Obstruction In Male Child Research Articles

Posterior Urethral Valve: Factors Affecting the Renal Outcome

Background: Posterior urethral valve (PUV) is the most common cause of lower urinary tract obstruction in male children with associated sequlae. Different factors, such as age at presentation, initial and nadir serum creatinine, renal parenchymal echogenicity on initial USG, vesicoureteric reflux (VUR) , recurrent UTI, bladder dysfunction and the presence or absence of pop-off mechanism like VURD have significant impact on ultimate renal outcome. The main aim of the study was to observe the effects of different prognostic factors like age of presentation and preoperative VUR of the PUV respondents on postoperative long term renal outcome as well as changes of renal function status on the basis of initial and postoperative serum creatinine level in our settings. Material Methods: This was a quasi-experimental study and conducted in the Department of Pediatric urology of Bangladesh Shishu Hospital and Institute, Dhaka. We enrolled 58 male children of different ages having posterior urethral valve, who were admitted in the pediatric urology department from July,2018 to Dec,2021. Results: Total 58 patients included in our study. Among all patients 53.4% were aged between 1 month to 1 year, 39.7% of them were more than 1 year old and 6.9% of them were neonates. Among 31 respondents, 32.3 % had poor renal function 35.5 % of them also had moderately impaired renal function. Again, out of 23 respondents, 30.4% had poor renal function 6% had moderately impaired renal function. The relation between age category and postoperative renal function status (On the basis of postoperative eGFR) of the posterior urethral valve respondents were statistically not significant. Patients who had no VUR, 66.7% of them had normal renal function, 25% had moderately impaired renal function and 8.3% had poor renal function. Respondents who had bilateral VUR, 55% of them had poor renal function and 35% had moderately impaired renal function. Among respondents who had unilateral VUR, 28.6% of them had poor renal function and 28.6% had moderately impaired renal function but 42.9% had normal renal function. The relation between preoperative VCUG findings and postoperative long term renal function status of the PUV patients were statistically significant. 7 (100%) respondents who had preoperative abnormal renal function, more than 71.4% of them had returned to normal renal function after operative procedure. But abnormal renal function was present in 2 (28.6%) patients during follow up. In our study we found 29.3% of our patients had poor renal outcome and 29.3% patients had moderately impaired renal function within the mean follow up period of 19.33±12.38 months (ranges from 9months to 4 years). Conclusion: Our research highlights the significance of age at presentation, despite its statistically negligible effect on long-term renal outcomes. However, among the children with PUV following valve ablation and with a long-term follow-up, beginning serum creatinine and the presence of various types of VUR on initial VCUG had a significant effect (p.05) on postoperative renal function on the basis of serum creatinine.

The Outcome of Posterior Urethral Valves among Children in Tertiary Care Hospital–A Prospective Study

Introduction: Posterior Urethral Valve (PUV) is the most common cause of lower urinary tract obstruction in male children. This obstruction in posterior urethra could lead to severe dilatation of upper urinary tract and functional impairment of one or both kidney. The presentations are not always same for all patients. Early diagnosis and appropriate treatment may reduce the progressive damage and helps in recovery. Aim of the Study: The aim of this study was to find out the presentation and to assess the short term functional outcome after fulgaration of the patients with PUV. Methods: This prospective study was conducted at Pediatric urology department, Bangladesh Shishu Hospital and Institute, Dhaka. We included fifty patients with Posterior urethral valve, who were treated at the pediatric urology department from Jan, 2019 to Nov, 2021. Result: Total 50 patients enrolled in the study. In our study we found 50% of our patients were aged between 1 month to 1 year, followed by 36% were more than 1 years old and 14% were less than 1 month old. 76% patients were presented with dribbling of urine. 40%,26%,10% and 6% patients had UTI, poor stream,, retention of urine and palpable bladder respectively. 45 patients had bilateral hydronephrosis ( HDN) at presentation and only 5 had unilateral hydronephrosis in USG. At follow up MCU, 14% patients had unilateral VUR and 10% patients had bilateral VUR. Mean postoperative serum creatinine was 0.585 mg/dl. We found residual Valve in 11(22%) patients during follow up who required repeat Valve ablation. Conclusion: In our study, we found that Cystoscopic valve ablation and follow up is the treatment of choice for PUV patients which may arrest the progressive damage of renal function and facilitate the improvement. Further multicenter study and long term follow up is necessary for understanding the ultimate outcome.

Posterior urethral valve in children: Using novel biomarkers as an early predictive tool for the onset and progression of chronic kidney disease

This narrative review aims to appraise the current evidence on using biomarkers of obstructive nephropathy to predict the onset and progression of chronic kidney disease (CKD) in infants with posterior urethral valves (PUV). PUV is the most frequently reported congenital anomaly of the kidney and urinary tract (CAKUT) associated with bladder outlet obstruction in male children. It contributes significantly to the CKD burden in childhood. Despite different approaches for its postnatal repair, evidence-based data still suggest a high risk of CKD and end-stage kidney disease (ESKD) later in childhood. In obstructive nephropathy, glomerular and tubulointerstitial lesions contribute to renal impairment. Although it may be difficult to predict these adverse renal outcomes in repaired PUV, detecting and monitoring future CKD appears enhanced using the combination of serum creatinine- or cystatin C-based estimated glomerular filtration rate (eGFR) and albuminuria. Given the drawbacks of these conventional biomarkers, there is a paradigm shift to novel biomarkers as tools for the early identification of glomerular and tubulointerstitial lesions seen in obstructive nephropathy. Most novel biomarkers are yet to be fully applied to routine clinical practice globally. Nevertheless, there is substantial evidence showing that they form part of the emerging diagnostics for obstructive nephropathy. From the reviewed studies, urine transforming growth factor-beta 1 (TGF-β1) is the most prominent biomarker among the novel biomarkers of obstructive nephropathy. However, other novel approaches like the machine learning (ML) model (a form of health-related artificial intelligence) and urodynamic parameters like bladder contractility index hold promise for PUV outcomes prediction (PUVOP). Because of the association of urine TGF-β1 with urine angiotensin level (a biomarker of the renin-angiotensin-aldosterone system [RAAS]), early angiotensin-converting enzyme inhibitor (ACEI) therapy in patients with PUV may potentially retard the progression of CKD and improve renal outcomes. Thus, future research directions will be to explore the role of ACEI as a pre-emptive treatment for poor renal outcomes in post valve-ablation patients and to conduct longitudinal studies that would properly demonstrate these biomarkers as predictors of these outcomes.

Imaging and clinical findings in late presenting posterior urethral valves in a resource-constrained economy

Posterior Urethral Valve (PUV) is the commonest cause of lower urinary tract obstruction in male children. Late presentation with delayed diagnosis is common in our setting. This study aims to review the clinical, biochemical, imaging findings and parental factors in late-presenting posterior urethral valves. A retrospective analysis of patients with PUVs seen at UNTH from 2011-2019 was done. Patients who presented at or later than six months of age were considered late presenters and were studied. Patients’ sociodemographic characteristics, antenatal diagnosis, clinical features, and imaging findings at presentation were retrieved. Data analysis was done using SPSS version 22. Statistical significance was set at a p-value<0.05. Twenty-four cases of PUV with complete clinical data were studied. Mean age 3.3 (SD±2.1) years had a positive association with maternal educational level (p≤0.001). Nineteen (72.9%) had antenatal care, 4 (16.7%) had prenatal Ultrasonography (USS), and were part of those who had antenatal care. None had a prenatal diagnosis. Prenatal USS was associated with higher paternal education (p=0.03). The most common clinical symptom and finding respectively were straining to pass urine 23 (95.8%) and palpable bladder 23 (95.8%). The common electrolyte derangements included hyperkalemia (50%), raised serum urea (70.8%) while postnatal hydronephrosis 23 (95.8%) was the main ultrasound and MCUG findings. Late presentation is common with urinary dysfunction and azotemia. Improved antenatal care including late trimester ultrasound and parental health education will enhance prenatal diagnosis and early presentation.

The protective arm of the renin‐angiotensin system may counteract the intense inflammatory process in fetuses with posterior urethral valves

ObjectivePosterior urethral valve is the most common lower urinary tract obstruction in male children. A high percentage of patients with posterior urethral valve evolve to end‐stage renal disease. Previous studies showed that cytokines, chemokines, and components of the renin–angiotensin system contribute to the renal damage in obstructive uropathies. The authors recently found that urine samples from fetuses with posterior urethral valve have increased levels of inflammatory molecules. The aim of this study was to measure renin–angiotensin system molecules and to investigate their correlation with previously detected inflammatory markers in the same urine samples of fetuses with posterior urethral valve. MethodsUrine samples from 24 fetuses with posterior urethral valve were collected and compared to those from 22 healthy male newborns at the same gestational age (controls). Renin–angiotensin system components levels were measured by enzyme‐linked immunosorbent assay. ResultsFetuses with posterior urethral valve presented increased urinary levels of angiotensin (Ang) I, Ang‐(1‐7) and angiotensin‐converting enzyme 2 in comparison with controls. ACE levels were significantly reduced and Ang II levels were similar in fetuses with posterior urethral valve in comparison with controls. ConclusionsIncreased urinary levels of angiotensin‐converting enzyme 2 and of Ang‐(1‐7) in fetuses with posterior urethral valve could represent a regulatory response to the intense inflammatory process triggered by posterior urethral valve.

Urinary ascitis in neonate with posterior urethral valve

Urinary ascites in a newborn infant is not very common. It indicates a disruption to the integrity of the urinary tract. Urinary tract obstruction leads to increased pressure which causes urine collection within the peri-renal spaces and subsequent urinary ascites either by calyceal perforation or filtration through the walls of urinary tract. Posterior urethral valve is most common cause of urinary tract obstruction in male child. The report describes a male child of age 17 days, presented with gross abdomen distension and diagnosed as urinary ascites, due to underlying posterior urethral valve. The abdominal distension was relieved with subsequent drainage of urine. Diagnosis was made using imaging techniques and corrective surgery planned.

The protective arm of the renin–angiotensin system may counteract the intense inflammatory process in fetuses with posterior urethral valves

ObjectivePosterior urethral valve is the most common lower urinary tract obstruction in male children. A high percentage of patients with posterior urethral valve evolve to end-stage renal disease. Previous studies showed that cytokines, chemokines, and components of the renin–angiotensin system contribute to the renal damage in obstructive uropathies. The authors recently found that urine samples from fetuses with posterior urethral valve have increased levels of inflammatory molecules. The aim of this study was to measure renin–angiotensin system molecules and to investigate their correlation with previously detected inflammatory markers in the same urine samples of fetuses with posterior urethral valve. MethodsUrine samples from 24 fetuses with posterior urethral valve were collected and compared to those from 22 healthy male newborns at the same gestational age (controls). Renin–angiotensin system components levels were measured by enzyme-linked immunosorbent assay. ResultsFetuses with posterior urethral valve presented increased urinary levels of angiotensin (Ang) I, Ang-(1-7) and angiotensin-converting enzyme 2 in comparison with controls. ACE levels were significantly reduced and Ang II levels were similar in fetuses with posterior urethral valve in comparison with controls. ConclusionsIncreased urinary levels of angiotensin-converting enzyme 2 and of Ang-(1-7) in fetuses with posterior urethral valve could represent a regulatory response to the intense inflammatory process triggered by posterior urethral valve.

Incidence and Progress of Vesicoureteric Reflux after Primary Fulguration of Posteriorurethralvalves

Introduction: Posterior urethral valve (PUV) is the most frequent cause of urethral obstruction in male child. These lesions usually result in lifelong disabilities with incontinence and decreased renal function despite optimal medical management. Primary fulguration without upper tract diversion is the preferred modality of treatment in most cases of PUV. Regular follow-up is needed to check completion of valve fulguration, renal function, status of hydronephrosis, vesicoureteric reflux (VUR), urinary tract infection (UTI), and bladder function.Materials and methods: We conducted interventional study among 30 purposively selected patients of PUV in the Department of Pediatric surgery, Dhaka Medical College Hospital (DMCH), Dhaka, over a period of 20 months from December 2009 to July 2011. Age of study subjects varied from 2 days to 14 years. Among the 30 patients, 16 were children in the age group between 1year to14 years (53.3%), 11(36.7%) were infants and the rest 03(10%) were neonates. Most of the patients presented with weak urinary stream, dribbling of urine, straining at micturition, UTI and palpable bladder. All children were subjected to ultrasonography (USG), blood urea, serum creatinine, routine urine examination and culture studies. Structured questionnaire was used to collect information regarding improvement or disappearance of VUR and renal functional status before & after primary fulguration of PUV.Results: Average serum creatinine level was found gradually decreased in subsequent follow up in comparison with the previous one. This difference of creatinine level was found statistically significant in t-test (p<0.01). Average blood urea nitrogen (BUN) was also decreased which was found statistically significant (p<0.05). VUR was present in 63.3% cases. Non- VUR was found in 60% cases on right side and 50% cases on left side. On the third follow-up after 3 months it became 73.3% on right side and 63.3% on left side. Positive correlation found in Pearson correlation test about the changes of reflux grades before and after fulguration was significant at the level of 0.01(p<0.001). It was significant on both left and right kidneys. Positive correlation found in Pearson correlation test about the changes of GFR before and after fulguration was also significant at the level of 0.01(p <0.001). Collected data was cleaned, edited and analyzed with the help of software SPSS window version 15.0.Conclusion: In this study, VUR disappeared in some cases and decreased in majority of the cases by 3 months after adequate restoration of urethral patency. Renal function came to normal range in two thirds of the cases.J. Paediatr. Surg. Bangladesh 3(2): 71-77, 2012 (July)

Outcome of Vesiciureteric Reflux After Primary Fulguration of Posterior Urethral Valves

Introduction: Congenital obstruction of the urethra is one of the most devastating anomalies to occur in the urinary tract and one of the few that are life-threatening in the neonatal period. Posterior urethral valve (PUV) is the most frequent cause of urethral obstruction in male child. These lesions usually result in lifelong disabilities with incontinence and decreased renal function despite optimal medical management. Primary fulguration without upper tract diversion is the preferred modality of treatment in most cases of PUV. Regular follow-up is needed to check completion of valve fulguration, renal function, status of hydronephrosis, vesicoureteric reflux (VUR), urinary tract infection (UTI), and bladder function.Materials and methods: We conducted interventional study among 30 purposively selected patients of PUV in the Department of Pediatric surgery, Dhaka Medical College Hospital (DMCH), Dhaka, over a period of 16 months from December 2009 to March 2011. Age of study subjects varied from 2 days to 14 years. Among the 30 patients, 16 were children in the age group between 1year to14 years (53.3%), 11(36.7%) were infants and the rest 03(10%) were neonates. Most of the patients presented with weak urinary stream, dribbling of urine, straining at micturition, UTI and palpable bladder. All children were subjected to ultrasonography(USG),blood urea, serum creatinine, routine urine examination and culture studies. Structured questionnaire was used to collect information regarding improvement of VUR and renal functional status before & after primary fulguration of PUV.Results: Average serum creatinine level was found gradually decreased in subsequent follow up in comparison with the previous one. This difference of creatinine level was found statistically significant in t test (p<0.01). Average blood urea nitrogen (BUN) was also decreased which was found statistically significant (p<0.05). VUR was present in 63.3% cases. Non- VUR was found in 60% cases on right side and 50% cases on left side. On the third follow-up after 3 months it became 73.3% on right side and 63.3% on left side. Positive correlation found in Pearson correlation test about the changes of reflux grades before and after fulguration was significant at the level of 0.01(p<0.001). It was significant on both left and right kidneys. Positive correlation found in Pearson correlation test about the changes of GFR before and after fulguration was also significant at the level of 0.01(p <0.001). Collected data was cleaned, edited and analyzed with the help of software SPSS window version 15.0.Conclusion: In this study, VUR disappeared in some cases and decreased in majority of the cases by 3 months after adequate restoration of urethral patency. Renal function came to normal range in two thirds of the cases.DOI: http://dx.doi.org/10.3329/jpsb.v2i2.19542

Incidence and Progress of Vesicoureteric Reflux after Primary Fulguration of Posterior Urethral Valves

Introduction: Posterior urethral valve (PUV) is the most frequent cause of urethral obstruction in male child. These lesions may result in lifelong disabilities with incontinence and decreased renal function despite optimal medical management. Primary fulguration without upper tract diversion is the preferred modality of treatment in most cases of PUV. Regular follow-up is needed to check completion of valve fulguration, renal function, status of hydronephrosis, vesicoureteric reflux (VUR), urinary tract infection (UTI), and bladder function. Materials and Methods: An interventional study among 30 purposively selected patients of PUV was conducted from December 2009 to July 2011. Most of the patients presented with weak urinary stream, dribbling of urine, straining at micturition, UTI, and palpable bladder. All children were subjected to ultrasonography (USG), blood urea, serum creatinine, routine urine examination, and culture studies. Structured questionnaire was used to collect information regarding improvement or disappearance of VUR and renal functional status before and after primary fulguration of PUV. Results: Ages ranged from 10 days to 14 years; 16 were between 1year and 14 years (53.3%), 11(36.7%) were infants, and the rest 03(10%) were neonates. Average serum creatinine levels were found gradually decreasing significantly (p < 0.01) in subsequent follow-ups. Average blood urea nitrogen (BUN) was also decreased significantly (p < 0.05). VUR was present in 63.3% cases. Non-VUR was found in 60% cases on right side and 50% cases on left side. On the third follow-up after 3 months it became 73.3% on right side and 63.3% on left side. Positive correlation found in Pearson correlation test about the changes of reflux grades before and after fulguration was significant (p < 0.001). It was significant on both left and right kidneys. Positive correlation found in Pearson correlation test about the changes of GFR before and after fulguration was also significant (p < 0.001). Collected data was cleaned, edited, and analyzed with the help of software SPSS window version 15.0. Conclusion: VUR disappeared in some cases and decreased in majority of the cases by 3 months after adequate restoration of urethral patency. Renal function came to normal range in two thirds of the cases. DOI: http://dx.doi.org/10.11593/bje.2013.0102.0013 Bangladesh Journal of Endosurgery Vol.1(2) May 2013: 23-28

Posterior urethral valves diagnosed by bedside ultrasound in the ED

Posterior urethral valves are the most common cause of urinary obstruction in male children. Presentations of posterior urethral valves beyond the neonatal period include urinary tract infection, abdominal mass, renal failure,diminished urinary stream, crying during micturition,incontinence, dysuria, hematuria, or failure to thrive. Early diagnosis is imperative because early surgical relief of the obstruction is believed to help prevent the progression to endstage renal disease.This case serves to remind us that, in the male child who presents with urinary symptoms and/or abdominal symptoms,the bedside sonogram is a valuable tool that can clarify the diagnosis and expedite care.

Management of Male Urethral Polyps in Children:Experience with Five Cases

Purpose Congenital urethral polyps area rare anomaly of the male urethra that may present with features of voiding dysfunction or obstruction. Although the exact incidence is unknown, they are important in the differential diagnosis of lower urethral obstruction in male children. We present our experience with five cases of male urethral polyps in boys and video presentation of resection of the urethral polyp. Material and Methods We retrospectively reviewed the medical records of five boys with urethral polyps. Patient characteristics, presentation, associated pathology, diagnosis and treatment were evaluated in all patients Results Median age at diagnosis was 5 years (range 1-12). Acute urine retention was the only symptom in 4 boys while loin pain due to reflux secondry to voiding dysfunction was documented in the other boy. Vesicoureteric reflux was associated in one patient. Voiding cystourethrography and CT and/or MRU were applied for diagnosis of voiding dysfunction in those boys but the only diagnostic tool for male urethral polyp is the cytsourethroscopy which revealed in all patients normal anterior urethra with a polyp arising from the veru montanum. Transurethral resection was applied for all boys with satisfactory results Conclusions Urethral polyps, although uncommon, are more common in males than in females. The incidence may not be as low as reported. They should be considered in the differential diagnosis of voiding dysfunction in male children. A high index of suspicion and possibly screening may be of help in knowing the exact incidence.

Management of male urethral polyps in children: Experience with four cases

Congenital urethral polyps area rare anomaly of the male urethra that may present with features of voiding dysfunction or obstruction. Although the exact incidence is unknown, they are important in the differential diagnosis of lower urethral obstruction in male children. Their diagnosis requires a high index of suspicion because of the variability of presentation. We present our experience with four cases of male urethral polyps in boys with discussion on the related literature.

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.

Fibromuscular hyperplasia of the posterior urethra: A cause for lower urinary tract obstruction in male children : D. Preseman, L. S. Ross, and S. V. Nicosia. J. Urol. 107:149–153 (January), 1972

Fibromuscular hyperplasia of the posterior urethra: A cause for lower urinary tract obstruction in male children : D. Preseman, L. S. Ross, and S. V. Nicosia. J. Urol. 107:149–153 (January), 1972

Fibromuscular Hyperplasia of the Posterior Urethra: A Cause for Lower Urinary Tract Obstruction in Male Children

Fibromuscular Hyperplasia of the Posterior Urethra: A Cause for Lower Urinary Tract Obstruction in Male Children