|Year : 2015 | Volume
| Issue : 3 | Page : 61-64
Early versus delayed presentation of posterior urethral valves in children: Consequences and outcome of vesico-ureteric reflux
Amit Sharma, Irfan Shaikh, Radheshyam Chaudhari, Mukund Andankar, Hemant Pathak
Department of Urology, TNMC and BYL Nair Hospital, Mumbai, Maharashtra, India
|Date of Web Publication||14-Mar-2016|
Dr. Amit Sharma
Department of Urology, TNMC and BYL Nair Hospital, Mumbai Central, Mumbai - 400 008, Maharashtra
Source of Support: None, Conflict of Interest: None
Introduction: Delayed presentation of patients with posterior urethral valve (PUV) is common in our country and is usually associated with complications and morbidities. Objective: To determine the pattern of presentation of PUVs and its complications and outcomes in these patients with respect to decrease or resolution of vesico-ureteric reflux (VUR) and/or requirement of additional operative procedures. Materials and Methods: A retrospective study was conducted, and 30 children of PUV were analyzed with respect to the pattern of presentation, duration of symptoms, age at primary fulguration, grade of VUR and its outcome. Results: Patients with early presentation were diagnosed early, had their PUV fulgurated early and had lesser grades and better resolution of their VUR and good outcome. The reverse was seen in those patients who presented late and already had some form of renal impairment such as higher and bilateral grades of VUR and higher serum creatinine levels. Some of them also required additional procedures which added to their morbidity. Discussion: Delayed presentation of PUV is common in our country and is associated with an increased incidence and a higher grade of VUR which does not decrease or resolve on follow-up and usually requires additional operative interventions adding to the morbidity of both the parents and the child. On the other hand, early presentation leads to early diagnosis and early relief of obstruction and is associated with lesser VUR, which resolves over time. Conclusion: With early presentation, diagnosis and treatment, the outcome of patients with PUVs is expected to improve. Efforts at improving awareness and early diagnosis and referral among the health team should be encouraged.
Keywords: Posterior urethral valves, re-implantation, serum creatinine, ureterostomies, vesico-ureteric reflux
|How to cite this article:|
Sharma A, Shaikh I, Chaudhari R, Andankar M, Pathak H. Early versus delayed presentation of posterior urethral valves in children: Consequences and outcome of vesico-ureteric reflux. Saudi Surg J 2015;3:61-4
|How to cite this URL:|
Sharma A, Shaikh I, Chaudhari R, Andankar M, Pathak H. Early versus delayed presentation of posterior urethral valves in children: Consequences and outcome of vesico-ureteric reflux. Saudi Surg J [serial online] 2015 [cited 2019 May 21];3:61-4. Available from: http://www.saudisurgj.org/text.asp?2015/3/3/61/178675
| Introduction|| |
Posterior urethral valves (PUVs) are one of the most common structural causes of lower urinary tract obstruction in male infants. ,, It is the most common type of obstructive uropathy leading to childhood renal failure. Prolonged and unrelieved lower urinary tract obstruction leads to back pressure effects on the kidneys resulting in obstructive uropathy with renal impairment.  Late presentation, which is common in a developing country like ours, is associated with urosepsis, uremia, anemia, and complications of PUV, which add to the morbidity of these patients. 
The aim of this study is to determine the pattern of presentation and the outcome and management of vesico-ureteric reflux (VUR) in these patients of PUV.
| Materials and Methods|| |
A retrospective study was conducted, and data of total thirty patients of PUVs were analyzed with respect to the age and pattern of presentation, age at primary fulguration, VUR and its outcome with respect to decrease or resolution of the reflux. Inclusion criteria were all patients who had a radiological diagnosis of PUV with voiding cystourethrogram (VCUG) and renal ultrasound. The outcomes of VUR were then compared between early fulguration group (fulgurated before 1 year of age) and late fulguration group (fulgurated after 1 year of age). The various parameters studied were age at presentation, presenting symptoms, age at primary fulguration, unilateral, or bilateral VUR; outcome in the form of decrease or resolution of the grade of VUR and/or the requirement of additional procedures (re-implantation or ureterostomies).
| Results|| |
Thirteen patients presented in infancy (43.3%) and the rest 17 patients (56.6%) presented later [Graph 1]. The most common presenting symptoms were urinary tract infection (UTI) in 13 patients (43.3%) and voiding difficulties such as poor stream, urgency, and incontinence in ten patients (33.33%) [Graph 2].
After investigation and confirmation of PUV by VCUG, cystoscopic PUV fulguration by Bugbee was done. Based on the age of the patient at which the PUV was fulgurated, the patients were divided into two groups and the various complications and the outcomes were compared between these two groups:
- Early fulguration group (fulgurated in <1 year of age)
- Late fulguration group (fulgurated after the age of 1 year).
There were 13 patients in the early fulguration group (43.33%) and 17 patients in the late fulguration group (56.66%).
Unilateral or bilateral VUR [Graph 3] and its outcome [Graph 4] were studied and compared between these two groups. In early fulguration group, unilateral VUR was seen in three patients (23%) and bilateral VUR was seen in three patients (23%). In the late fulguration group, unilateral VUR was seen in four patients (23.5%) and bilateral VUR was seen in seven patients (41.2%).
Of the total six patients with unilateral VUR in the early fulguration group (46.15%), three patients (50%) had lower grades of VUR (Grade 2 and 3) on one side and all three of them had their VUR resolved after 5 years of follow-up. Of the three patients with bilateral VUR (50%), two patients (66.6%) had their VUR decreased on follow-up from Grade 4-2 bilaterally in one patient and from Grade 3-1 in the other patient. One patient (33.33%) who had bilateral Grade 5 VUR did not decrease during follow-up, and he also had persistent Grade 5 VUR with urosepsis and hence got bilateral ureterostomies done later. Another patient with bilateral VUR, who had decrease in the grade of VUR (from Grade 4-2) had increased serum creatinine levels and bilateral decreasing function on annual scans, and so he got bilateral re-implantation done after urodynamic study which revealed good bladder parameters. Thus, only 2 additional procedures were required in the early fulguration group (15.4%).
In the late fulguration group, there were 4 patients with unilateral VUR (23.5%) and seven patients of bilateral VUR (41.2%). There was neither decrease nor resolution of VUR in the patients of late fulguration group on 5 years of follow-up. All these 11 patients (64.7%) required additional procedures in the form of unilateral re-implantation in four patients (23.5%) and bilateral re-implantation in six patients (35.3%) and bilateral ureterostomies in one patient (5.8%).
Persistently, high serum creatinine was present in two patients (15.3%) in early fulguration group and 11 patients (64.7%) in late fulguration group. The common additional procedures required were U/L or B/L re-implantation and ureterostomies.
| Discussion|| |
PUV are the most common cause of lower urinary tract obstruction in male infants. , Of the total 30 males studied, 13 patients (43.3%) presented in infancy, 12 patients (40%) presented between 1 and 5 years of age and five patients (16.66%) presented after 5 years of age. Thus, still more patients present after infancy when the damage to the upper urinary tract due to back pressure has already set in. More patients are being diagnosed antenatally, a direct consequence of the extensive use of antenatal ultrasonography. ,, We had 5 of our patients diagnosed antenatally (16.6%). Most of our patients had symptoms of UTI and voiding difficulties such as poor stream, urgency, and incontinence. Thus, it is important to have a high index of suspicion of PUV in any child presenting with such symptoms. Patients who presented after 5 years of age (five patients) had a failure to thrive and bilateral hydroureteronephrosis (16.6%).
In patients with PUV, the ureters are in constantly dilated; vesicoureteral reflux is met in 2/3 of the cases.  The presence of the reflux is interpreted as a severe associated factor.  In this study, there were 6 patients of VUR in the early fulguration group (46.15%) and 11 patients of VUR in the late fulguration group (64.7%).
As is seen from this study, VUR has a tendency to decrease or resolve over time if the distal obstruction, i.e., the PUV is fulgurated and relieved early in life during infancy. The resolution of VUR is more for unilateral cases. This is very well evident by the other studies in literature. ,, All our patients who had early presentation were diagnosed early, had their PUV fulgurated early and had lesser grades and better resolution of their VUR and good outcome. The reverse was seen in those patients who presented late and already had some form of renal impairment like higher and bilateral grades of VUR and higher serum creatinine levels. Persistently, high serum creatinine seen in two patients of early fulguration group resolved after fulguration as opposed to those 11 patients in the late fulguration group. More of these patients required additional procedures which added to their morbidity. ,, Similar results have been reported in various studies in the literature which state that as the age increases, the complications and long-term morbidities also increase in the patients of PUV. ,,,
Thus, to sum up, in spite of more and more cases being diagnosed antenatally, delayed presentation of PUV is still common in our country and is associated with an increased incidence and a higher grade of VUR which does not decrease or resolve on follow-up and usually requires additional operative interventions adding to the morbidity of both the parents and the child. On the other hand, early presentation leads to early diagnosis and early relief of obstruction and is associated with lesser VUR, which resolves over time.
| Conclusion|| |
With the early presentation, diagnosis, and treatment, the outcome is expected to improve. Delayed presentation, on the other hand, is associated with long-term morbidity and further operative procedures and also affects the development of the child.
Efforts at improving awareness and early diagnosis and referral among the health team should be encouraged.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Nasir AA, Ameh EA, Abdur-Rahman LO, Adeniran JO, Abraham MK. Posterior urethral valve. World J Pediatr 2011;7:205-16.
Imaji R, Dewan PA. The clinical and radiological findings in boys with endoscopically severe congenital posterior urethral obstruction. BJU Int 2001;88:263-7.
Atwell JD. Posterior urethral valves in the British Isles: A multicenter B.A.P.S. review. J Pediatr Surg 1983;18:70-4.
Elder JS. Management of antenatally detected hydronephrosis. In: Puri P, editor. Newborn Surgery. London, UK: Hodder Arnold; 2003. p. 793-808.
Odetunde OI, Odetunde OA, Ademuyiwa AO, Okafor HU, Ekwochi U, Azubuike JC, et al.
Outcome of late presentation of posterior urethral valves in a resource-limited economy: Challenges in management. Int J Nephrol 2012;2012:345298.
Anochie I, Eke F. Obstructive uropathy in childhood, as seen in University of Port Harcourt Teaching Hospital, Nigeria. Niger J Med 2004;13:136-9.
Woolf AS, Thiruchelvam N. Congenital obstructive uropathy: Its origin and contribution to end-stage renal disease in children. Adv Ren Replace Ther 2001;8:157-63.
Hutton KA, Thomas DF, Arthur RJ, Irving HC, Smith SE. Prenatally detected posterior urethral valves: Is gestational age at detection a predictor of outcome? J Urol 1994;152 (2 Pt 2):698-701.
American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No 101: Ultrasonography in pregnancy. Obstet Gynecol 2009;113(2 Pt 1):451-61.
Dinneen MD, Dhillon HK, Ward HC, Duffy PG, Ransley PG. Antenatal diagnosis of posterior urethral valves. Br J Urol 1993;72:364-9.
Reinberg Y, de Castano I, Gonzalez R. Prognosis for patients with prenatally diagnosed posterior urethral valves. J Urol 1992;148:125-6.
Chowdhary SK, Wilcox DT, Ransley PG. Posterior urethral valves: Antenatal diagnosis and management. J Indian Assoc Pediatr Surg 2003;3:163-8.
Ylinen E, Ala-Houhala M, Wikström S. Prognostic factors of posterior urethral valves and the role of antenatal detection. Pediatr Nephrol 2004;19:874-9.
Denes ED, Barthold JS, González R. Early prognostic value of serum creatinine levels in children with posterior urethral valves. J Urol 1997;157:1441-3.
Lopez Pereira P, Espinosa L, Martinez Urrutina MJ, Lobato R, Navarro M, Jaureguizar E. Posterior urethral valves: Prognostic factors. BJU Int 2003;91:687-90.
Ansari MS, Singh P, Mandhani A, Dubey D, Srivastava A, Kapoor R, et al.
Delayed presentation in posterior urethral valve: Long-term implications and outcome. Urology 2008;71:230-4.
Asinobi AO, Gbadegesin RA, Shittu OB. A review of cases of posterior urethral valves seen at the University College Hospital, Ibadan (Nigeria). Pediatr Med Chir 2004;26:430-3.
Bomalaski MD, Anema JG, Coplen DE, Koo HP, Rozanski T, Bloom DA. Delayed presentation of posterior urethral valves: A not so benign condition. J Urol 1999;162:2130-2.
El-Sherbiny MT, Hafez AT, Shokeir AA. Posterior urethral valves: Does young age at diagnosis correlate with poor renal function? Urology 2002;60:335-8.