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Follow-Up of 50 Children After Posterior Urethral Valve Management in Al 116 Original article Follow-up of 50 children after posterior urethral valve management in Al-Azhar University Hospitals Abdelrahman I. Ebeid, Mohamed A. Hindawy, Hussein H. Mhamoud, Farouk I. El-Guoshy and Hussein Galal Objective This study was performed to assess the various hydronephrosis in 82.6%, whereas complications occurred clinical presentations, complications, and surgical in three (6%) children. Mortality occurred in five (10%) management, as well as follow-up, of patients with patients. Postoperative improvement of hydronephrosis posterior urethral valve (PUV). grade in both categories is not appreciably different. 08/07/2018 on BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3l7ttZ9b/VuKxIwH3Dy/2pqEl0VxTbhh37J87j9nSKYU= by https://journals.lww.com/aps from Downloaded Patients and methods This is a prospective descriptive Conclusion Urinary drainage using small catheters or analysis of the data of 50 patients with PUVs of different age nasogastric tube in the early days of infancy followed Downloaded reviewed. Serum creatinine levels, clinical examination, by valve ablation is the best treatment modality abdominopelvic ultrasound, and magnetic resonance in PUV. Ann Pediatr Surg 14:116–120 © 2018 Annals of from urography were performed, and the diagnosis was confirmed Pediatric Surgery. https://journals.lww.com/aps by voiding cystourethrography. The patients were divided into Annals of Pediatric Surgery 2018, 14:116–120 two categories: primary intervention and surgical intervention. Keywords: children, outcome, posterior urethral valve, urinary drainage, Results A total of 50 boys with a mean age at diagnosis valve ablation, vesicostomy by of 100 ± 15 days were included in this work. The most Department of Urology, Al-Azhar University, Cairo, Egypt BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3l7ttZ9b/VuKxIwH3Dy/2pqEl0VxTbhh37J87j9nSKYU= common presentation in patients managed by valve Correspondence to Abdelrahman I. Ebeid, MD, Department of Urology, Al-Azhar ablation was difficult micturition (60%), whereas in patients University Hospitals, Cairo 11249, Egypt managed by initial vesicostomy the most common Tel: + 20 100 535 7034; e-mail: [email protected] presentation was febrile urinary tract infection (67%). Received 11 October 2017 accepted 17 December 2017 Vesicoureteral reflux presented in 61.2% and Introduction endoscope. The major area of continuing controversy Posterior urethral valves (PUVs) are the most common involves the most right approach for management of the form of congenital urethral obstruction (ranging from infant who has significant renal insufficiency that persists 1/3000 to 1/8000 male births) and the most congenital after a satisfactory period of transurethral drainage. The abnormalities giving rise to bilateral renal obstruction [1]. options for managing this group of children include PUV carries out the most causes of renal failure in 25–30% endoscopy fulguration of the urethral valves only, of these children [2,3]. According to the North American elective vesicostomy, or high-loop ureterostomy [7]. Pediatric Renal Transplant Cooperative Group, end-stage The aim of this work is to decide which method achieves renal disease secondary to PUV accounts for 16.8% [4]. the current PUV management goals of preserving renal PUV(S) are classified into three types: valves representing function, as well as the lower urinary tract function folds extending inferiorly from the verumontanum to the integrity. It also aimed to evaluate and record the various membranous urethra (type 1); valves as leaflets that glow clinical presentations and management maneuvers, from the verumontanum, proximal to the bladder neck complications, and surgical management and long-term on outcome (for 1 year) of PUV. 08/07/2018 (type 2); and valves forming diaphragms within the prostatic urethra, either above or below the verumonta- num (type 3). Type 1 is the most common [5]. Patients and methods Voiding cystourethrography (VCUG) evaluations are This is a prospective descriptive analysis of the data of 50 needed for the diagnosis. PUV evaluated whether the patients admitted at the Urology Department of our valve leaflets are present, bladder trabeculation, dilated University Hospital (from October 2011 to July 2015) in or elongated posterior urethra, and bladder neck whom PUVs were reviewed after local and ethical hypertrophy. VCUG is the gold-standard imaging proce- committee approval, and an informed written consent dure for documenting PUVs [6]. was obtained from the patient’s relative. The patients were classified according to surgical management into The procedure of choice for PUV management is two different categories. Complete blood count, urina- performed according to the degree of renal function. lysis, blood urea, creatinine, and serum electrolytes were After birth, a urethral catheter is placed; further manage- analyzed. Ultrasonography, VCUG, and cystoscopy was ment is dictated by the level of renal function. If normal performed in all children. In all neonates with urinary or satisfactory renal function is present, transurethral retention, the bladder was drained with a small-caliber valve ablation is performed. An elective vesicostomy is catheter or feeding tube in the urethra within the early proper and safe in situations in which the newborn neonatal period. After that they were treated with urethra seems too small to accommodate the available fulguration/ablation of the PUVs by pediatric resecto- 1687-4137 © 2018 Annals of Pediatric Surgery DOI: 10.1097/01.XPS.0000529796.57938.83 Copyright r 2018 Annals of Pediatric Surgery. Unauthorized reproduction of this article is prohibited. Follow-up of 50 children after PUV management Ebeid et al. 117 scope under general anesthesia; valve ablation was Table 2 Correlation between preoperative and postoperative accomplished using cutting current and incisions at the variables in the initial vesicostomy cases 5o’ clock, 7 o’ clock, and 12 o’ clock positions. Variables Preoperative [n (%)] Postoperative [n (%)] Vesicostomy was performed in 15 newborns and infants Febrile urinary tract infection 17 (68) 5 (20) with urinary sepsis or poor general condition in spite of Difficult micturition 8 (32) 5 (20) urethral catheter drainage and corrective medical treat- Chronic retention with overflow 7 (28) 0 (0) incontinence ment. Another indication for temporary vesicostomy in 10 Suprapubic swelling 4 (16) 0 (0) cases was a small-caliber urethra, which precluded primary Upper abdominal swelling 4 (16) 1 (4) Antenatal diagnosis 2 (8) 0 (0) transurethral valve ablation. Vesicoureteral reflux (VUR) Urge incontinence 0 (0) 10 (40) and hydronephrosis were assessed after 3, 6, and 12 months Urinary frequency 0 (0) 12 (48) by ultrasonography; VCUG and isotope scan were P-value < 0.0001* performed using DTPA and DMSA for all cases. *Statistically significant. Pelvic ultrasound was used to evaluate the urinary bladder size, the urinary bladder wall thickness, the retention with overflow incontinence in seven (28%) presence of diverticula, posterior urethral dilatation, and patients, suprapubic swelling in seven (28%) patients, postvoiding residual urine. VCUG was performed to and upper abdominal swelling in four out of 25 (16%) confirm the diagnosis and to assess the urinary bladder patients. PUV was diagnosed during an antenatal period for associated findings such as VUR, its degree, in two out of 25 (8%) patients. diverticula, and residual urine. Urodynamic study was At 1 year of follow-up, six (40%) cases were free of performed for persistent bladder dysfunction and complaints. The postoperative presentations in the videourodynamics was performed to assess bladder remaining patients were urinary frequency in seven capacity in cases associated with VUR. (47%) patients, urge incontinence in six (40%) patients, and difficult micturition in three (20%) patients (Table 2). Statistical analysis The data were analyzed using statistical package for the Serum creatinine social sciences (SPSS version 20.0) for Windows The mean preoperative serum creatinine after stabiliza- (SPSS Inc., Chicago, Illinois, USA). The results were tion with urethral catheter drainage in primary urethral expressed as mean ± SE with 95% confidence interval by valve ablation patients was 1.16 ± 0.32, which is signifi- using medians for quantitative variables, and using the cantly improved with a mean value of 0.55 ± 0.22 when frequencies and percentages for qualitative ones; a measured 1 year after valve ablation (P < 0.001). One P-value of less than 0.05 is statistically significant. patient had renal insufficiency with serum creatinine level of 1.2 mg/dl. The mean serum creatinine after Results stabilization with a urethral catheter in vesicostomy ± A total of 50 boys with a mean age at diagnosis of patients was 1.529 0.522. When serum creatinine was 100 ± 15 days (1 day to 4 years) were included in this work. measured at 1 year of follow-up, the mean value was ± P < The most common presentation in cases treated with significantly improved for 0.8 0.39 ( 0.01). Three primary valve ablation was difficult micturition in 15 (60%) patients had renal insufficiency with serum creatinine patients, urinary frequency in 13 (52%) patients, febrile level of 1.4, 1.5, and 1.6 mg/dl. Comparison of post- urinary tract infection (UTI) in 10 (40%) patients, and urge operative serum creatinine in both categories showed incontinence in five (20%) patients. At 1 year of follow-up, that postoperative
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