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 Table of Contents  
Year : 2018  |  Volume : 4  |  Issue : 1  |  Page : 29-33

The experience of managing Posterior Urethral Valve (PUV) over a period of 5 years: A single centre study at a tertiary care centre in Bihar

1 Department of Paediatric Surgery, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna-14, Bihar, India
2 Department of General Surgery, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna-14, Bihar, India

Date of Web Publication10-Dec-2020

Correspondence Address:
Ramdhani Yadav
Assistant Professor, Pediatric Surgery, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna-14, Bihar
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Source of Support: None, Conflict of Interest: None

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Objective: To evaluate the clinical presentation, management, complications, surgical management and long term outcome of Posterior urethral valve.
Methods: A retrospective study was done on 203 patients of Posterior urethral valve treated in the Department of Paediatric surgery, Indira Gandhi Institute of Medical Sciences, Patna from January, 2011 to December, 2016. Data regarding clinical history, examination findings, investigation results and treatment given were collected from their case records. Data collected were analyzed.
Results: A total of 203 patients with a mean age of 31.78 ± 9.11 months presented to the Paediatric surgery department with dribbling, poor urinary stream (55.17%) and urinary tract infection (36.94%) as the major symptoms. Ten patients had an antenatal diagnosis and twenty five patients presented early as neonates. Vesico-ureteric reflux was found in 55.66% cases. While 71.92% patients had cystoscopic fulguration, in 13.79% patients we had to use Chooramani Hook to ablate the valves and 14.29% patients had to be diverted to treat urosepsis. Residual valves were seen in 15.76% cases. Valve bladder syndrome occurred in 60.59% cases. There were seven deaths in the study. Mean follow-up in our series was 2.6 ± 1.1years.
Conclusion: Urinary drainage by feeding tube in neonatal period, followed by cystoscopic valve ablation is the appropriate treatment in patients of PUV. Urinary diversion helps in cases of urosepsis which don’t settle on catheterization or valve ablation. Early diagnosis, early valve fulguration and management of Valve bladder syndrome have significant impact on outcome.

Keywords: Children; Posterior Urethral Valve; Urinary diversion; Urinary drainage; Valve ablation

How to cite this article:
Yadav R, Rahul Sk, Kumar V, Thakur VK, Hasan Z, Jaiswal P, Kumar P, Agarwal A, Sweta. The experience of managing Posterior Urethral Valve (PUV) over a period of 5 years: A single centre study at a tertiary care centre in Bihar. J Indira Gandhi Inst Med Sci 2018;4:29-33

How to cite this URL:
Yadav R, Rahul Sk, Kumar V, Thakur VK, Hasan Z, Jaiswal P, Kumar P, Agarwal A, Sweta. The experience of managing Posterior Urethral Valve (PUV) over a period of 5 years: A single centre study at a tertiary care centre in Bihar. J Indira Gandhi Inst Med Sci [serial online] 2018 [cited 2022 Jan 20];4:29-33. Available from: http://www.jigims.co.in/text.asp?2018/4/1/29/302980

  Introduction : Top

Posterior urethral Valves (PUV) are the commonest cause of bladder outlet obstruction in male children[1]. Despite being simple membranous obstructive lesions in posterior urethra, they have devastating effects on bladder dynamics resulting in significant morbidity and mortality in pediatric patients. Repeated Urinary tract infection (UTI), chronic renal failure (CRF), Urinary incontinence, Urinary ascites and Urosepsis represent the spectrum of manifestations of this anomaly. Due to heterogeneity in its presentation by age and symptoms and also due to the wide range of bladder functional abnormalities accompanying PUV, it is difficult to divide these patients into a few representative groups to guide treatment. Apart from managing the valves, bladder management is equally important and at our centre it is guided by the urodynamic features of a patient. We present the results of a retrospective study conducted at our centre to share our experience of managing PUV in the last five years.

  Materials and Methods : Top

A retrospective study was conducted in the department of Paediatric surgery, Indira Gandhi Institute of Medical Sciences (IGIMS), Patna. All patients of PUV managed in the department from January, 2011 to December, 2016 constituted the study group. 203 patients of PUV were included in this study. These patients were managed according to the protocol for management of PUV patients in our department. Details of each patient were collected from their case records, investigation sheets and operative records. Patients who turned up for follow-up in the outpatients department gave an opportunity to include their follow-up details in this study. Unfortunately, we had a large number of drop-outs in our study.

The collected data was analyzed and results presented as tables and frequencies.

Protocol for management of PUV in Department of Paediatric surgery, IGIMS Patna

Patients suspected of having PUV present to us with heterogeneous symptoms.

Neonates often present with difficulty in voiding or not voiding urine at all; some of them present in urosepsis with raised serum creatinine and altered electrolytes; some have a diagnosis of PUV done already on an antenatal ultrasonogram (USG); a few of them present with urinary ascites or other pop-off mechanisms. After general assessment of the patient management at our centre begins with urethral catheterization, fluid and electrolyte resuscitation with intravenous antibiotics after initial evaluation of blood counts, serum electrolytes & creatinine, blood gas and urine culture. These investigations were repeated when needed during the course of management of the patients. When patient’s condition stabilized and his counts and culture normalize, USG and Micturiting cystourethrogram (MCUG) were done. Due to lack of neonatal and small-sized resectoscopes in our department, we use the Chooramani hook to fulgurate the PUV with a vigilant look on the improvement in the stream of the child on suprapubic pressure, in the operation theatre. Children who had difficulty in accommodating this instrument or have persistent UTI or urosepsis are diverted with either vesicostomy or ureterostomy depending upon the findings on MCUG and normalization of serum creatinine level on catheterization. All these children are periodically evaluated by USG, serum creatinine, routine urine examination and renograms if needed on follow-up visits to the hospital. Patients are instructed to follow-up initially monthly and also at the time of any febrile UTI.

Having a poor and illiterate population with resource-challenged hospitals, we routinely come across older children who present with chronic kidney disease (CKD), valve-bladder syndrome and renal rickets. These children are very difficult to manage despite adequate cystoscopic valve fulguration and need periodic urodynamic evaluation to guide bladder management and CKD medications. Due to cost constraints and ease of performance, we have now shifted to bedside cystometry to assess the bladder variables recently. Some of these patients ultimately need dialysis and renal transplantation. Two of our patients were referred to higher centers excelling in Pediatric renal transplantation.

Patients of PUV with vesico-ureteric reflux (VUR) are very commonly seen and initially managed on prophylactic antibiotics after valve fulguration with circumcision, if consent is given by the parents for the same. If recurrent UTI occurs or there is evidence of renal scarring on Dimercapto-succinic acid (DMSA) scan, diversion is done to protect the kidneys.

Acute renal failure (ARF) is defined as per the RIFLE system criteria[2],[3] and estimated glomerular filtration rate (eGFR)[4] and persistent proteinuria are used to define chronic kidney disease (CKD).

  Results : Top

  1. Epidemiology - A total of 203 patients of PUV treated during this period were included in our study. Mean age of presentation to the hospital in these patients was 31.78 ± 9.11 months. However, there was a great variation in the range of age of presentation of these patients. Age of presentation ranged from 2days to 10years.

  2. Despite advances in antenatal USG, only 10(4.93%) of our patients had an antenatal diagnosis of PUV.

  3. Symptoms at presentation - [Table 2] demonstrates the different symptoms with which these patients presented with their frequencies. These symptoms weren’t mutually exclusive and this table only represents symptoms with which they first presented to the hospital.
  4. Associated anomalies in PUV patients - Most of the patients of PUV (86.70%) in this study did not have any other associated anomaly. [Table 3] depicts the details of associated anomalies in our study group.
  5. Vesico-ureteric reflux (VUR) in PUV patients - 113 (55.66%) of PUV patients in this study had VUR. While 82 (40.39%) had bilateral reflux, 31 (15.27%) had unilateral reflux.
  6. PUV associated VURD (unilateral Vesico-ureteric reflux, renal dysplasia) - VURD was found in 8 patients; 5 on left side; 3 on right side.
  7. Surgical Procedure - [Table 4] shows the procedure used to manage PUV in this study.

  8. In patients who have had vesicostomy, our protocol is to manage these children on vesicostomy for at least 2 years during which maximum growth of the kidney occurs and then do cystoscopic valve fulguration with vesicostomy closure.

    Patients who have enormously dilated and tortuous ureters on MCUG and don’t settle on catheterization and intravenous antibiotics need high ureterostomy to protect their kidneys. We had B/L high ureterostomy in 8 of our patients. We plan to do definitive surgery with ureterostomy closure in these patients at around 5 years of age.

    Ureteric reimplantation for VUR patients in this study group have been done in very few patients (3 patients) at our centre during the study interval. Most of them have been managed on chemoprophylaxis and bladder management depending on their urodynamic findings. A few others have had diversion procedures and are awaiting subsequent management. Our protocol is strictly to avoid reimplanting ureters into badly managed bladders.

    We have not had any patients with cystoscopic injection of DEFLUX for VUR management.

    We haven’t had bladder augmentation in any of our patients in the last five years. Most of the parents have either not given consent or were unwilling to do clean intermittent catheterization (CIC) through Mitrofanoff’s channel or show commitment to do daily bladder wash.

  9. Type of PUV on Cystoscopy - Most of the valves were type 1 (97.54%); 1.48% had type 3 PUV and 2 (0.98%) patients had type 4 PUV in association with Prune belly syndrome.
  10. Long term follow-up - Mean follow-up time in our series is 2.6±1.1 years. [Table 5] summarizes the long term results in our patients.
Table 1

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Table 2

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Table 3

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Table 4

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Table 5

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  Discussion : Top

With an incidence of 1:5000, PUV remains the most common cause of urethral obstruction in male children[1]. The extent of damage caused by PUV and its severity are variable and depend mainly on the extent of impedance to the passage of urine. However, PUV is not the only culprit responsible for the morbidity of these patients. Even in patients who have had adequate fulguration of valves, Urinary symptoms and upper tract dilatation/injury is a possibility due to the affection of urinary bladder. Altered bladder dynamics is responsible for Valve bladder syndrome and its consequences[5].

In this study, we have attempted to share our experience in managing PUV patients. To begin with, this was a large study with 203 patients forming the study group. So, it had a large sample size; yet being a retrospective study, it has its own limitations. Several investigators have had similar studies at their centre with a smaller sample size[6],[7],[8],[9],[10].

With advancements in antenatal diagnostic modalities like sonogram, fetal magnetic resonance imaging (MRI), amniotic and fetal bladder fluid sampling and assessment, management of PUV in developed countries has reached the stage of fetal intervention[11]. Most of the cases in Western world are antenatally detected and sometimes treated. So, most of the affected newborns are born as a diagnosed case of PUV which helps in instituting appropriate care promptly at a well equipped centre. Recent evidence suggests that children who have had neonatal fulguration of their PUV had a better functional outcome and lesser bladder dysfunction[12],[13]. In contrast to this, in a developing country like ours, we still struggle to make antenatal diagnosis and most of the parents do not turn up until it is quite late to save the child and his kidneys from the devastating effects of this lesion. This is reflected in this study as well. In all, we had only ten patients who were antenatally diagnosed. Similarly, among all 203 patients, only 25 were neonates. This is unlike many other studies[7],[8] where most cases had early detection in the neonatal period or within first year of age. Ziylan et. al.[14] and Schober et. al.[15] have analyzed the impact of late presentation on bladder and renal function. It may be a possibility that the valves in a few patients are not significant enough to cause early changes detectable on a fetal or neonatal USG and being trivial, they become symptomatic later in life.

Dribbling and poor stream were the commonest symptoms with which PUV patients presented in our study. This was followed by UTI. A few patients also presented with unrelated fever, haematuria, hypertension and renal rickets. Similar observations have been reported elsewhere in the literature[7].

We had two patients who turned up with urinary Ascites of which one was very sick and died within 24 hours of admission; other child improved after catheterization and tapping of ascites. But, after a few days he succumbed to a subsequent UTI following MCUG. 8 patients in our series had VURD. Most of them had it on left side. Left VURD has been reported to be more common in literature. We don’t remove the affected kidney in VURD and keep the patient on wait and watch for the development of hypertension or any other changes. We believe that this benefits the opposite kidney from getting damaged during the first two years of life. We had a patient of Prune belly syndrome with Imperforate Anus who could not be catheterized; he had a patent urachus. 3 patients in our series had a large diverticulum at presentation on being evaluated by MCUG. PUV with Urinary Ascites, VURD, patent Urachus, Urinoma and bladder diverticula are all reported to be pop-off mechanisms which help in the protection of kidneys by dissipating pressure[16].

VUR in PUV is an important association, reported worldwide. We found it to be in 55.66% patients of which majority had bilateral VUR. Our practice is to initially manage these children on prophylactic antibiotics after valve fulguration with circumcision, if consent is given by the parents for the same. If, however, recurrent UTI occurs or there is evidence of renal scarring on DMSA scan, diversion is done to protect the kidneys. We refrain from doing Ureteric reimplantation on badly managed bladder and so delay it until we are convinced that bladder has been managed appropriately. Also, if diversion has been made to protect the kidneys, we don’t reverse it before 2 years of age fearing damage to the developing kidneys.

Bladder function has an immense impact on the long-term renal function and continence. So, even after proper valve fulguration, it is important to manage the bladder properly. This is done in accordance with urodynamic evaluation of the bladder. Bladder capacity, Post void Residual volume (PVRV), bladder pressure, presence of detrusor instability and urinary flow rates are a few important variables which guide bladder management. We have recently shifted to Bedside Cystometry to assess these variables. Simplicity of its technique, its cost-effectiveness, reproducibility and non-dependence on power supply are a few of its qualities which make it efficient in our scenario. For instance a high pressure, unstable bladder merits treatment with oxybutynin, tolterodine or imipramine. Significant PVRV necessitates CIC or timed voiding. Low capacity, high pressure bladders unresponsive to all treatment would benefit from Bladder Augmentation, if patient or parents accept CIC and daily neo-bladder wash. Unfortunately, in our study, none of the parents showed interest in Bladder augmentation.

Puri et. al. compared the urodynamic patterns of PUV bladders managed by fulguration with those which were diverted using vesicostomy or ureterostomy[17]. Fulgurated and ureterostomy groups showed good-capacity, compliant bladder while vesicostomy group showed small- capacity, hyper-reflexic bladder. They concluded that primary fulguration is better than vesicostomy and that vesicostomy and ureterostomy have different effects on the bladder. We also, at our centre, prefer doing valve fulguration and divert only when urosepsis does not settle. In case both ureters are tortuous, we prefer to do bilateral ureterostomy instead of vesicostomy due to this reason.

Neonatal valve fulguration is difficult due to nonavailability of small scopes at our centre. We manage such children by serially increasing the caliber of urethral catheter until finally we can introduce either a scope or Chooramani’s hook. The later being a blind procedure, incidence of residual valves in our study is higher than that reported by some other investigators[6],[7]. We manage residual valves by doing a proper cystoscopic fulguration as soon as it is possible to accommodate the available-sized cystoscope into the child’s urethra.

Two of our patients who have had deteriorating renal function have visited centers with facilities for pediatric renal transplantation and dialysis but to this day, none of them has received a renal transplant.

  Conclusion : Top

PUV management in children is a continuous process which begins at the time of antenatal detection and has to continue later even after fulguration of valves. Appropriate bladder management is a must to prevent damage to the kidneys and improve long-term survival. In a resource challenged country, late presentation increases morbidity and mortality. Early detection, early valve-fulguration and management of valve bladder syndrome should be done for better outcome.

  References Top

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Hoste EAJ, Clermont G, Kersten A, Venkataraman R, Angus DC, Bacquer DD, Kellum JA. RIFLE criteria for acute kidney injury are associated with hospital mortality in critically ill patients: a cohort analysis.Crit Care.2006;10:R73.  Back to cited text no. 2
Venkataraman R, Kellum JA. Defining acute renal failure: the RIFLE criteria.J Intensive Care Med.2007;22:187-93.  Back to cited text no. 3
National Kidney foundation: K/DOQI. Clinical Practice Guidelines for chronic kidney disease: Evaluation,Classification and Stratification. Am J Kidney Dis 2002;39:S1-266.  Back to cited text no. 4
Glassberg KI. The valve bladder syndrome:20 years later. JUrol.2001;166:1406-14.  Back to cited text no. 5
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Shittu OB, Asinobi AO. Long-term outcome of posterior urethral valves ablation using the Mohan’s urethral valvotome. West Afr J Med 2004;23:35-7.  Back to cited text no. 10
Morris RK, Kilby MD. An overview of the literature on congenital lower urinary tract obstruction and introduction to the PLUTO trial: percutaneous shunting in lower urinary tract obstruction. Aust N Z J Obstet Gynaecol.2009;49:6- 10  Back to cited text no. 11
Youssif M, Dawood W, Shabaan S, Mokhless I, Hanno A. Early valve ablation can decrease the incidence of bladder dysfunction in boys with posterior urethral valves. J Urol.2009;182:1765- 8.  Back to cited text no. 12
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Ziylan O, Oktar T, Ander H, Korgali E, Rodoplu H, Kocak T. The impact of late presentation of posterior urethral valves on bladder and renal function. J Urol.2006; 175:1894-7.  Back to cited text no. 14
Schober JM, Dulabon LM, Woodhouse CR. Outcome of valve ablation in late-presenting posterior urethral valves. BJU Int.2004;94:616-9.  Back to cited text no. 15
Kaefer M, Keating MA,Adams MC, et. al.Posterior urethral valves, pressure pop-offs and bladder functions. J Urol1995;154:708-11.  Back to cited text no. 16
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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