Impact of surgical intervention on progression to end-stage renal disease in patients with posterior urethral valve

Background Posterior urethral valve patients present with varied presentations at any age of life and have significant associated morbidity and require long-term follow-up and care. Methods This was a single-center ambispective cohort study carried out over a period of 2 years. Patient data regarding the symptoms, investigations, interventions, secondary complications were recorded and were followed up regularly during the study till either normalization of their creatinine level which was maintained up to one-year post-fulguration (non-CKD) or progression to end-stage renal disease (ESRD) requiring renal transplant. Various clinical factors were then compared between these groups. Results The age of presentation varies from 6 months antenatal period to a maximum of 34 years. Most common symptom was of lower urinary tract obstruction, followed by recurrent febrile UTI. The interval between disease presentation detection and PU valve fulguration ranged from 6 days to more than 5 years, median duration being 1 month. 85.7% patients had hydroureteronephrosis on initial USG. In VCUG, there was no significant difference found between the presence of reflux and poor renal outcome. Age of presentation greater than 2 years was seen in 52% of patients with CKD compared to only 10% patients in non-CKD group (significant, p value 0.02). Among patients who developed CKD, 60% of patients had PU valve fulguration after one month of disease presentation, while in contrast, among the non-CKD group, 80% of patients had it done within one month of disease presentation. (significant, p value 0.03). Conclusions Late age of presentation, delayed fulguration with high initial creatinine, and failure of serum creatinine to return to normal after one-month post-fulguration are important risk factors in the progression of the disease to ESRD. Symptomatic improvement after interventions does not correlate with progression to ESRD. The number of interventions also does not predict progression to ESRD. Interventions should be chosen wisely on case to restore near-normal physiology and delay progression to ESRD.

Spontaneous bladder rupture secondary to posterior urethral valves in a boy with Down syndrome

We describe a case of a 3-year-old boy with Down syndrome who developed a bladder rupture as a consequence of an undiagnosed posterior urethral valve (PUV). He had a history of urinary tract infections and constipation and was acutely admitted in poor condition and underwent laparotomy that revealed peritoneal sepsis secondary to bladder perforation. Bladder was drained using a suprapubic catheter and the condition of the boy gradually improved. Once stable, a cystourethroscopy confirmed the presence of PUV. Video-urodynamic studies performed at the check cystoscopy showed the bladder to be of reduced compliance (end fill pressure at 100 mL fill 30 cmH2O) with raised voiding pressures (76–100 cmH2O) and significant incomplete bladder emptying. Currently, the patient is doing very well, serum creatinine has normalised, he is infection-free and thriving; his bladder is managed with a vesicostomy.

Pseudotail with closed neural tube defect and neurogenic bladder masquerading as posterior urethral valve: a case report

Background Pseudotail with occult spinal dysraphism with neurological deficit is a rare phenomenon. Ignoring pseudotail as sign of occult spinal dysraphism may lead to catastrophe in diagnosis and further management. Case presentation We are reporting a case of a 30-month-old male child who presented with a tail-like structure at lower back and dribbling of urine since birth. On initial evaluation at some other hospital, he was misdiagnosed as posterior urethral valve and underwent fulguration of valve. However, dribbling of urine persisted after initial procedure. On evaluation at our center, he was found to have pseudotail with occult spinal dysraphism and neurogenic bladder. Conclusion Pseudotail with occult spinal dysraphism with neurological deficit is a rare phenomenon. Neurogenic bladder in such case can be misdiagnosed as posterior urethral valve. So, neurogenic bladder with pseudotail should be evaluated cautiously to avoid misdiagnosis and mismanagement.

Early Outcome of Cold Knife Ablation and Diathermy Fulguration of Posterior Urethral Valve; A Comparative Study

Background: Posterior urethral valve (PUV) is the most common obstructive anomaly of the urethra. Urethral valves have a wide range of clinical and anatomical presentations and today most patients are diagnosed in the prenatal or early neonatal period. Cold knife and diathermy fulguration are two of the technique of PUV ablation. Objective: To find out early outcome of posterior urethral valve ablation between cold knife and diathermy fulguration. Methodology: This prospective comparative interventional study was conducted in the Department of Pediatric surgery in Dhaka Shishu Hospital (DSH), Dhaka. 54 patients with PUV, admitted for valve ablation during study period were included in this study. Patients were divided in to two group. Among them, 27 were in Group-A, whose PUV ablation were done by cold knife and 27 were in Group-B whose PUV ablation were done by diathermy fulguration. Successful ablation was confirmed under endoscopic vision as well as with the demonstration of good stream following supra pubic compression, at the end of the procedure. All patients were kept with 72 hours of urethral catheterization (All silicon self retaining Foley’s catheter according to body texture ) .Post PUV ablation pt. were given discharged with prophylactic antibiotics on 4th POD. Results: The mean age was found 18.37±16.13 months in cold knife ablation group and 12.70±11.03 months in diathermy fulguration group. Significant number (06/22.2%) of cases were associated with residual valve in diathermy fulguration group and non signicant number (301/3.7%) cases in cold knife ablation group . Significant number (04/14.8%) of cases were associated with post PUV ablation stricture urethra also in diathermy fulguration group and no stricture was found in cold knife ablation group . Significant hematuria. was present in 2(7.4%) in cold knife ablation group and 1(3.7%) in diathermy fulguration group. Conclusion: This study concludes that use of cold knife in case of ablation of PUV causes less post ablation obstruction (residual valve and stricture urethra) than using diathermy fulguration and can be regarded a safe and better option for PUV treatment.

An Obstructive Prostatic Urethral Calculus in a Patient with Urethral Strictures: A Case Report

Urinary calculi are the third most common affliction of the urinary tract only exceeded by urinary tract infections and pathologies of the prostate gland. Urinary tract calculi contribute to a major concern encountered in the practice of urology, it affects about 10-12% of the population with a variable incidence with respect to sex, age, occupation, geographical area, climate, dietary fluid intake, social class and race. Urethral calculus is always found on the site of prostatic urethra, bulbar and fossa navicularis. Primary urethral calculi are usually associated with urethral strictures, posterior urethral valve and a diverticulum. Urethral calculi represent 1-2% of all calculi in the urinary tract. This is a case of a 32-year-old farmer and fisherman who had a retrograde urethrocystography (RUCG) that showed an obstructive prostatic calculus, bladder wall calcification and thickening with contrast refluxing into the seminal vesicles bilaterally.