Valve Bladder Syndrome Research Articles

Ureterocystoplasty in Boys with Valve Bladder Syndrome-Is This Method Still up to Date?

Boys with valve bladder syndrome (PUV) require adequate treatment of the lower urinary tract to preserve renal function and improve long-term outcomes. In some patients, further surgery may be necessary to improve bladder capacity and function. Ureterocytoplasty (UCP) is usually carried out with a small segment of intestine or, alternatively, with a dilated ureter. Our aim was to evaluate the long-term outcomes after UCP in boys with PUV. UCP had been performed in 10 boys with PUV at our hospital (2004-2019). Pre- and postoperative data were evaluated in relation to kidney and bladder function, the SWRD score, additional surgery, complications, and long-term follow-up. The mean time between primary valve ablation and UCP was 3.5 years (SD ± 2.0). The median follow-up time was 64.5 months (IQR 36.0-97.25). The mean increase in age-adjusted bladder capacity was 25% (from 77% (SD ± 0.28) to 102% (SD ± 0.46)). Eight boys micturated spontaneously. Ultrasounds showed no severe hydronephrosis (grade 3-4). The SWRD score showed a median decrease from 4.5 (range 2-7) to 3.0 (range 1-5). No conversion of augmentation was required. UCP is a safe and effective approach to improve bladder capacity in boys with PUV. In addition, the possibility of micturating naturally is still maintained.

Late diagnosis of posterior urethral valves: a case report and the literature review

Posterior urethral valves (PUV) are the most common cause of lower urinary tract obstruction in boys. They are usually suspected antenatally or soon after the birth as the cause of severe hydronephrosis, oligohydramnios, renal hypodysplasia, and kidney failure. In milder forms of PUV, the uncharacteristic symptoms occur later in childhood, adolescence, or even adulthood and cause diagnostic problems. The final diagnosis and causative treatment of PUV are possible due to cystourethroscopy. Nevertheless, as a consequence of the defect, valve bladder syndrome (VBS) occurs and requires long-term treatment. The authors present a case of a 14-year-old boy with a late diagnosis of PUV at the age of 7. Recurrent pyelonephritis and nonspecific voiding dysfunction were the first symptoms. Ultrasounds(US) were initially normal while videocystometry(VCM) showed the 3rd-grade right-sided vesicoureteral reflux (VUR), bladder diverticulum as well as discrete detrusor overactivity, and reduced bladder capacity without any signs of bladder obstruction. Bilateral post-inflammatory nephropathy completed the clinical picture. In urethrocystoscopy surprisingly PUV were found and incised. Due to recurrent urinary tract infections (UTIs) one year later the STING procedure was performed which resulted in the resolution of VUR. Despite this, the features of bladder dysfunction, requiring regular urodynamic evaluation and pharmacotherapy, persisted. Recurrent UTIs in boys may suggest urinary tract obstruction and PUV should be considered regardless of the patient's age. Early diagnosis and appropriate management may improve the prognosis.

Outcome of Urinary Bladder Dysfunction in Children.

Bladder dysfunction in children is common, the most frequent underlying causes are neurologic bladder (NB), dysfunctional voiding syndrome (DVS), and the valve bladder syndrome (VBS). The aim of this study was to determine the 10-y survival rate and the associated morbidities in children with bladder dysfunction. One hundred ninety-nine children were included in the study; 60 with VBS, 75 DVS, and 64 NB. The mean age was 44 mo (CI: 37-50.9) and mean GFR 50.1 (CI 44.6-55.6) mL/min/1.73m2. The 10-y survival rate was 89%. Compared with patients with VBS, the mortality was 11 times higher among patients with NB (p = 0.02) but not significantly higher than patients with DVS (p = 0.2). GFR < 15mL/min/1.73 m2 increases mortality rate by 6 times compared with normal GFR (p = 0.007). Late age at presentation (> 5 y) increases mortality risk and/or the need for renal replacement therapy (RRT) by almost 5 times (p = 0.013). It was concluded that the etiology of bladder dysfunction, baseline GFR, and the age at presentation significantly influence the survival rate and morbidities.

Voiding dysfunction in children causes, management, and prognosis: A single-center retrospective study.

Objectives:To review voiding dysfunction caused by 3 different etiologies; dysfunction voiding syndrome (DVS), neurogenic bladder secondary to spinal dysraphisim (NB), and valve bladder syndrome (VBS).Methods:A single-center retrospective study on children with voiding dysfunction followed up at King Abdulaziz University Hospital, Jeddah, Saudi Arabia from 2005 to 2017.Results:One hundred and ninety-nine children (67.3% boys) were included: Group 1 (n=75, DVS), Group 2 (n=64, NB), and Group 3 (n=60, VBS). Further classification according to the age at presentation; infants (46%), toddlers (27%) and school aged (28%). Management categories: 31% children needed observation only, 25% needed clean intermittent catheterization (CIC), 13% needed only surgery and 31% needed both surgery and CIC. Associated comorbidities: hydronephrosis (81%), vesicoureteral reflux (47%), pyelonephritis (37%) and renal scar (60%), all have negative impact on estimated glomerular filtration rate (eGFR). Urodynamic studies revealed poor bladder compliance in 57.6% and atonic bladder in 1.1%, progression to chronic kidney disease (22%), commenced on renal replacement therapy 11.5% and 4% died with ESKD. Overall improvement in the last eGFR is observed (p<0.001), but VBS group was the least to improve (p=0.021). There was a negative correlation between the last eGFR and age at presentation (p=0.002).Conclusion:Early diagnosis and management of childhood voiding dysfunction was associated with better prognosis. Children managed conservatively have better preservation of kidney function than those who needed surgery.

Хирургическое лечение детей с клапаном задней уретры

Objective. To assess treatment outcomes in children with posterior urethral valve (PUV). Patients and methods. We analyzed treatment outcomes in 60 children with PUV within a non-randomized, retrospective, single-center, pilot study. Sixty patients have undergone PUV ablation; 8 of them required repeated ablation. Endoscopic treatment of vesicoureteral reflux (VUR) was performed in 31 ureters; 5 children had botulinum toxin therapy. Results. Type 1 PUV was diagnosed in 49 patients (81.6%), whereas type 3 PUV was identified in 11 patients (18.3%). VUR was detected in in 65 ureters (54.1%); obstructive ureterohydronephrosis was diagnosed in 40 ureters (33.3%). Ablation of the valve flaps improved lower urinary tract (LUT) urodynamics in 27 children. Thirty-three patients had valve bladder syndrome (VBS). Improvement of the upper urinary tract (UUT) condition was achieved in 54 cases. Fifteen children have undergone nephroureterectomy. There was a significant decrease in the activity of pyelonephritis in children after endoscopic ablation of the PUV. Fifty-three patients (88.3%) demonstrated severe UUT urodynamic disorders. The baseline grade of UUT lesions affected treatment outcome (p = 0.0009). Children with VBS symptoms had progressive UUT pathology and persistent urinary incontinence. Six patients eventually required replacement therapy. Conclusion. The majority of PUV children (88.3%) presented with severe UUT impairments. More than half of the patients (55.0%) had VBS symptoms. Their treatment should be comprehensive and include long-term monitoring of urodynamics and kidney function. Key words: posterior urethral valve, valve bladder syndrome, vesicoureteral reflux

P1815LONG-TERM OUTCOME OF BLADDER DYSFUNCTION IN CHILDREN

Abstract Background and Aims Bladder dysfunction is an important cause of chronic kidney disease (CKD) due to neurogenic causes such as a spinal lesion (SL), Hinman's syndrome, or non-neurogenic neurogenic bladder (NNNB), and valve bladder syndrome (VBS). In this study, we evaluated the outcomes of neurogenic bladder caused by different etiologies. Method Single-center retrospective study of children with neurogenic bladder (NB) over 13 years (2005-2017). Results Totally, 199 children (134 boys, 67.3%) were included and divided into three groups: Group 1 (75, NNNB), Group 2 (64, SL), and Group 3 (60, VBS). Urodynamic examination revealed impaired bladder capacity in 49 children (57.6%), atonic bladder in 1 child (1.1%), and normal bladder compliance in 35 children (41.1%). Additionally, 113 children (56.8%) experienced clean intermittent catheterization (CIC). A significant improvement in the mean estimated glomerular filtration rate and CKD stages was observed among the three studied groups, but the NNNB group showed the least improvement. Children diagnosed and treated during their first year of life had better outcomes than those who presented at a later age. CIC without the need for surgical intervention was associated with improved renal function. Pyelonephritis and hydronephrosis had significant negative impacts on kidney function Conclusion Early diagnosis and management of NB in infancy are associated with better outcome and preservation of renal function. CIC is associated with better preservation of kidney function, while vesicostomy is associated with a worse outcome. Children with NB caused by SL experienced the best kidney function preservation, while those with VBS experienced the worst.

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.

SUN-104 Long term outcome of childhood bladder dysfunction

Bladder dysfunction is an important cause of chronic kidney disease (CKD). It could be due to neurogenic causes mostly spinal lesion (SL), Hinman syndrome or non-neurogenic neurogenic bladder (NNNB) and following posterior urethral valve ablation named valve bladder syndrome (VBS). A retrospective study of all children with neurogenic bladder (NB) over 12 years duration from single center. 199 children (134, boy, 67.3%), were included and divided into three groups; group1 (75 NNNB), group2 (64 SL) and group 3 (60 VBS). Their mean (SD) age at presentation was 43.96(49.66) month. The mean (SD) duration of follow up 71.79(45.46) month. Urodynamic study was done in 85 children before any surgical intervention, it revealed impaired bladder capacity in 49 children (57.6%), atonic bladder in one child (1.1%) while normal bladder compliance in 35 children (41.1%). 113 children (56.8%) were performing clean intermittent catheterization (CIC). Surgical interventions were required in 86 (43.2%). A significant improvement in the mean eGFR and the CKD stages was observed among the three studied groups but the NNNB group showed the least improvement. Children diagnosed and started management during their first year of life had better outcome. Performing CIC without the need for surgical intervention were associated with more improvement of renal function. Pyelonephritis and hydronephrosis have significant negative impact on kidney function. Renal scars was positive in 62%, but did not have negative effect on eGFR at the last follow up. Forty children (20%) progressed to end stage kidney disease (ESKD), mainly from the VBS group. Renal replacement therapy was performed in 23 children (11.5%); 11 hemodialysis, 11 peritoneal dialysis and one child received renal transplantation. Mortality was 7.5% (15 children), caused y ESKD complications in 10 children, while the remaining 5 children died from non-renal causes. Diagnosis and management of NB in early infancy is associated with better outcome. Successful CIC is more beneficial than vesicostomy and NB caused by spinal lesion is the best regarding preservation of kidney function, while VBS group is the worst.

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.

Valve bladder syndrome in children: On the trail of the best strategies to prevent chronic kidney disease.

Pediatric patients suffering from valve bladder syndrome (VBS) are at risk of developing chronic kidney disease (CKD) and renal failure in later life. Therefore, it is of vital importance to determine the risk factors and the best possible strategies for diagnosis and treatment in patients with VBS that would minimize the risk of developing CKD. In this review we have presented the current knowledge of CKD risk factors in patients with posterior urethal value (PUV). We have also discussed possible recommendations for prenatal diagnostics procedures to be undertaken in patients with PUV, postnatal monitoring and therapeutic strategies that could reduce the risk of developing CKD in this population. Although in most cases there are no clear guidelines for appropriate clinical actions that can be undertaken in patients with PUV to minimize the risk of kidney failure, we have tried to present concise and accurate advice for physicians taking care of patients with PUV.

Mitrofanoff for Valve Bladder Syndrome: Effect on Urinary Tract and Renal Function

Despite early diagnosis and valve ablation, progressive renal impairment develops in a significant proportion of boys born with posterior urethral valves. Bladder dysfunction is thought to have an important role in the etiology of this renal deterioration. We report the outcome of treating bladder dysfunction with clean intermittent catheterization and overnight drainage via a Mitrofanoff appendicovesicostomy with respect to upper tract imaging, urodynamic findings and renal function. All patients were established on a clean intermittent catheterization program via the Mitrofanoff stoma, including 3 or 4 daytime catheterizations and overnight drainage with an indwelling catheter. We analyzed trends in serum creatinine, renal ultrasound appearance and urodynamic data. Mitrofanoff formation was performed in 24 patients with valve bladder syndrome. Median followup was 6.2 years. Hydronephrosis, quantified by combined anteroposterior diameter measurements of the renal pelvis, significantly improved with a mean combined anteroposterior diameter reduction of 14.2 mm (95% CI 7.6-20.9, p ≤ 0.001). Overall bladder dysfunction improved. Capacity was decreased in 9 of 12 patients (75%) initially compared with 12 of 21 (57%) after Mitrofanoff surgery (p = 0.457). Compliance was poor in 75% of patients initially vs 28.6% at followup (p = 0.014). Despite improvements in hydronephrosis and urodynamic parameters the mean estimated glomerular filtration rate deteriorated. End stage renal failure developed in 35% of cases during followup. Treatment of valve bladder with clean intermittent catheterization and overnight drainage via a Mitrofanoff stoma can achieve significant improvements in hydronephrosis and bladder dysfunction urodynamic parameters. However, it does not prevent renal deterioration.

Colovesical Fistula: Unexpected Complication 7 Years After Augmentation Ileocystoplasty

Augmentation enterocystoplasty has been extensively used to attain high-capacity low-pressure urinary reservoirs in patients with neuropathic bladder, exstrophy-epispadias complex, valve bladder syndrome, and contracted bladder. Enterovesical fistula might occur as an early complication after enterocystoplasty. We report the case of a 16-year-old boy, who presented with chronic watery diarrhea 7 years after augmentation ileocystoplasty. A colovesical fistula was diagnosed. We discuss the clinical presentation, management plan, and operative findings.

Yang-Monti’s Catheterizable Stoma in Children

BackgroundIn 1981, Mitrofanoff described a procedure to create a continent urinary stoma for clean intermittent catheterization. Since then several procedures have been described including Yang-Monti ileovesicostomy for effective catheterization.ObjectivesWe report on our experience from the use of Monti’s procedure in children at our center.Patients and MethodsChildren < 18 years of age undergoing urinary diversion/reconstruction with Yang-Monti’s procedure for congenital conditions or neuropathic bladder formed the study group. All these children, post-operatively were taught clean intermittent catheterization (CIC) and put on a regime using a 14/16 Fr catheter every 3 hours. The children were followed regularly at 3, 6, 12, 18 and 24months post-operatively, with special attention paid to any problems with catheterization and incontinence.ResultsDuring the period from Jan 2000 to Dec 2011, at our center, 19 children less than eighteen years of age underwent urinary diversion with Yang-Monti’s catheterizable stoma. The indications for urinary diversion was neuropathic bladder in eight, exstrophy bladder in seven , valve bladder syndrome in three and persistent urethral stricture in one. None of the children found CIC difficult during the post-operative period and there was no hindrance to the passage of the catheter.ConclusionsAlthough the appendix remains the tissue of choice for creation of catherterizable stoma, the Yang-Monti ileovesicostomy is effective, convenient conduit for children. Long-term complications are minimal and children find this comfortable to do CIC.

Combined laparoscopic-assisted nephrectomy, augmentation ureterocystoplasty and Mitrofanoff appendicovesicostomy

Conventional and robotic-assisted laparoscopy is being used for more and more complex urological procedures in children. There have recently been reports of laparoscopic or laparoscopic-assisted appendicovesicostomies in children. We report a case of combined laparoscopic-assisted nephrectomy, augmentation ureterocystoplasty and Mitrofanoff appendicovesicostomy in a 5-year-old boy with valve bladder syndrome.

Early Valve Ablation Can Decrease the Incidence of Bladder Dysfunction in Boys With Posterior Urethral Valves

Valve bladder syndrome represents the worst end of the posterior urethral valve spectrum. Recent data suggest that early valve ablation can provide the chance for the bladder to heal and improve dynamics. We tested the hypothesis that early valve ablation can decrease the incidence of bladder dysfunction in these boys. A total of 16 full-term males with prenatally diagnosed hydronephrosis and a full bladder proved postnatally to have posterior urethral valve were studied. Valve ablation was performed during the neonatal period (group 1). The records of 16 boys with posterior urethral valves who underwent valve ablation after age 1 year were obtained (group 2). Ultrasound was performed every month and urodynamics were performed every 6 months. At age 3 years voiding diary and toilet training results were obtained. The incidence of bladder dysfunction in the 2 groups was recorded according to clinical, ultrasound, voiding cystourethrogram and urodynamic parameters. Mean followup was 3 years. Post-void residual urine, measured as more than 30% of expected bladder capacity for age, improved in 14 patients (87.5%) in group 1 and in 10 (62.5%) in group 2. Excluding cases of vesicoureteral reflux-renal dysplasia syndrome, vesicoureteral reflux was present in 20 renal units initially in group 1 and showed resolution or improvement in 16. In group 2 vesicoureteral reflux was present in 26 units and improved in 14. At last followup mean cystometric bladder capacity, measured at 30 cc H(2)O, in group 1 was 145 +/- 22 ml which was comparable to age matched normal bladder capacity. In group 2 mean +/- SD cystometric bladder capacity was 130 +/- 30 ml, which was significantly lower than age matched normal bladder capacity. Hypocompliance and instability were significantly lower in group 1. Toilet training was easier and yielded better results for dryness in group 1. Overall bladder dysfunction was present in 2 boys (12.5%) in group 1 and in 8 (50%) in group 2. Neonatal valve ablation would protect the bladder and allow normal cycling, which helps in bladder healing. This underscores the importance of routine prenatal screening and early intervention at a specialized center.

SECONDARY BLADDER NECK OBSTRUCTION IN BOYS WITH A HISTORY OF POSTERIOR URETHRAL VALVE: REVISITED

You have accessJournal of Urology1 Apr 2009SECONDARY BLADDER NECK OBSTRUCTION IN BOYS WITH A HISTORY OF POSTERIOR URETHRAL VALVE: REVISITED Andrew J Combs, Mark Horowitz, and Kenneth I. Glassberg Andrew J CombsAndrew J Combs More articles by this author , Mark HorowitzMark Horowitz More articles by this author , and Kenneth I. GlassbergKenneth I. Glassberg More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(09)60490-0AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "SECONDARY BLADDER NECK OBSTRUCTION IN BOYS WITH A HISTORY OF POSTERIOR URETHRAL VALVE: REVISITED." The Journal of Urology, 181(4S), p. 171 © 2009 by American Urological AssociationFiguresReferencesRelatedDetailsCited byGlassberg K and Combs A (2016) The Valve Bladder Syndrome: 35+ Years LaterJournal of Urology, VOL. 196, NO. 1, (16-17), Online publication date: 1-Jul-2016. Volume 181Issue 4SApril 2009Page: 171 Advertisement Copyright & Permissions© 2009 by American Urological AssociationMetricsAuthor Information Andrew J Combs More articles by this author Mark Horowitz More articles by this author Kenneth I. Glassberg More articles by this author Expand All Advertisement PDF downloadLoading ...

Augmentation ureterocystoplasty in boys with valve bladder syndrome

Objective Children with valve bladder syndrome represent the worst end of the posterior urethral valve spectrum. When conservative measures fail to control recurrent infections, prevent deterioration of the upper tract (in the form of increasing hydronephrosis and or worsening of kidney function) and improve incontinence, augmentation cystoplasty is considered. In most of these boys, renal insufficiency precludes the use of intestine for augmenting the bladder. Our aim was to evaluate the efficacy and safety of ureterocystoplasty in managing children with valve bladder syndrome. Patients and methods Eight boys (mean age 5 years) with valve bladder syndrome were included in this study. All boys had successful valve ablation at the time of presentation. When conservative treatment failed, ureterocystoplasty was scheduled. The entire ureter was folded and used in four boys after nephrectomy for a non-functioning kidney. The lower dilated ureter was used to augment the bladder, and transureteroureterostomy in two and re-implantation of the remaining ureter in two were performed. Radiological and urodynamic investigation was performed preoperatively and postoperatively at 3, 6 and 12 months. Improvement of hydroureteronephrosis was judged by ultrasound. Results Bladder capacity (as measured during cystometry at 30 cm H 2O) and compliance were significantly improved in all children following the procedure ( P < 0.001), and reached or exceeded the normal calculated capacity for age-matched boys. Hydroureteronephrosis improved in six boys (75%). The procedure avoids almost all the complications of enterocystoplasty. Clean intermittent self-catheterization was performed in all cases routinely after surgery, weaning off as judged by the voiding pattern of the child. Conclusion Ureterocystoplasty is an ideal option for augmenting the hypocompliant bladder in boys with valve bladder syndrome. The entire ureter or the dilated lower part can be used. This is a solution for boys with impaired renal function when enterocystoplasty cannot be performed.

Urodynamic investigation of valve bladder syndrome in children

Objective To investigate urodynamic manifestations and their relationship with the postoperative experience of children with valve bladder syndrome (VBS). Methods Included were 16 children (mean age 3.2 ± 1.8 years) with VBS, who were divided into two groups. The urodynamic study was performed less than 1 year in group 1 (seven boys, aged 1–1.9 years) and more than 1 year in group 2 (nine boys, aged 2.9–6.5 years) after urethral valve fulguration; at the time of operation patients were less than 2 years old. Standards of the International Children's Continence Society were respected, and results were compared between the two groups. Results Compared to group 1, group 2 showed a significant decrease in maximum detrusor voiding pressure (Pdet.void.max) and bladder compliance (BC), and an increase in post-voiding residual (PVR) and maximum bladder capacity (MBC) ( p < 0.05), but the difference in detrusor instability was not significant ( p > 0.05), Pdet.void.max and PVR were 56.2 ± 14.1 cmH 2O and 96.6 ± 52.4 ml, respectively, in group 2, and there were more intermittent detrusor contractions during voiding in this group. Conclusion Patients with VBS frequently present with multiple bladder dysfunctions that can be diagnosed accurately using urodynamics. Even after urethral valve fulguration Pdet.void.max and BC were inclined to decrease, while PVR and MBC increased with the growth of the children.

Management of the valve–bladder syndrome and congenital bladder obstruction: the role of nocturnal bladder drainage

Valve-bladder syndrome often develops after the resolution of posterior urethral valves, but is also found after the resolution of congenital bladder obstruction. The features of this syndrome include the persistent dilation of the upper urinary tracts, a thick-walled, noncompliant urinary bladder, urinary incontinence, and polyuria secondary to nephrogenic diabetes insipidus. Nocturnal bladder management, which involves timed emptying of the bladder or continuous drainage, has been recommended in conjunction with diurnal timed voiding therapy as an adjunct to the treatment of valve-bladder syndrome. This treatment is derived from the hypothesis that valve-bladder syndrome is caused by congenital obstruction, and that the resultant changes in detrusor muscle are associated with a persistent bladder dysfunction characterized by chronic overdistention of the urinary bladder. Such overdistention is exacerbated by polyuria, and can be a cause of secondary hydronephrosis. Bladder dysfunction and overdistention is usually treated during waking time, but occasionally this is not effective on its own, and nocturnal therapy is used as well. To date, there are a few sets of data that suggest overnight bladder drainage can bring about profound improvements in the degree of upper-tract hydronephrosis, renal function, or bladder function. Nocturnal bladder drainage seems, in these initial reports, to be a simple and safe therapeutic maneuver. This review discusses the etiology of valve-bladder syndrome and examines each of the studies which have investigated nocturnal bladder drainage in its treatment.

The Impact of Late Presentation of Posterior Urethral Valves on Bladder and Renal Function

We retrospectively reviewed the records of patients with late presentation of PUVs, and compared bladder and renal function to that in patients with an early diagnosis of PUVs. We retrospectively reviewed the charts of 36 males (mean age at diagnosis 8.8 years, range 5 to 14) with late presentation of PUVs who were treated at our institution between 1986 and 2004. Of these patients 20 had undergone urodynamic evaluation during followup (mean age 10.65 years, range 5 to 23). We chose as controls 19 age matched children with PUVs who were diagnosed and treated before age 5 years and underwent urodynamic evaluation during followup (mean age at urodynamic evaluation 8.52 years, range 6 to 15). Urodynamic parameters were compared between the 2 patient groups. Renal function in the late presenting cases was also compared to controls. The most common symptoms at presentation were diurnal enuresis (17 patients, 47.2%) poor stream (7, 19.4%) and urinary retention (5, 13.9%). Overall, urodynamic bladder abnormalities were detected in 17 of 20 patients (85%), detrusor overactivity in 3 (15%), significant post-void residual in 9 (45%) and bladder capacity greater than expected for age in 9 (45%). No significant difference in bladder capacity, compliance or post-void residual was demonstrated between the late presenting and control groups. Only detrusor overactivity was significantly lower in the late presenting group (p = 0.013). After a mean followup of 67.03 months age specific creatinine levels were increased in 13 of 27 patients (48.1%), including 7 (25.9%) with ESRD. Renal function was significantly impaired in the late presenting group compared to controls (48.1% vs 13.7%, p = 0.001). We found a significantly lower rate of detrusor overactivity (15%) in patients with late presenting PUVs. Comparison of urodynamic parameters between the early and late presenting groups did not reveal any significant difference. This similar pattern of bladder dysfunction, independent of age at relief of obstruction, may indicate a common pathophysiological etiology for bladder dysfunction in all patients with PUVs. Also, renal function was significantly impaired in the late presenting group in this series.