeons. Its success, however, depends on several factors ranging from prenatal preservation of upper tracts to postoperative pharmacological compliance. Regardless of measures available, some cases do not respond and progress to end stage. The management depends on several issues ranging from age and severity at presentation to long-term follow-up and prevention of secondary renal damage and managing valve bladder syndrome. This article is based on a consensus to the set of questionnaires, prepared by research section of Indian Association of Paediatric Surgeons and discussed by experienced pediatric surgeons based in different institutions in the country. Standard operating procedures for conducting a voiding cystourethrogram and cystoscopy were formulated. Age-wise contrast dosage was calculated for ready reference. Current evidence from literature was also reviewed and included to complete the topic.

Posterior Urethral Valves: Prenatal, Neonatal, and Long-Term Management

A posterior urethral valve (PUV) is a membranous fold within the lumen of the posterior urethra that causes functional obstruction of the urine outflow. It is a common cause of obstructive uropathy in boys during the neonatal period. The disorder varies in its severity; in extreme cases, PUVs can be incompatible with postnatal life while other patients can suffer from renal and respiratory failure associated with oligohydramnios. Milder cases can present later in life with urinary incontinence and other urinary symptoms. The management of patients with PUVs remains a clinical challenge and includes endoscopic surgical resection of the urethral valve and follow-up during early infancy and adulthood to avoid progressive bladder dysfunction and monitor for chronic renal disease. This review will address the management of PUVs during the prenatal period, the neonatal period, and throughout the entire life of the patient.

Posterior urethral valves: Metabolic consequences in a cohort of patients

Despite the improvements in diagnosis and management of posterior urethral valves (PUVs), about one third of patients develop chronic kidney disease (CKD). Children with PUVs might have abnormal calcium, phosphorus, vitamin D and parathyroid hormone levels, which could affect their bone growth and overall health. The aim was to determine the relationship between kidney function, vitamin D deficiency and secondary hyperparathyroidism in children with PUVs. Sixty-four children with PUVs were followed for a period of 3.64 ± 2.50 years after their initial presentation and management. Their laboratory parameters were compared with 20 age-, gender- and race-matched children in a control group, including: serum calcium, phosphorus, intact parathyroid hormone (iPTH), 25-hydroxyvitamin D levels, and kidney function. Children with PUVs had significantly lower estimated kidney function (P = 0.006) and vitamin D levels (P < 0.001) and higher iPTH levels (P = 0.042). There were no significant between-group differences in serum calcium, phosphorus, alkaline phosphatase, sodium, potassium, and bicarbonate levels. There was a strong correlation between the degree of vitamin D deficiency and hyperparathyroidism and the degree of kidney dysfunction (r = 0.52 and -0.52, respectively) in the PUV group. On a multivariate analysis, the kidney dysfunction was the only independent predictor of vitamin D deficiency (ρ = 0.271, P < 0.001), while kidney dysfunction, serum calcium and alkaline phosphatase were independent predictors for hyperparathyroidism (ρ = 0.925, P<0.001, ρ = 0.933, P<0.001 and ρ = 0.913, P < 0.001, respectively). The prevalence of CKD in children with PUVs ranges from 30 to 60%. Patients with CKD are more likely to have vitamin D deficiency and display more-prominent hyperparathyroidism. Compared with a control group with normal kidney function, the present cohort had lower 25-hydroxyvitamin D and higher iPTH serum levels. Abnormal kidney function was a major predictor for both serum levels. In this cohort, there were no significant differences in serum calcium and phosphorus between children with PUVs and the control group, and also between those with and without CKD. On the contrary, vitamin D level decreased early in the disease and progressively declined thereafter, while iPTH was the opposite. These findings were comparable to previous studies. This study had some limitations because it was a single center cross-sectional non-randomized study. However, the findings in this study can be extrapolated to children with PUVs and CKD from other origins because the unit is considered as a referral center in the Middle East region. Abnormal kidney function, vitamin D deficiency, and secondary hyperparathyroidism are prevalent in children with PUVs. Kidney function is the main determinant of vitamin D and parathyroid hormone levels. Efforts should be directed toward managing CKD, and controlling vitamin D deficiency and hyperparathyroidism in children after ablation of PUV.

Posterior Urethral Valves in Children: Pattern of Presentation and Outcome of Initial Treatment in Ile-Ife, Nigeria.

Background:The management of posterior urethral valves (PUV) and its sequelae is still a challenge to most pediatric surgeons in our environment due to late presentation and inadequate facilities for long-term evaluation and treatment. Despite initial successful treatment about 40% would develop chronic renal failure. The aim is to describe the presentation, management and outcome of the initial treatment in boys with PUV.Materials and Methods:It is a retrospective analysis of PUV in boys 8 years and below over a 17 years period. Demographic characteristics, clinical features, investigations, and treatment outcome were reviewed.Results:Thirty-seven cases were analyzed. The median age was 5 months (range from birth to 8 years). Three (8.1%) patients had prenatal ultrasound diagnosis. The most common presentation was voiding dysfunction 37 (100%). Part of the preoperative investigation included micturating cystourethrogram (n = 31: 83.8%) and abdomino-pelvic ultrasonography (n = 37:(100%). The mean serum creatinine value of those who presented within the first 30 days of life and those who presented afterwards were 325 (±251) µmol/L and 141 (±100) µmol/L respectively, P = 0.003. Surgical interventions included trans-vesical excision of valves (n = 9: 28.1%), valvotomy (n = 10: 31.3%), balloon avulsion (n = 8: 25.0%), vesicostomy (n = 4: 12.5%) and endoscopic valve avulsion (n = 1: 3.1%). Seventeen (56.7%) patients had serum creatinine >70.4 µmol/L after 1-month of valve excision. Five (13.5%) patients had postrelief complications and 5 (13.5%) died on admission. Ninety percentage (27/30) of patients had poor prognostic indices.Conclusions:The initial treatment outcome was good but most had poor prognostic factors.

The Management of Vesicoureteral Reflux in the Setting of Posterior Urethral Valve With Emphasis on Bladder Function and Renal Outcome: A Single Center Cohort Study

To represent our experience in the management of posterior urethral valves and concomitant vesicoureteral reflux (VUR). A total of 326 children with posterior urethral valve who had underwent valve ablation/bladder neck incision were studied, and those who had persistent VUR and were categorized under 3 main groups were followed up. Group 1 (n= 71) received prophylactic antibiotic, group 2 (n= 50) underwent Deflux injection (2a) (n= 28): Deflux injection alone, group 2b (n= 22) Deflux with concomitant autologous blood injection (HABIT), and group 3 (n= 19) underwent ureteroneocystostomy before referral and was followed up conservatively. VUR resolution, incidence of urinary tract infections (UTI), and bladder function were assessed. Mean duration of follow-up was 3.8years; VUR resolution occurred in 66.1%, 86.0%, and 94.0% of groups 1-3, respectively (P= .013). Resolution rate in group 2b was significantly higher than group 2a (90.9% vs 78.5%). Patients in group 2 experienced a longer UTI-free period compared with others (P<.05). Urodynamic studies demonstrated significant decrease in maximum voiding detrusor pressure and detrusor overactivity in all groups (P<.001). Children in group 3 ended up with lower compliance compared with others (P<.001). After toilet training, only 2.8%, 21.4%, 13.6%, and 27% children were diagnosed with lower urinary tract dysfunction in groups 1-3, respectively (P= .027). Myogenic failure developed only in 3 boys in group3. Ablation/bladder neck incision leads to significant improvement in VUR status in part because of improvement in bladder function. After successful valve removal, conservative therapy can be regarded as the mainstay of reflux treatment, whereas HABIT is recommended for high grade VUR associated with febrile UTI or deterioration in renal function.

S130 Effectiveness of valve ablation with holmium laser ablationin the management of posterior urethral valve

S130 Effectiveness of valve ablation with holmium laser ablationin the management of posterior urethral valve

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

ObjectiveTo review the role of vesicostomy in the management of posterior urethral valve (PUV), in neonates and infants, given the limitations for endoscopic treatment in this setting. MethodsA review of 35 patients who presented with posterior urethral valve over a 10-year period. Demographic and clinical information were prospectively recorded on a structured pro forma, and the data extracted analysed using SPSS 11.0. ResultsThe 35 boys were aged 3 days to 10 years (median 3 weeks). Twenty-three (65.7%) had a vesicostomy (age range 3 days–3 years, median 3 weeks). The mode of presentation was poor urinary stream 15 (65.2%), urinary retention 4 (17.4%), and renal failure 6 (26.1%). Main findings were palpable bladder 23 (100%), hydronephrosis 4 (17.4%). Abdominal ultrasound confirmed hydronephrosis and thickened bladder wall, and voiding/expressive cystourethrogram confirmed dilated posterior urethra and vesicoureteric reflux in all 23 patients. Complications following vesicostomy were stoma stenosis 1 (4.3%), bladder mucosal prolapse 1 (4.3%), perivesicostomy abscess 1 (4.3%); there was no mortality. Following vesicostomy, 10 (43.5%) patients had excision of the valves and vesicostomy closure at age 2–8 years (median 4 years). They are well, with normal renal ultrasonographic findings, bladder capacity range 115–280 ml, and normal urea, serum electrolytes, creatinine, at 3 years of follow up. Thirteen (56.5%) are still awaiting valvotomy but have remained well and with normal ultrasonographic renal findings. ConclusionVesicostomy is a useful temporising mode of urinary diversion in neonates and infants with posterior urethral valve (in the absence of unobstructed upper tracts) when facilities for endoscopic valve ablation are not readily available.

Outcome of Late Presentation of Posterior Urethral Valves in a Resource-Limited Economy: Challenges in Management

Delayed presentation of patients with posterior urethral valve with complications like severe urosepsis, uremia, and anemia are seen in our setting. Renal replacement therapy which should have been offered to these patients is not readily available for children in our country. The aim of this study is to determine the pattern of late presentation and outcome of management of posterior urethral valve in a resource-limited setting. A descriptive retrospective study (1997–2009) was conducted. Data including pattern of presentation, duration of symptoms, complications, and outcome of initial management were analyzed. Twenty-one patients were seen. The median age was 3 years (2 days–13 years). The mean duration of symptoms before presentation was 2.6 years. Nineteen patients (91%) presented with urosepsis while 8 patients (36%) presented with significant renal insufficiency. Laboratory findings varied from-mild-to marked elevation in serum creatinine. Radiological findings confirmed the diagnosis of posterior urethral valve. We concluded that late presentation is common in our setting. This is associated with high morbidity and mortality rates. Efforts at improving awareness and early diagnosis among the health team should be made to stem the tide.

Posterior Urethral Valve Treatments and Outcomes in Children Receiving Kidney Transplants

We evaluated the impact of surgical approaches to posterior urethral valves on renal transplant survival and compared transplant survival in children with vs without posterior urethral valves. We reviewed the records of all children who underwent renal transplantation from January 1984 to March 2008 and performed univariate subgroup analysis in those with posterior urethral valves. We evaluated the ureteroneocystotomy method, immunosuppression and valve treatment. In patients with posterior urethral valves we regarded nocturnal and/or daytime incontinence, severe urgency and the need for intermittent catheterization or double voiding for increased post-void residual urine as signs of bladder dysfunction. The initial renal transplant was received by 418 children at a mean age of 5.6 years. The 59 boys with posterior urethral valves received a total of 69 kidneys. By 8-year followup the kidney had failed in 24 of 59 boys with and 143 of 359 without posterior urethral valves (OR 0.9665, 95% CI 0.5462-1.692, p = 0.9105). Immunosuppression was consistent in the 2 groups. Outcomes were similar across all ureteroneocystotomy techniques. Initial management for posterior urethral valves was valve ablation alone in 12 boys, vesicostomy in 7 and supravesical diversion in 11. There was no difference in transplant survival or bladder dysfunction based on valve intervention. In 18 boys (55%) we noted overlapping signs of bladder dysfunction, of whom 11 performed intermittent catheterization or had increased post-void residual urine, 4 had severe urgency, 4 had daytime incontinence and 7 had nocturnal incontinence. Bladder dysfunction did not predict increased graft loss (OR 3.306, 95% CI 0.7615-16.27, p = 0.1134). Of children who undergo renal transplantation boys with posterior urethral valves do not have a higher graft failure rate. Treatment for posterior urethral valves did not significantly impact transplant survival or bladder dysfunction.