Transurethral Ablation Research Articles

Recurrence after postoperative intravesical instillation therapy in Hunner type interstitial cystitis

We performed a prospective, single-arm study comparing outcomes between transurethral ablation plus postoperative instillation of hyaluronic acid and chondroitin sulfate (HACS group) and transurethral ablation only in patients with Hunner type interstitial cystitis (historical control group). A total of 78 patients were enrolled, and 51 were included in the per-protocol analysis set. The 2-year recurrence rate was 47.1% (95% CI, 32.9–61.5) in the HACS group, which was significantly lower than that in the control group (86.2%; 95% CI, 74.6–93.9, P < 0.001). After instillation therapy, the hazard ratio for recurrence was 0.38 (95% CI, 0.23–0.65, P < 0.001). The HACS group had an increased recurrence-free survival with the median interval not being reached, while it was 11.4 months in the control group (95% CI, 8.8–13.8, P < 0.001). Regardless of the instillation treatment, there were significant improvements in all symptom questionnaire scores and pain compared to the baseline. However, in the instillation group, improvement was stable even after 12 months. In patients with Hunner type interstitial cystitis, intravesical instillation of hyaluronic acid and chondroitin sulfate after transurethral ablation significantly reduced the recurrence rate and maintained symptom improvement for more than 1 year.

Optimal endoscopic treatment and partial cystectomy with or without bladder augmentation for Hunner-type interstitial cystitis.

Interstitial cystitis/bladder pain syndrome (IC/BPS) presents a significant challenge for urologists in terms of management, owing to its chronic nature and adverse impact on patient quality of life. Given the potential distinction between two disease entities within IC/BPS, namely Hunner-type IC and BPS without Hunner lesion, there is a need for an optimal therapeutic approach that focuses on the bladder lesions in Hunner-type IC. In cases where Hunner lesions are observed, complete transurethral ablation of these lesions should be prioritized as the initial intervention, as it has demonstrated effectiveness in symptom control. However, recurrence remains a limitation of this intervention. The techniques of resection and coagulation are equally effective in terms of symptom relief and recurrence prevention. Reconstructive surgery becomes necessary in cases of end-stage IC/BPS where various therapeutic approaches have failed. Patient selection is crucial in reconstructive surgery, particularly for patients with clear Hunner lesions and small bladder capacity who have not responded to previous treatments. Furthermore, it is vital to consider the patients' expectations and preferences adequately. Based on a comprehensive review of the literature and our own clinical experiences, subtotal cystectomy followed by bladder augmentation is considered a safe and effective surgical option. This stepwise and tailored therapeutic approach aims to optimize patients' quality of life by specifically targeting Hunner-type IC.

The impact of Hunner lesion-type interstitial cystitis/bladder pain syndrome on health-related quality of life and the effects of transurethral ablation.

Interstitial cystitis/bladder pain syndrome (IC/BPS) has a negative impact on quality of life. We compared health-related quality of life (HRQoL) of patients with IC/BPS with patients having other diseases using the EuroQol five-dimension (EQ-5D) and evaluated whether the HRQoL is improved after surgery. We compared EQ-5D of patients with Hunner lesion type IC/BPS with patients who had other diseases that cause chronic and severe pain including arthritis and cancer from a cross-sectional analysis of responses to the 2012-2016 Korea National Health and Nutrition Examination Survey. Changes in EQ-5D after transurethral coagulation (TUC) or resection (TUR) were measured in the IC/BPS participants. Compared to the EQ-5D index of normal population, patients with arthritis, cancer and IC/BPS had -0.07 (95% CI -0.07, -0.06), -0.01 (95% CI -0.02, -0.01), and -0.21 (95% CI -0.23, -0.20) lower scores, respectively. Patients with IC/BPS were 35.9, 9.24, and 9.05 times more likely to have "extreme problem" in pain/discomfort, anxiety/depression, and usual activities EQ-5D domains, respectively, than patients without arthritis/cancer. After TUC or TUR, EQ-5D index was 0.90 in the TUC group and 0.92 in the TUR group. IC/BPS patients have worse HRQoL than healthy individuals. However, after surgical treatment, HRQoL is restored to a level close to normal.

A Prospective Observational Study of the Recurrence Characteristics of Hunner Lesion After Repeated Transurethral Ablation in Patients With Interstitial Cystitis/Bladder Pain Syndrome.

PurposeThe aim of this study was to investigate the rate and pattern of recurrence for patients with Hunner lesion (HL) type interstitial cystitis/bladder pain syndrome (IC/BPS) after transurethral ablation.MethodsThis prospective study included 210 patients with HL type IC/BPS. The primary outcomes were the recurrence rate according to 3 patterns of recurrence: pattern A (according to the relationship with the previous surgical site), pattern B (according to the bladder zone), and pattern C (according to the number of lesions). The secondary outcomes were recurrencefree time after treatment according to pattern A and pattern C.ResultsThe pattern A recurrence rate was 50.8% in the same site (A1), 6.7% at a new site (A2), and 42.5% at mixed sites (A3). The pattern B recurrence rate was 10.5% for the anterior wall, 59.0% for the posterior wall, 69.5% for the lateral wall, and 69.0% for the dome area. Multiple lesions recurred as multiple lesions in 75.8% of cases. The pattern C recurrence rate was 10.8% for C1 (single → single), 6.7% for C2 (single → multiple), 6.7% for C3 (multiple → single), and 75.8% for C4 (multiple → multiple). The recurrence-free time in pattern A was 13 months for A1, 12.5 months for A2, and 8 months for A3, with a significant difference between A1 and A3 (P=0.008). There was no significant difference in recurrence-free time in pattern C, either with single or multiple HLs.ConclusionsThe distinct recurrence characteristics of HLs was not predictable despite repeated ablations. Complete remission should not be expected because the whole bladder was to have the potential to develop the HLs even after repeated transurethral ablation.

Fiducial markers and their impact on ablation outcome for patients treated with MR-guided transurethral ablation (TULSA): a retrospective technical analysis

Objectives Fiducial markers improve accuracy in external beam radiation therapy (EBRT) for treatment of prostate cancer (PCa). However, many patients recur after EBRT necessitating additional treatment, such as MR-guided transurethral ultrasound ablation (TULSA). Residual markers may compromise TULSA through ultrasound field distortions and generation of local susceptibility artifacts. The objective was to investigate how markers affect the ablation outcome during clinical TULSA treatments. Subjects and methods A retrospective analysis was performed on nine patients with radiorecurrent PCa and residual markers who received TULSA. The MR susceptibility artifact was quantified as a function of marker type, size and orientation, in particular for thermometry. The spatial distribution of markers inside the prostate was recorded, and the resulting impact on the thermal dose was measured. The thermal dose measurements were directly compared to the residual enhancing prostatic tissue observed on the immediate and control post-TULSA contrast enhanced (CE) image. Results Successful thermal dose accumulation to the target boundary occurred for 14/20 (70%) of markers, confirmed with CE imaging. Gold markers situated simultaneously close to the urethra (≤12 mm) and far from the target boundary (≥13 mm) reduced the ultrasound depth of heating. Nitinol markers produced large, hypointense artifacts that disrupted thermometry and compromised treatment. Artifacts from gold markers were less pronounced, but when located near the target boundary, also affected treatment. Conclusion Marker composition, orientation and location inside the prostate can all potentially impact treatment outcome. Proper patient selection through detailed MRI screening is critical to ensure successful radiorecurrent PCa treatment outcomes with TULSA.

“When ablation goes wrong”- urethral strictures after ablation of posterior urethral valves-characteristics, management and outcomes”

Post-ablation urethral strictures are a rare but devastating complication following transurethral ablation of posterior urethral valve which can be more difficult to treat than the valve itself. Though with the miniaturization of scopes the incidence of these strictures has decreased, sadly they still continue to occur. Hence, literature on these strictures is also limited due to the rarity of occurrence. To analyze the management strategies and outcomes of post-valve-ablation urethral strictures managed in a tertiary care center. A retrospective review of all boys with the diagnosis of urethral strictures who had undergone management in our center from January 2000 to July 2017, with a minimum follow-up data for 12 months following interventions was done and among them the subset who developed strictures following valve ablation were identified. We also included those patients who had been referred for management of strictures following ablation elsewhere and had all their preoperative and operative details recorded. Out of a total of 199 boys who had undergone management of stricture during this time period, 13 boys with stricture of urethra following valve ablation were identified and studied. The history, presentation, timeline of events leading to stricture formation, possible predisposing factors, characteristics of strictures, mode of management and outcomes were recorded. Among the 13 boys, 5 had developed strictures following in-house fulguration while 8 developed strictures following ablation elsewhere. The median age at diagnosis in these patients was 8 years (range, 3-18). The length of stricture varied from very short in the proximal bulbar to long penobulbar stricture. Median length of strictures was 10mm (range: 3-35). Of the 9 patients who underwent primary endoscopic intervention, 8 had successful outcomes (88.7%) while one patient ultimately required open urethroplasty. Of the 4 patients who had open intervention, except the patient who underwent meatoplasty, the rest needed multiple surgical and endoscopic interventions. Median follow up period was 20 months (range: 12-68). Urethral Stricture disease continues to be a rare but significant complication of valve ablation. Post ablation stricture can happen in any part of the urethra. Our data suggests that if a DVIU or dilatation is to be implemented for the treatment of a stricture after ablation, it may be most suitable for short, proximal strictures. Proper technique of valve ablation by a dedicated pediatric urologist using a proper sized resectoscope with proper isolation of electrode from the rest of urethral wall is crucial to prevent these strictures.

Magnetic Resonance-Guided High-Intensity Focused Ultrasound (MR-HIFU): Overview of Emerging Applications (Part 2).

High-intensity focused ultrasound (HIFU) allows noninvasive heating of deep-seated tissues. Guidance under magnetic resonance imaging (MR-HIFU) offers spatial targeting based on anatomical MR images as well as MR-based near-real-time temperature maps. Temperature feedback allows delivery of a well-defined thermal dose enabling new applications such as the ablation of malignant tissue. Peer-reviewed publications on MR-HIFU were studied and are summarized in this review. Literature was restricted to applications in oncology. Several MR-HIFU-based applications for the treatment of malignant diseases are currently part of clinical trials or translational research. Recent trials regarding the treatment of prostate cancer with MR-HIFU have already shown this to be a safe and patient-friendly method. For the treatment of breast cancer and malignancies within abdominal organs, MR-HIFU has been applied so far only in proof of concept studies. MR-HIFU is currently being investigated for the ablative treatment of malignant tissue in a variety of oncological applications. For example, the transrectal as well as transurethral ablation of prostate cancer using MR-HIFU was shown to be a patient-friendly, safe alternative to other local treatment options with low side effects. · MR guidance offers high soft tissue contrast for treatment planning, near-real-time temperature monitoring, and post-interventional therapy evaluation.. · Special HIFU transducers and technological solutions are available for the treatment of e. g. prostate cancer, breast cancer or abdominal malignancies.. · Siedek F, Yeo SY, Heijman E et al. MR-Guided High-Intensity Focused Ultrasound (MR-HIFU): Overview of Emerging Applications (Part 2). Fortschr Röntgenstr 2019; 191: 531 - 539.

Transurethral ablation of a prostatic utricle cyst with the use of a holmium laser

To demonstrate a safe and effective approach to the treatment of obstructing midline prostate utricle cyst with the use of a holmium laser. Video presentation. University hospital. A 33-year-old man presented with chronic pelvic pain, pain with ejaculation, and infertility. Semen analysis demonstrated oligoasthenospermia with poor viability and computerized tomographic scan identified the presence of a midline 2-3-cm prostatic cyst with dilated seminal vesicles bilaterally. Transrectal ultrasound in the office confirmed the diagnosis of midline obstructing prostatic utricle cyst and estimated the distance from the urethra. Transurethral ablation of a midline prostate utricle cyst with the use of a holmium laser. Intraoperative technique highlighting the main steps for a transurethral ablation of a midline prostate utricle cyst with the use of a holmium laser. This video highlights the technique for transurethral ablation of a midline prostate utricle cyst with the use of a holmium laser to unroof the cyst. Retrograde vesiculography was performed to confirm patency of the ejaculatory ducts. Outpatient surgery was tolerated well and the patient was discharged. After surgery at 4weeks, his symptoms had abated and semen analysis revealed normozoospermia. We demonstrate safe and effective transurethral ablation of a midline prostate utricle cyst with the use of a holmium laser. Preoperative transrectal ultrasound or cross-sectional imaging can be useful for operative planning. When the orifices of the ejaculatory ducts can be identified, vesiculography can be performed to confirm patency of the ducts and seminal vesicles after relief of the obstructing cyst.

Therapeutic effects of endoscopic ablation in patients with Hunner type interstitial cystitis

To investigate the efficacy of endoscopic ablation of Hunner lesions (HLs) in patients with interstitial cystitis (IC) and to find predictors of early recurrence of HLs. A prospective study was performed of patients with Hunner type IC who underwent transurethral ablation. We repeated endoscopic ablation when symptoms and HLs recurred during the follow-up period. The primary endpoint was recurrence-free time. Secondary endpoints were a change in frequency, nocturia, and urgency episodes, and changes in visual analogue scale (VAS) pain scores and other symptom indices at follow-up visits. A total of 72 patients were analysed. The median (range) follow-up period was 29.5 (12.0-50.0) months. After primary ablation treatment, HLs recurred in 75.0% (54/72) of patients, and the median (sd) recurrence-free time was 12.0 (1.6) months. Amongst the 54 patients with recurrence, 50 underwent a second ablation treatment. HLs occurred in 44.0% (22/50) of individuals after the second operation, and the median (sd) recurrence-free time was 18.0 (5.1) months. Lower maximal cystometric capacity (odds ratio 1.01, 95% confidence interval 1.001-1.013) was the predictive factor for early recurrence. There were significant improvements in the VAS pain scores, O'Leary-Sant Interstitial Cystitis Symptom Index and Problem Index, Pelvic Pain and Urgency/Frequency Patient Symptom Scale after treatment (all, P < 0.05). Endoscopic ablation is an effective treatment option for HLs and significantly reduces pain and improves voiding symptoms. Repeat ablation upon recurrence could help symptom control and bladder preservation only if the bladder capacity is maintained.

Use of holmium:YAG laser in posterior urethral valves: Another method of fulguration

ObjectiveTo evaluate the use of holmium:YAG laser for posterior urethral valve (PUV) fulguration and compare with electro-fulguration. MethodsForty boys underwent primary fulguration of PUV using 20–25 W holmium laser (Group 1) from January 2009 to December 2011. Data of last 40 boys (retrospective cohort: January 2005 to December 2008) who underwent electro-fulguration (Group 2) for PUV were compared with group 1. Ultrasonography was done at 2 weeks and 3 months and voiding cystourethrography at 3 and 6 months respectively after fulguration and as needed thereafter. DTPA scan and urodynamic study were performed during follow-up in select patients, as required. ResultsPre-operative parameters were comparable between groups. Improvement in voiding occurred in 38 and 34 boys in group 1 and 2, respectively. Hydroureteronephrosis and vesico-ureteric reflux resolved in 53% and 60% in group 1 and 51% and 53% in group 2, respectively. Boys in group 1 had statistically significant greater success in voiding after catheter removal (40 vs 32), shorter period of catheterization (1 vs 1.8 days), lower mean operative time (15 vs 20 min), needed re-fulguration less commonly (2 vs 6), and were less likely to develop urethral stricture (0 vs 2) and urinary incontinence (0 vs 1). ConclusionPUV fulguration using holmium:YAG laser is a feasible, safe and effective alternative for endoscopic transurethral ablation with similar success, and appears to have fewer complications than electro-fulguration.

POD-10.02: Evaluation of the Transurethral Protease Ablation of the Prostate for Benign Prostatic Hyperplasia (BPH) Accompanied by Low Urinary Tract Symptoms: A Five-Year Follow-up Evaluation

POD-10.02: Evaluation of the Transurethral Protease Ablation of the Prostate for Benign Prostatic Hyperplasia (BPH) Accompanied by Low Urinary Tract Symptoms: A Five-Year Follow-up Evaluation

Local treatment of prostate cancer using thermal-ablative energy

Thermal and thermal-ablative procedures for treating prostate cancer have been investigated systematically since approximately 1980 (apart from some historical predecessors), and numerous experimental and clinical reports have been published on this subject. Various technologies have been used, including transurethral ablation of prostatic tissue using laser or microwave energy, interstitial application of laser or microwave energy, and inductive heating of previously implanted thermoseeds or injected magnetic nanoparticles in a magnetic field. For all of these procedures, clinical studies with a total of some 350 patients have been performed. However, the results cannot be judged correctly because of a lack of adequate control parameters for the older studies and inadequately short follow-up of all studies. Conclusions regarding treatment-related morbidity seem to be possible, with a generally positive impression and low rates of adverse effects. But before such results can be generalized, patient selection bias and the technology standards that existed when the studies were performed must be taken into consideration. Various papers are reviewed and summarized. In the author's opinion, the different options for thermal and thermal-ablative treatment of prostate cancer are very promising, but in light of the existing standard procedures, feasibility must not overrule reasonableness.

Primary Ablation of Posterior Urethral Valves in Low Birth Weight Neonates by a Visually Guided Fogarty Embolectomy Catheter

In low birth weight neonates primary ablation of posterior urethral valves represents a particular difficulty. The tiny caliber of the urethra presents a challenge for even the smallest commercially available pediatric resectoscope. Transurethral ablation by wired electrodes is difficult due to the narrow field of neonatal scopes with slow irrigation and restricted maneuverability. A Fogarty embolectomy catheter under fluoroscopic control does not allow direct visual assessment, and can be a lengthy procedure with numerous manipulations at the radiology suite. We describe a hybrid technique for primary valve ablation in neonates using a Fogarty catheter working retrograde under direct visual guidance of a neonatal cystoscope. A total of 17 low birth weight newborns (median 2,100 gm, range 1,760 to 2,690) underwent primary valve ablation using a 2Fr Fogarty catheter working through a 7.5Fr neonatal cystoscope with an offset lens. Both components were withdrawn as a single unit to avulse the valve leaflets under vision. Vesicoureteral reflux was present in 13 patients (76%) involving 24 renal units. A voiding cystourethrogram was performed 8 to 10 weeks postoperatively to delineate adequate decompression of the posterior urethra and mark the end point of the study in evaluating the efficiency of the technique. There were no immediate perioperative complications. Three patients died of causes unrelated to the procedure, leaving 14 boys (21 refluxing units) for evaluation. Voiding cystourethrogram revealed effective decompression of the posterior urethra with adequate drainage in all but 1 remaining patient (93%) due to a persistent left leaflet. Of 21 refluxing units reflux resolved in 6 (29%), was downgraded in 10 (48%) and remained unchanged in 5 (24%). In low birth weight neonates primary valve ablation by a visually guided Fogarty catheter ensures effective disruption of the valvular obstructive mechanism. The technique maintains the transurethral visual standard and avoids the difficult manipulation of wired electrodes in a restricted field. It is devoid of radiation exposure and its simplicity enables safe performance at the neonatal intensive care unit, where the support needs of this fragile subset of patients are optimally provided for.

Lasers in urology

In contrast to other technical developments, it was understood at an early stage that lasers would be of great help for medical purposes and the medical society embraced this new tool instantly. Interestingly, the typically destructive feature of laser technology was not the original focus. This lay in the area of reconstructive potential and was therefore used in ophthalmology for retina repair. In contrast to almost all other technical developments a sharing of knowledge between physicians and scientists took place from the very beginning. Whereas this cross subject exchange worked very eVectively in the initial phase, a time came where, Wrst and formost, physicians did not heed the principles of laser technique and thereby ignored the balance of eVect and side eVect. This was when the medical application of lasers took a wrong turning, which led to a detriment in the reputation of laser technology for a long time. It is therefore understandable that after the initial enthusiasm in the early 1990s the laser, although physically present in many clinics, was hardly in use anymore. Hence, we felt the need to introduce the basic technical aspects of lasers after displaying the historic development of lasers in our article. We are especially pleased that the physicist and pioneer of Holmium laser technology, Heinrich-Otto Teichmann, has agreed to contribute a review on the subject “Technical aspects of lasers in urology”. For the past 20 years he has been well acquainted with the problems and needs of urologists in this Weld. In his article, he explains the physical basics of laser systems, whose application is theoretically possible and feasible in the Weld of urology. The article “Lasers in clinical urology: state of the art and new horizons” could be seen as the clinical pendant to the work of Heinrich-Otto Teichmann. Here, we have the same approach, but this time from the perspective of the urologists Andrew Marks and Joel Teichman from Vancouver, Canada, both with major reputations in their respective Welds of endoscopy and laser therapy. Today, the use of lasers in clinical urology mainly consists of stone therapy and transurethral ablation of the prostate. For these speciWc application we were able to enlist Sean Pierre and Glen Preminger from Duke, USA and Rainer Kuntz from Berlin as distinguished urologists. Both Preminger and Kuntz are pioneers in their Weld and experienced laser therapists. Courtney Philips and Jamie Landman from New York complete the line up of the afore-mentioned excellent urologists. In their article “Lasers in the upper urinary tract for non-stone disease” they refer to the utilisation of laser systems outwith the above-mentioned Welds. Technical innovation and medical demands/requirements evoke a constant evolution in medical laser systems and their applications. In this respect, the Thullium:YAG laser is the “new kid on the block”. It is a continuous laser on almost the same wavelength as the Holmium:YAG laser. Our group presents early results in the treatment of BPH and recurrent bladder neck strictures. Lasers have become the interesting products they are mainly through the tools with which they are utilized. The downside is the high cost of purchase of the lasers and the T. R. W. Herrmann (&) Department of Urology and Pediatric Urology, Medical School of Hannover, Carl Neuberg Strasse 1, 30625 Hannover, Germany e-mail: trwh@trwh.de URL: http://www.mh-hannover.de

The Combined use of Transurethral Electrovaporization Ablation and Transurethral Resection of High-risk benign Prostatic Hyperplasia

目的 探讨高危前列腺增生症的有效治疗方法.方法 回顾分析2000年1月～2006年10月我院52例高危前列腺增生症患者采用经尿道前列腺电汽化术(transurethral electrovaporization of prostate,TRVP)联合经尿道前列腺电切术(transurethral resection of prostate,TRUP)治疗的诊治过程及预后情况.结果 手术平均时间70 min,平均切除腺体重量45g,术中无发生大出血、电切综合征等并发症,全部患者安全渡过围手术期,拔除尿管后,全部患者恢复自主排尿.术后随访5～36个月,IPSS评分由术前平均27分下降至术后平均6分;QOL评分由术前平均5分下降至术后平均1分;QMAX由术前平均6.1ml升高至术后平均16.3ml;剩余尿量由术前平均230ml下降至术后平均23ml.结论 采用TRVP联合TRUP治疗高危前列腺增生症,兼有两者优点,并发症少、安全性大、疗效显著是治疗高危BPH的有效方法。

MP-06.03: Laparoscopic bladder diverticulectomy

Bladder diverticula can be of congenital or acquired origin. More common problem in adults urology are lesions formed as a result of obstruction of lower urinary tract. The surgical treatment of bladder diverticula consists of diverticular excision by open approach with simultaneously (adenomectomy) or previously performed transurethral ablation of prostatic adenoma. An interesting alternative for conventional surgery, especially in cases of large diverticulas, can be laparoscopic diverticulectomy (LD) which has been performed since 1992 and technically it is reproduction of open procedure.

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.

Myogenic failure in posterior urethral valve disease: real or imagined?

It has been suggested that hypocontractility or myogenic failure develops in older boys with a history of 9 posterior urethral valved as the hyperactive, poorly compliant bladders decompensate with age. Also a much higher prevalence of myogenic failure has been reported than we have observed. We determine the prevalence of myogenic failure in boys with a posterior urethral valve and whether myogenic failure was a consequence of earlier detrusor instability or diminished compliance. We retrospectively reviewed the urodynamic findings of 51 boys after transurethral ablation of a posterior urethral valve. Group 1 (longitudinal group) consisted of 11 boys 12 to 19 years old who had undergone at least 1 serial urodynamic study before and 1 after age 10 years. Group 2 (younger group) included 33 boys whose urodynamic testing was performed before age 10 years. Group 3 (older group) comprised 7 previously treated boys whose initial urodynamic study was done after age 12 years. Overall, myogenic failure was noted in 3 (all group 1) of 51 (5.9%) patients. Each of the 3 boys initially had a hypocompliant bladder, and myogenic failure developed only after institution of anticholinergic therapy and resolved once anticholinergics were discontinued. An additional 34 boys treated with anticholinergics did not have myogenic failure. No tendency towards myogenic failure or marked increase in bladder capacity for age was noted in the older boys. In our experience myogenic failure is uncommon and more likely secondary to anticholinergic therapy than a preordained consequence of valve disease. We postulate that our proactive, early aggressive use of urodynamic studies and pharmacotherapy to identify and manage the secondary effects of valve disease reduces the incidence of myogenic failure.

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.

THE TRANSURETHRAL RESECTION SYNDROME: AN UNUSUAL COMPLICATION OF POSTERIOR URETHRAL VALVE ABLATION

A male prenatally diagnosed with posterior urethral valves and bilateral hydronephrosis was born elsewhere at 38 4⁄7 weeks of gestation. Voiding cystourethrography shortly after birth revealed posterior urethral valves with bilateral grade V reflux but no urinary extravasation. On day 1 of life creatinine was 0.8 mg./dl. (normal 0.6 to 1.1), while on day 2 preoperative serum electrolyte evaluation demonstrated sodium 141 mmol./l. (normal 135 to 145) and chloride 106 mmol./l. (normal 98 to 110). Transurethral valve ablation was performed on day 2 of life using water irrigation and a pediatric resectoscope. Operative time was 1 hour 15 minutes. A seizure occurred within 2 hours of the completion of this apparently uncomplicated procedure. Serum electrolyte evaluation at that time demonstrated sodium 113 mmol./l. and chloride 85 mmol./l. The neonate was treated intravenously with normal saline. During the next 2 days sodium slowly increased to 139 mmol./l. and creatinine to 2.8 mg./dl. Because of worsening renal function the newborn was transferred to our tertiary care facility. At presentation the abdomen was tense and scrotal swelling was evident. Abdom-