2005, Number 3
Posterior urethral valves: 62 cases presentation
Landa-Juárez S, Hernández-J G, Meneses-Juárez JH
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Language: Spanish
References: 16
Page: 136-145
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ABSTRACT
Introduction: Obstructive Uropathy that takes to the renal failure with more frequency in pediatric age is secondary to posterior urethral valves. The management has change in important form in last years and prenatal diagnosis has improved the opportune detection of these patients.Material and methods: From january of 1983 to march of 2003, by means of a descriptive and retrospective survey the charts were revised of patient with posterior urethral valves (PUV). The studied variables were age, renal function, clinical manifestations, associate anomalies, treatment, complications and results. Patients were categorized according to the approach described by Churchill in the groups: favorable and unfavorable, with relationship to renal function, incluiding the seric levels of azoados after the temporary relief of the obstruction by means of transurethral probe and to anatomical and functional state of the urinary tract or renal dysplasia.
Results: 62 charts were revised about patients with diagnosis of PUV, age range was since newborn until the five years of age, with a 3.7 year-old stocking. Clinical manifestation was presented mainly as urinary obstruction in smaller than one year and like an urinary tract infection in older than this age 15% had associated anomalies, among those that highlighted the criptorchidism, occlusion duodenal and trisomy 21, In all cases cystourethrogram corroborated characteristic lesion of PUV. Total of 9 patients (14%) corresponded to favorable group, being all these, older than a year of age. Fifthy three children, (86%), corresponded to unfavorable group. When the urinary tract was evaluated 51 patient had bilateral hydronephrosis, 17 of them had severe hydronephrosis and 12 had unilateral hydronephrosis. In 40 patients (64%) presented vesicoureteral reflux (VUR), being bilateral in 31 cases and unilateral in 9 cases. In two cases reflux was associated to hypertrophied bladder of disminished capacity . Resection of valves was carried out by menas of two methods: 1) Forced rupture with probe was practice in 6 patients, corresponding to the oldest cases 2) Transurethral endoscopic resection or through the vesicostomy, was made in 56 patients. Of the 55 transurethral resections, four developed urethral stenosis and were subjected to dilations; one of them required internal urethrotomy. Four (8%) of the posterior urethral ablaction were made using 20Wtts vaporizing laser Ho-YAG. Forty percent of patients with VUR improved after resection of the valves and 60% they underwent vesicoureteral reimplantation. In two patients with severe vesicoureteal reflux and hypertonic bladder were practiced reimplantation of one of the ureters and increase ureterocistoplasty.
Discussion: Apropiate treatment of patients with PUV, resides in a series of requeriments that include: 1.- Opportune diagnosis, of being possible prenatal; 2.-Useof fine endourological equipment of being possible under videoassistence, HoYAG seems a much more logical and preferable choice for these procedures to maximize efficacy and minimize morbidity due to collateral thermal effects; 3.-Patients categorization for groups presage that allows to value the functional renal evolution and therapeutic result: and 4.- Study of dynamics vesical function. In our experience ideal treatment was primary transurethral resection in newborn period or at the moment of diagnosis. The VUR of low degree showed the same as in other series a marked tendency to disappear spontaneously following valve ablation. In those patients with important reflux or some other alterations of the upper urinary tract, vesicostomy remains a treatment of choice, besides the primary resection. This vesicostomy can also be used as anterograde access for resection of valves, for infants whose urethras are too small to accept the currently available endoscopes. According to reached renal improvement, you will proceed to the later desderivation with previous progressive hydraulic dilation of bladder, ureterovesical reimplantation and augmentation cystoplasty.
Conclusion: The diagnosis and management of posterior urethral valves continues to envolve with impruved US technology an new techniques for fetal intervention. Advances in endoscopic instrumentation permit early surgery for most neonates. Improved understanding of bladder dysfunction in these boys has resulted in maximizing preservation of renal function and furthering our knowledge of the underlying pathophysiology of bladder outlet obstruction.
REFERENCES