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

• Main Authors: Menon Prema, Rao K. L. N., Vijaymahantesh S, Kanojia R, Samujh R, Batra Y, Sodhi K, Saxena A, Bhattacharya A, Mittal B
• Format: Article
• Language: English
• Published: Wolters Kluwer Medknow Publications 2010-01-01
• Series: Journal of Indian Association of Pediatric Surgeons
• Subjects: Cystourethrogram; hydronephrosis; posterior urethral valves; vesicoureteral reflux; voiding dysfunction; valve bladder
• Online Access: http://www.jiaps.com/article.asp?issn=0971-9261;year=2010;volume=15;issue=3;spage=80;epage=86;aulast=Menon

<b>Aim:</b> 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. <b>Materials and Methods:</b> 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). <b>Results:</b> Group A: Of the 133 patients, 131 had normal urinary stream and 4 (3&#x0025;) had nocturnal enuresis. Vesicoureteral reflux (VUR), initially seen in 83 units (31&#x0025; units), regressed completely at a mean duration of 6 months in 41 units (49&#x0025;). Of the 152 non-VUR, hydroureteronephrosis (HUN) units, 11 were poorly functioning kidneys. Persistent slow but unobstructed drainage was seen in 23 units (16&#x0025;) 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&#x0025;) had daytime frequency for a mean duration of 1 year and one (9&#x0025;) 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&#x0025;). In the non-VUR, HUN patients, slow (but unobstructed) drainage was persistent in two units (14&#x0025;) at 3 years. Group C: Of the 16 patients, only 5 (31.3&#x0025;) were asymptomatic. Six patients (nine units) had persistent VUR for 6 months to 3 years. Of the 20 units with HUN, 17 (85&#x0025;) were persistent at 1-4 years (mean 2 years). Eight patients (50&#x0025;) required a second fulguration while 3 (18.7&#x0025;) required urethral dilatation for stricture following which all parameters improved. <b>Conclusions:</b> Adequacy of fulguration should be assessed by a properly performed MCUG. A postop PU/BU ratio &gt;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.