Year : 2006 | Volume
: 22 | Issue : 3 | Page : 281--282
Outcome of valve ablation in late presenting posterior urethral valves
Naval Khurana, Saurabh Agarwal, Aneesh Srivastava
Department of Urology, SGPGIMS, Lucknow, India
Department of Urology, SGPGIMS, Lucknow
|How to cite this article:|
Khurana N, Agarwal S, Srivastava A. Outcome of valve ablation in late presenting posterior urethral valves.Indian J Urol 2006;22:281-282
|How to cite this URL:|
Khurana N, Agarwal S, Srivastava A. Outcome of valve ablation in late presenting posterior urethral valves. Indian J Urol [serial online] 2006 [cited 2021 Jul 25 ];22:281-282
Available from: https://www.indianjurol.com/text.asp?2006/22/3/281/27648
This retrospective study between 1986 and 2004 included 106 patients with PUVs. Thirty-six boys (34%) were diagnosed after age five. Mean patient age at diagnosis was 8.8 years. Surgical management consisted of endoscopic valve ablation in 32 cases and vesicostomy with delayed valve ablation in four. Presenting symptoms, renal function and presence of vesicoureteral reflux and urinary tract infection were determined. Renal function was evaluated by plasma creatinine at presentation and during follow-up. Mean creatinine levels were compared to those in 51 patients with PUVs who had been diagnosed and treated before age five and followed regularly. Of the 36 patients 20 underwent urodynamic evaluation during follow-up. A total of 19 age-matched children with PUVs who were diagnosed before age five (mean 17.7 months) and underwent urodynamic evaluation during follow-up were selected as the control group. The most common symptoms at presentation were diurnal enuresis (47.2%) poor stream (19.4%) and urinary retention (13.9%). Overall, urodynamic bladder abnormalities were detected in 17 of 20 patients (85%). No significant difference in bladder capacity, compliance or postvoid residual was demonstrated between the late-presenting and control groups. Only detrusor overactivity was significantly lower in the late-presenting group. After a mean follow-up of 67.03 months age-specific creatinine levels were increased in 13 of 27 patients (48.1%), including 7 (25.9%) with ESRD. Renal function was significantly impaired in the late-presenting group compared to controls.
Reports on the long-term follow-up after valve ablation of late-presenting PUV are scant.
Hendren observed that PUVs are associated with a wide spectrum of obstruction. He graded the degree of obstruction on the basis of the secondary urinary tract changes. Early presentation was viewed as a poor prognostic sign and suggestive of a severe degree of obstruction. Late presentation suggested a lesser degree of obstruction with little clinical significance.
According to this retrospective study late-presenting PUV had significantly impaired renal function and lesser incidence of detrusor overactivity in comparison to early-presenting PUV. The comparison group was not made up of all newborns when first diagnosed (mean age 18 months) and late late-presenting PUV had an average age of 8.5 years at the time of urodynamic evaluation. Therefore, the two groups do not offer a true contrast between early and late presentation.
IM.T. EL-Sherbeny et al in their study of late-presenting PUV in 28 children (median age 3.5 years) depicted less favorable outcome of late-presenting PUV relative to those diagnosed in the first year after birth in respect to renal function and upper tract dilation. Similar were the results of some other studies too.,,
Parkhouse et al reviewed the renal function outcome in 98 boys with PUVs. Approximately two-thirds of the patients presented before one year of age and one-third after one year of age. Twenty-six (41%) of the 64 boys presenting before one year of age had a poor long-term outcome for renal function, in contrast to only five (15%) of 34 presenting after one year of age. The study also identified bilateral VUR at presentation as a poor prognostic factor.
There is a great deal of confusion regarding the prognosis of PUVs in relation to the age at presentation. If, on the one hand, one agrees with either Hendren and Pieretti that mild cases of PUVs occur in older children or with John Duckett who proposed that many late-appearing valves were not obstructive, then late presentation is a good prognostic sign.
On the other hand this may be because most neonatal patients are those for whom there is little argument in diagnosis, but in a group with a later presentation will be included those patients in whom the diagnosis would lack unanimity. Early detection of PUVs by prenatal ultrasonography portends a poorer prognosis, than that for those diagnosed in childhood. One must be careful not to equate "delay in diagnosis" with late presentation. They are two distinct groups. We should redefine presentation as it relates to prognosis by the presentation. Those presenting with hydronephrosis on prenatal ultrasonography or with neonatal obstructive symptoms likely have a poorer prognosis than the group presenting later with urinary tract infection and enuresis. This latter group will have some patients with renal insufficiency but not the proportion that the early group has. There is a spectrum of PUV. The question is how each of us defines that spectrum.
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