Posterior urethral valves: Morphological normalization of posterior urethra after fulguration is a significant factor in prognosis

Abstract

Aim:To assess the changes in urethral morphology 3 months post fulguration of posterior urethral valves (PUVs) on micturating cystourethrogram (MCUG) and correlate these changes with the overall clinical status of the patient.Materials and Methods:A total of 217 children, managed for PUVs during a period of 6 years in a single surgical unit were prospectively studied. The ratio of the diameters of the prostatic and bulbar urethras (PU/BU) was calculated on the pre- and post-fulguration MCUG films. They were categorized into three groups based on the degree of normalization of posterior urethra (post-fulguration PU/BU ratio).Results:Group A: Of the 133 patients, 131 had normal urinary stream and 4 (3%) had nocturnal enuresis. Vesicoureteral reflux (VUR), initially seen in 83 units (31% units), regressed completely at a mean duration of 6 months in 41 units (49%). Of the 152 non-VUR, hydroureteronephrosis (HUN) units, 11 were poorly functioning kidneys. Persistent slow but unobstructed drainage was seen in 23 units (16%) over a period of 1.5–5 years (mean 2.5 years). Group B: All the 11 patients had a normal stream. Four (36.4%) had daytime frequency for a mean duration of 1 year and one (9%) had nocturnal enuresis for 1 year. Grade IV–V VUR was seen in five patients (three bilateral), which regressed completely by 3 months in five units (62.5%). In the non-VUR, HUN patients, slow (but unobstructed) drainage was persistent in two units (14%) at 3 years. Group C: Of the 16 patients, only 5 (31.3%) were asymptomatic. Six patients (nine units) had persistent VUR for 6 months to 3 years. Of the 20 units with HUN, 17 (85%) were persistent at 1–4 years (mean 2 years). Eight patients (50%) required a second fulguration while 3 (18.7%) required urethral dilatation for stricture following which all parameters improved.Conclusions:Adequacy of fulguration should be assessed by a properly performed MCUG. A postop PU/BU ratio >3 SD (1.92) should alert to an incomplete fulguration or stricture. Patients within normal range ratio have faster recovery of slow draining units, reflux and less voiding dysfunction. There is a strong correlation between incomplete fulguration and persistent slow draining units, uremia, voiding dysfunction and urinary tract infections.

Early outcome following diathermy versus cold knife ablation of posterior urethral valves

“…Objective measurement of posterior to anterior urethral ratio has been reported recently although there is no consensus on the cut-off. Menon et al [12] felt a postoperative ratio of more than 1.9 should alert to persistent obstruction while Gupta et al [13] considered a ratio of 2.5e3 to be an acceptable result. Bani Hani et al [14], on the other hand, reported 2.6 as the normal urethral ratio in those without PUV, 8.6 in those with PUV and 3.5 as an acceptable postoperative outcome.…”

Posterior urethra: Anterior urethra ratio in the evaluation of success following PUV ablation

“…Bani hani [18] described a PAR of 2.6 in normal children, 8.8 in those with PUV, and 3.1 with successful ablation. Menon [19] reported a more acceptable PAR of 1.04 in controls, 7.8 in those with PUV, and suggested that a PAR of >1.92 should alert to persistent obstruction due to residual valve or stricture. The gross discrepancy in their values is probably related to the ways of computing the ratio.…”

Outcome of Vesiciureteric Reflux After Primary Fulguration of Posterior Urethral Valves

“…Another study showed that a total of 181 boys with PUVs were age ranged from 2 days to 12 years. There were 53 (29.5%) neonates (mean 12 days), 61 (33.5%) patients between 1 month and 1 year (mean 5.5 months), 46 (25.5%) between 1 and 5 years (mean 2 years 7 months) and 21 (11.5%) between 5 and 12 years (mean 8 years 3 months) 9 .…”