膀胱皮肤造口术在新生儿尿路畸形中早期应用探讨

目的探讨膀胱皮肤造口术在新生儿尿路畸形患儿中的早期应用。方法回顾性分析我院2003年1月至2006年6月因先天性尿路畸形行膀胱皮肤造口术的患儿资料,包括原发病、临床表现、影像检查、皮肤膀胱造口术后转归等。结果共13例新生儿,均为男婴,手术日龄16～28天,平均22天,其中后尿道瓣膜8例,前尿道瓣膜1例,双侧原发性膀胱输尿管反流4例。膀胱皮肤造口术后半年至1年复查,2例因皮肤膀胱造口狭窄改为膀胱造瘘,1例仍间断反复泌尿系感染,17侧膀胱输尿管反流中6侧反流消失,16侧肾输尿管积水中5侧消失,无肾、输尿管积水及膀胱输尿管反流加重病例。结论尿路畸形新生儿行皮肤膀胱造口术操作简单、易护理,可有效引流尿液,抑制膀胱输尿管反流,改善泌尿系感染,保护肾功能。     

前尿道瓣膜切除术后膀胱功能异常与上尿路损害的关系

目的探讨前尿道瓣膜切除术后造成上尿路持续损害的尿动力学危险因素。方法回顾性分析2007年1月至2020年1月26例前尿道瓣膜切除术后患儿的临床资料,平均年龄3.4岁(5个月至14岁)。瓣膜切除术后4个月至12.5年,平均5.5年。患儿术后均进行尿动力学检查。手术前后均进行血生化(包括尿素氮、肌酐)检查、泌尿系统B超检查、静脉肾脏造影(intravenous pyelography,IVP)和排尿性膀胱尿道造影(voiding cystourethrogram,VCUG)。比较瓣膜切除前后肾和输尿管积水以及膀胱输尿管反流情况,分析造成前尿道瓣膜术后上尿路持续损害的危险因素。结果前尿道瓣膜切除手术前肾和输尿管积水患儿共15例24侧,占57.7%(15/26);膀胱输尿管反流8例11侧,占30.8%(8/26)。瓣膜切除术后有5例7侧肾和输尿管积水消失,占19.2%(5/26);2例3侧膀胱输尿管反流消失。瓣膜切除术后肾和输尿管积水患儿共10例17侧,占38.5%(10/26);膀胱输尿管反流6例8侧,占23.1%(6/26)。有7例11侧肾和输尿管积水较术前加重,占26.9%(7/26),其中4例6侧膀胱输尿管反流较术前加重。根据术后肾和输尿管积水以及膀胱输尿管反流恢复情况,分为上尿路损害加重组(7例)和上尿路损害减轻或消失组(19例)。行瓣膜切除术后尿动力学检查发现,在上尿路损害加重组7例患儿中,压力流率图显示5例依然存在下尿路梗阻或可疑梗阻。上尿路损害减轻或消失组19例患儿压力流率图均显示无梗阻(P<0.05);两组最大尿流率平均值、膀胱顺应性、排尿期最大逼尿肌压力值差异均存在统计学意义(P<0.05);上尿路损害加重组中5例动态VUCG显示排尿时膀胱颈全程开放不全,行膀胱尿道镜检查发现3例膀胱壁增厚,呈小梁样改变和膀胱假性憩室形成,尤其膀胱基底以及膀胱内口附近组织明显增厚。结论前尿道瓣膜是一种罕见的下尿路梗阻性疾病,瓣膜切除之后上尿路损害仍然会持续存在或加重,可能与患儿异常的膀胱功能有关。排尿期最大逼尿肌压力升高、最大尿流率低、膀胱顺应性低以及压力流率图显示梗阻仍存在是导致膀胱功能异常的尿动力学危险因素,可能与前尿道瓣膜患儿同时存在膀胱颈部功能与结构的异常有关。     

小儿前尿道瓣膜诊治11例

目的探讨小儿前尿道瓣膜的治疗方法及临床疗效。方法回顾性分析2003年1月至2013年5月作者收治的11例前尿道瓣膜患儿临床资料,患儿均为男性,年龄3个月至8岁,平均2岁8个月,其中年龄1岁以下6例。8例使用7.5F或9F膀胱尿道镜在尿道的4点、6点和8点处切开瓣膜,并留置导尿管10 d。对其中3例合并前尿道憩室的患儿,2例行憩室切除、尿道成形术;1例一期行膀胱造瘘术,二期行憩室切除、尿道成形术。结果 11例均手术顺利,术后均排尿通畅。无尿瘘及尿道海绵体损伤。随访3个月至4年,平均1.5年。尿白细胞消失,阴茎阴囊交界处包块消失。合并肾积水2例,膀胱输尿管反流3例,B超复查均有不同程度缓解。肾功能检查血清尿素、肌酐均正常。结论腔内冷刀切开治疗前尿道瓣膜症是一种可行的方法,疗效确切,术后并发症少,预后好。合并前尿道憩室患儿可选择憩室切除、尿道成形术。     

小儿输尿管膨出症的治疗--附91例分析

目的 选用创伤小，疗效好的术式治疗输尿管膨出症，减法二次手术。方法 91例输尿管膨出症，男25例，女66例，其中70例（76.9%)并发于重肾双输尿管畸形，其中左上输尿管膨出症40例，右上27例，双上3例，影像学检查；双上肾积水4例，患侧上肾积水52例，患侧上下肾积水10例，患侧上，下及对侧都有肾积水4例。21例单一系统输尿管膨出症中，左侧5例，右侧11例，双侧5例。影像学检查；患侧肾积水10例，双侧肾积水5例，患肾功能严重受损5例。上尿路正常1例。结果 78例（85.7%)术后平均随访2年。重肾组；（1）上肾部切除48例52侧，治愈36例，失访7例，需加做输尿管残留切除3例，需再经尿道戳穿输尿管膨出2例；（2）切除输尿管膨出及输尿管膀胱再吻合6例，治愈5例。术后加做上肾部切除1例；（3）经尿道戳穿输尿管膨出15例，治愈9例，失访4例。需加做上肾部切除2例；（4）输尿管膨出自行缩小，症状消失1例。单一系统21例中15例经尿道戳穿输尿管膨出，治愈12例，失访2例，需加做输尿管膀胱再植1例，1例经输尿管膨出切除，输尿管膀胱再植治愈，发育不良肾切除5例。治愈2例，有尿失禁症状2例，仍时有尿路感染1例。全组1次手术治愈65例。结论 输尿管膨出症的治疗须根据患肾功能决定，如患肾功能严重受损，首选患肾或肾部切除，反之则经尿道做膨出部下缘戳孔术，对单一系统肾发育不良并发异位输尿管膨出的女性，其位置低至尿道远端，因该处尿道肌肉缺损造成失禁，须进一步治疗。     

钬激光技术治疗后尿道瓣膜疾病的疗效观察

目的探讨钬激光治疗后尿道瓣膜疾病的疗效,总结临床经验,推广钬激光在后尿道瓣膜疾病中的应用。方法 29例后尿道瓣膜症患者,均为男性,行膀胱尿道造影、静脉尿路造影、经尿道输尿管镜检查诊断。均采用全麻,取膀胱截石位,运用钬激光电视监视下将后尿道瓣膜逐个点烧灼切除,再次检查后尿道,后尿道通畅,撤镜。挤压耻骨上膀胱体表处,见冲水样尿液从尿道流出,尿线较前明显增粗。术后给予抗炎、补液及对症处理。留置导尿管2 d~1周不等,并留置膀胱造瘘管。结果行钬激光后尿道瓣膜切除术,术中诊断后尿道瓣膜类型均为I型,手术几乎无出血,手术时间短,操作方便。术后随访3个月至2年,24例行经尿道膀胱输尿管镜钬激光手术治疗1次后,排尿费力症状缓解,延缓上尿路扩张损害。表现为:双肾积水改善,B超随访双肾及输尿管扩张情况均不同程度好转,残余尿均较小,术后半年随访尿流率,最大尿流率、平均尿流率均明显高于术前,排尿时间较术前明显缩短。5例症状无改善,行二次钬激光后尿道瓣膜切除术,术后尿流率在7~18 mL/s范围。本组病例术后尿动力学检查结果示:29例中,16例(占94.1%)存在不同程度膀胱功能损害,尿动力学检查表现为顺应性降低,逼尿肌不稳定(占37.9%),10例(占34.5%)残余尿增多。结论经尿道钬激光治疗后尿道瓣膜是一种安全、微创、有效治疗后尿道瓣膜的手段,值得推广。     

输尿管口囊肿残余致排尿困难1例

患儿：女，７岁。因左肾输尿管切除术后排尿困难１８个月入院。患儿１８个月前因高热、腹部肿块在外院诊断为左肾积脓行左肾切除，术中见左输尿管亦扩张积脓，予以全段切除，留置导尿管。术后恢复顺利，但拔导尿管后即出现严重排尿困难，后多次插导尿管通畅，每次拔管后排尿困难，最终行穿刺膀胱造瘘持续引流。入我院后观察发现，患儿排尿极为费力，每次仅滴沥数滴尿，痛苦异常，ＩＶＰ见右侧双肾盂输尿管畸形并轻度积水，左侧上尿路未显影，尿道膀胱镜检见膀胱壁重度小梁增生及假性憩室形成，相当于左输尿管口部位一巨大囊肿，伸入膀胱颈和…     

B超影像尿动力学检查在诊断小儿下尿路功能障碍中的应用

目的探讨B超影像尿动力学检查在下尿路功能障碍患儿诊断中的应用价值。方法69例小儿分2组，患儿组54例，为下尿路功能障碍的患儿，男30例，女24例，年龄4～18岁，平均（10．7±3．6）岁；对照组15例，为下尿路正常的患儿（因上尿路异常作下尿路检查者），男11例，女4例，年龄3～17岁，平均（9．9±3．7）岁。分别进行尿动力学检查，同步耻骨上、会阴部和直肠B超观察膀胱壁厚度、膀胱颈口形态、膀胱充盈和排尿后尿道形态等。结果患儿组尿动力学异常表现有残余尿量增多、膀胱顺应性降低、逼尿肌过度活动、逼尿肌括约肌协同失调和逼尿肌瘫痪等，B超影像检查异常表现有膀胱壁增厚、毛糙，颈口抬高，后尿道扩张，排尿期尿道开放不完全等，其中2例后尿道瓣膜患儿发现膀胱憩室。对照组B超影像检查显示充盈期膀胱壁光滑，厚度（2±1）mm，均小于3mm；膀胱颈口关闭，无抬高；排尿期膀胱颈口、后尿道充分开放，残余尿量小于10ml。结论B超影像尿动力学检查可将膀胱的功能性改变和形态学信息相结合，能更全面准确地诊断和了解下尿路功能障碍。     

二维FASE技术MRU成像对小儿泌尿外科疾病诊断的意义

自 1996年 6月至今 ,我院采用高级转换快速自旋回波 (ＦＡＳＥ)序列为 32例小儿行ＭＲＵ(磁共振尿路造影 )检查 ,取得理想效果 ,现报道如下。资料与方法1.一般资料　本组 32例 ,男 19例 ,女 13例 ,年龄 16ｄ～ 13岁 ,平均 (5 .2±4.8)岁。其中新生儿 2例 ,婴幼儿13例 ,学龄前儿童 9例 ,学龄儿童 8例。病种为 :肾盂输尿管连接部梗阻 16例(1例并发肾盂结石 ,1例为脓肾 ) ,肾胚胎瘤 4例 ,先天性巨输尿管 3例、输尿管膨出 2例 ,重肾双输尿管伴输尿管异位开口 2例 ,多囊肾、双侧输尿管炎性狭窄、原发性膀胱输尿管反流、膀胱憩室、后尿道瓣膜症各 …     

小儿输尿管囊肿的诊断与治疗

目的探讨小儿输尿管囊肿诊断与治疗的方法及效果。方法输尿管囊肿39例进行总结分析。病例均行B超和静注尿路造影（IVU）检查。IVU不显影者行CT检查14例，行MRI检查8例。行膀胱镜检查10例。结果13超确诊31例，IVU确诊17例。行CT、MRI、膀胱镜检查者均得到确诊。输尿管囊肿39例中行上肾段及输尿管切除26例。行囊肿切除加输尿管膀胱移植术7例，经尿道行囊肿电切开窗术6例。并发症：膀胱输尿管返流3例，囊肿边缘出血、输尿管残端感染各1例。结论B超适于囊肿的筛选。IVU可了解肾脏功能及畸形情况。CT、MRI对IVU不显影有帮助。膀胱镜对了解囊肿大小、位置起确诊作用。囊肿侧肾发育不良或伴严重积水者行上肾段及输尿管切除；囊肿大者宜行囊肿切除加输尿管膀胱移植术，较小囊肿可经尿道电切开窗术。     

钬激光腔内治疗在小儿泌尿系统疾病的初步应用

目的评价钬激光腔内治疗小儿泌尿系统疾病的方法和疗效。方法回顾性分析采用钬激光腔内治疗18例小儿泌尿系统疾病的临床资料，男12例，女6例，年龄1～14岁（平均6．6岁）。输尿管结石6例，上段1例、中下段5例，结石直径0．5～0．9cm；后尿道及膀胱结石7例，结石直径0．8～1．5cm；先天性单纯性输尿管口囊肿3例，直径2．0～3．5cm；前、后尿道狭窄各1例，长度分别为0．4cm和0．5cm。进行输尿管镜和小儿膀胱镜下钬激光腔内微创治疗。结果6例输尿管镜下钬激光输尿管碎石术、7例小儿膀胱镜下钬激光膀胱结石碎石术、3例输尿管镜下钬激光输尿管囊肿去顶开窗术和2例尿道狭窄内切开加瘢痕组织切除术均一次成功，无并发症。手术时间8～25min，平均16min。尿道狭窄术后留置导尿管2周，拔管后次H出院；其余患儿术后留置导尿管1～3d，住院2～5d。术后2周拔除双J管。碎石术后随访2～12个月无残留和复发，原伴随的肾积水消失；输尿管口囊肿术后随访3～9个月无膀胱输尿管反流；尿道狭窄术后1个月和3个月时各预防性尿道扩张1次，随访4～12个月排尿通畅。结论钬激光腔内治疗小儿泌尿系统疾病安全、有效、微创，但需要积累更多的病例和更长时间的随访。     

Urinary ascites in young infants--report of 9 cases

Nine boys whose age ranged from 5 days to 3 months with urinary ascites were managed in Beijing Children's Hospital. All of them presented with gradual abdominal distension from birth, 5 had dripping of urine, the 5-day old new born had anuria since birth. In 2 other infants one had cystostomy and the other, ureterostomy before admission. Urinary ascites was confirmed by abdominal paracentesis. Intravenous pyelography (IVP) and Voiding cystourethrography (VCUG) in 7 cases showed bilateral hydroureteronephrosis and dilatation of the posterior urethra consistent with congenital posterior urethral valves. The 40-day old infant who had cystostomy followed subsequently by vesicostomy is still waiting for ablation of the valves. The remaining 6 were managed by 2 stage operation, 5 had vesicostomy first, one; ureterostomy. They had valves ablation either through urethra or bladder at the age of 3 months to 2 years old. Urinary ascites disappeared spontaneously after urinary drainage. Two patients died; one due to dehydration after drainage of the obstructed renal pelvis, the other (in 1977) had no urinary drainage for obstructed urinary tract.     

Initial surgical treatment as a determinant of bladder dysfunction in posterior urethral valves

Bladder function in patients with posterior urethral valves (PUV) has an immense impact on long-term continence and renal function. Bladder dysfunction was corelated with the initial surgical treatment in 67 patients with PUV treated between 1985 and 2000. Age at presentation, current age, duration of follow-up, initial surgical treatment (diversion or valve fulguration), trends of renal function tests, voiding disturbances, and changes in the upper tracts were recorded. Urodynamic studies were done in all patients to determine urine flow rates, residual volume, maximal cystometric capacity (MCC), bladder compliance, involuntary detrusor activity, and pressure-specific bladder volume (PSBV) at 30 cm water. The patients were divided into three groups depending on the initial treatment: fulguration (n = 38), vesicostomy (n = 25), and ureterostomy (n = 4). At the time of this study voiding symptoms persisted in 45 patients. Mean percent MCC (% MCC) was 62%, 96%, and 100% of normal in the vesicostomy, fulguration, and ureterostomy groups, respectively (P = 0.002). Large-capacity bladders were seen in 10.9% of patients, mostly in pubertal and post-pubertal boys who were treated initially by either fulguration or ureterostomy; vesicostomy adversely affected bladder capacity and compliance (P = 0.007). PSBV was decreased in 48% of patients in the vesicostomy group and was significantly lower in the other groups (P = 0.01). Mean percent PSBV was 75%, 95%, and 96% of normal in the vesicostomy, fulguration, and ureterostomy groups, respectively. Uninhibited contractions were present in 21 patients (14 in the vesicostomy group) (P = 0.01). The highest incidence of upper-tract deterioration was seen with %MCC below 60% of normal (P = 0.001). The predominant urodynamic patterns were: (1) fulgurated group: good-capacity, compliant bladder; (2) vesicostomy group: small-capacity, hyperreflexic bladder; and (3) ureterostomy group: good capacity, compliant bladder. Primary valve ablation is associated with better bladder function than vesicostomy and should be the treatment of choice in PUV. Also, vesicostomy and ureterostomy have distinctly different effects on bladder function.     

Posterior urethral valves: incidence and progress of vesicoureteric reflux after primary fulguration

This is a prospective study of 20 cases of posterior urethral valves (PUV) presenting between the ages of 12 days and 5.5 years (median 15 months) in order to determine the incidence and progress of vesicoureteric reflux (VUR), hydronephrosis (HN), and renal functional status. The efficacy of fulguration as the sole modality of treatment for PUV was assessed in terms of improvement or disappearance of VUR over a 6-month follow-up period. VUR was present in 60% of the patients, being unilateral in 41.7%. Out of 19 renal units with VUR, reflux subsided in 31.5% by 3 months and 78.94% by 6 months. The blood urea and serum creatinine levels, which were raised in 50% of the patients at presentation, came down to normal by 6 months in all the cases. Improvement in glomerular filtration rates (GFR) was noted in all the children at each follow-up and was found to be statistically significant (p<0.01). HN was present in all the patients at presentation and was bilateral in 90%. It decreased significantly during the follow-up period, though its complete disappearance was seen only in one case. Vesicoureteric reflux dysplasia syndrome (VURD) was present in two cases. Our study showed that VUR disappeared in a majority of the cases by 6 months once adequate urethral patency was restored, although hydronephrosis persisted.     

Protective Temporary Vesicostomy for Upper Urinary Tract Problems in Children: A Five-Year Experience

Objective

Temporary vesicostomy is a urinary diversion procedure for patients with upper urinary tract (UUT) dilatation, secondary to bladder outlet obstruction or dysfunction. The aim of this study was to evaluate our experience in children undergoing such diversion, analyzing its efficacy to prevent urinary tract infection (UTI), improve or resolve hydronephrosis, stabilize or improve kidney function and restore the health of UUT.

Methods

In this retrospective study, patients who had vesicostomy by Blocksom technique due to bladder outlet obstruction or dysfunction were evaluated in Mofid Children’s Hospital (in Tehran) from March 2007 to March 2012. The reason for applying this procedure was failure in clinical treatment. Data regarding gender, age, diagnosis, time of any surgical intervention, associated anomalies, primary/secondary complications and mortality were collected using a questionnaire, and evaluated by giving a grade that ranged from 0 (worst) to 10 (best) based on Lickert’s scale.

Findings

From a total number of 53 patients, (88.7% male and 11.3% female) with a mean age of 225 days, 66% had posterior urethral valve and 16 (30%) neurogenic bladder. UTI was present in all cases, hydronephrosis in 52 (98.1%), and vesico-ureteral reflux only in 45 (84.9%) patients. Valve ablation was performed in 17 cases, and clean intermittent catheterization in14 patients which were unsuccessful. We performed vesicostomy in all patients. Mortality rate was 7.5%. Vesicostomy was closed in 35 patients. Cure rate was 85% in UTI, 82.7% in hydronephrosis, 80% in VUR, and 86.5% in kidney function.

Conclusion

Vesicostomy is a simple procedure that protects upper urinary tract, decreases hydronephrosis, and improves kidney function. The procedure is well tolerated and reversible, with less complication and should be considered in children in whom conservative and medical treatment has failed.     

Role of vesicostomy in the management of posterior urethral valve in Sub-Saharan Africa

ObjectiveTo review the role of vesicostomy in the management of posterior urethral valve (PUV), in neonates and infants, given the limitations for endoscopic treatment in this setting.MethodsA review of 35 patients who presented with posterior urethral valve over a 10-year period. Demographic and clinical information were prospectively recorded on a structured pro forma, and the data extracted analysed using SPSS 11.0.ResultsThe 35 boys were aged 3 days to 10 years (median 3 weeks). Twenty-three (65.7%) had a vesicostomy (age range 3 days–3 years, median 3 weeks). The mode of presentation was poor urinary stream 15 (65.2%), urinary retention 4 (17.4%), and renal failure 6 (26.1%). Main findings were palpable bladder 23 (100%), hydronephrosis 4 (17.4%). Abdominal ultrasound confirmed hydronephrosis and thickened bladder wall, and voiding/expressive cystourethrogram confirmed dilated posterior urethra and vesicoureteric reflux in all 23 patients. Complications following vesicostomy were stoma stenosis 1 (4.3%), bladder mucosal prolapse 1 (4.3%), perivesicostomy abscess 1 (4.3%); there was no mortality. Following vesicostomy, 10 (43.5%) patients had excision of the valves and vesicostomy closure at age 2–8 years (median 4 years). They are well, with normal renal ultrasonographic findings, bladder capacity range 115–280 ml, and normal urea, serum electrolytes, creatinine, at 3 years of follow up. Thirteen (56.5%) are still awaiting valvotomy but have remained well and with normal ultrasonographic renal findings.ConclusionVesicostomy is a useful temporising mode of urinary diversion in neonates and infants with posterior urethral valve (in the absence of unobstructed upper tracts) when facilities for endoscopic valve ablation are not readily available.     

Posterior urethral valves: long-term outcome

Posterior urethral valves represent the most common cause of bladder outlet obstruction in infancy that impairs renal and bladder function. Long-term outcome of patients with previous PUV is evaluated. Patients over 18 years of age, treated from 1982 to 1995 before the age of 3 years were considered. Previous surgery, renal function, bladder activity, urinary incontinence, and fertility/sexual activity were evaluated. Clinical interview, creatinine clearance, uroflowmetry with ultrasound post-void urine residue, and self-administered questionnaire were recorded. Out of 45 identified records, 24 patients (53.3%) accepted to be enrolled (age 18–34 years, mean 23 years). The mean follow-up was 19.5 years (16–30 years). Out of the 21 excluded patients, 20 did not reply to the clinical interview and 1 died at age of 6 years. All the 24 patients had early endoscopic section of PUV; nine also received transient ureterocutaneostomy or vesicostomy. Ureteroneocystostomy was performed in five patients and ureterocystoplasty with unilateral nephrectomy in two. At follow-up chronic renal failure was detected in 13 patients (54.1%) and 9 (37.5%) had arterial hypertension. End-stage renal disease developed in five patients (20.8%): three had successful renal transplantation and two were in dialysis. Lower urinary tract symptoms were present in seven patients (29.1%). No significant fertility deficit and sexual dysfunction were observed in 23 patients, while 1 patient was azoospermic. No paternity was reported so far. Long-term outcome of patients with previously treated PUV is mandatory. Kidney, bladder, and sexual functions should be monitored till adulthood to verify any modified behaviour.     

Posterior Urethral Valves; A single Center Experience

Objective

Posterior urethral valves (PUV) are the most common cause of bladder outlet obstruction in infancy that impair renal and bladder function. This study was planned to evaluate and record the various clinical presentations and management, complications, and surgical management and long-term outcome of PUV.

Methods

In a retrospective study, 98 patients who have been treated for PUV are evaluated in Mofid Children''s Hospital from January 2007 to December 2012. Detailed history taken and paraclinical examinations were performed in each patient and diagnosis was confirmed by voiding-cysto-urethrography (VCUG). PUV had been ablated in 62 patients by electric hook, and diversion was performed in 42 (42.85%) cases. Data were analyzed by SPSS software version18.

Findings

Totally 98 patients with mean age at diagnosis 62 (±13) days were included in this study. Fifty seven cases had been catheterized within one to 6 days of life (mean age one day), PUV was ablated in 62 patients by electric hook, and diversion was performed in 42 cases. The most common symptom in our group was dribbling poor stream 51% and urinary tract infection (UTI) 40.8%. There was vesico-ureteral-reflux (VUR) in 61.2%, and hydronephrosis in 82.6%. Most common associated anomaly was kidney anomalies (multicystic kidney disease and renal agenesis/dysplasia) in 8 (8.2%) patients. Twenty patients had prenatal diagnosis of PUV. Complication occurred in three (3.1%) patients. Mortality occurred in 5 (5.1%) patients. Mean follow-up period was 3.4±1.2 years (1.5 months to 5 years).

Conclusion

Urinary drainage by feeding tube in early days of infancy, followed by valve ablation is the best treatment in PUV, and urinary diversion improves the outcome. VCUG is still the gold-standard imaging modality for documenting PUVs. The factors like renal dysplasia and UTI have their role in final outcome.     

Validation of initial serum creatinine as a predictive factor for development of end stage renal disease in posterior urethral valves

Objective  The aim of this study was to determine the value of initial serum creatinine in prediction of End-stage renal disease (ESRD) in children with posterior urethral valves PUV. Methods  In this retrospective study, patients diagnosed with PUV admitted in Aliasghar Children’s Hospital in Tehran, Iran from 1991 through 2001 were studied. Based on the development of ESRD (need for dialysis) they were classified in two groups and their demographics, initial presentations, laboratory data, imaging findings and outcomes were reviewed and compared. Results  Thirty six male patients with PUV, treated with valve ablation (13), vesicostomy (13), or high ureterostomy (10) were followed for developing ESRD. Sixteen of the 36 patients developed ESRD at their last follow-up. There was no significant difference in age at initial presentation, presence of urinary tract infections, incidence of vesicoureteral reflux, renal dysplasia or type of primary surgical intervention between the patients with or without ESRD. Patients who progressed to ESRD had serum creatinine concentration > 1.0 mg/dl at diagnosis as compared to those without ESRD (P = 0.001). Conclusion  Initial serum creatinine is a valuable factor for prediction of renal outcome in patients with PUV.     

Primary vesicoureteral reflux in blacks with posterior urethral valves: does it occur?

Primary vesicoureteral reflux (VUR) is thought to be largely independent of obstruction. Therefore, in patients with urethral obstruction due to posterior urethral valves (PUV) the occurrence of VUR is coincidental. In addition, primary VUR is reported to be uncommon in black children. If these two premises are correct, then primary VUR should be rare in black males with PUV. To test this hypothesis, we reviewed the medical records and radiographs of 43 males with PUV. Twenty-one of the 37 non-black males with PUV had VUR, of which 67% was primary and 33% was secondary. Three of the six blacks with PUV had VUR of which all was secondary. Thus, blacks with PUV lend credence to the theory that primary VUR is not caused by obstruction and support the observation that primary VUR is rare in black children, even those with PUV.     

Evolution of upper urinary tract and renal function in patients with posterior urethral valves

From January 1972 to June 1993, 166 patients with posterior urethral valves (PUV) were treated in our surgical department, 59 with a milder form of PUV (upper urinary tract [UUT] complication rate 29%) and 107 with a severer form (UUT complication rate 96.3%). Only the latter group was studied for long-term (mean 9.3 years) evaluation of the UUT and renal function. A temporary vesicostomy was the primary treatment in 25 patients. Indications for temporary diversion were very young age and/or low birth weight, severe and bilateral UUT complications, and severe renal damage. All the other patients were treated by primary endoscopic valve fulguration. After removal of the lower urinary tract obstruction, vesicorenal reflux (VRR) resolved spontaneously or was ameliorated in 59.2% of the renal units. Spontaneous normalization or evident amelioration were found at long-term follow-up in nearly 70% of dilated, non-refluxing ureters. Ureteral reimplantation was performed on 41 of the 202 dilated or refluxing ureters (surgical rate 20.3%). The surgical failure rate requiring reoperation was 5% (2/41). The prerequisite for successful reimplantation was a large-capacity, stable, and compliant bladder. Ten nephroureterectomies were carried out for unilateral, massive VRR and renal dysplasia; 1 late nephrectomy was performed for arterial hypertension. The evolution of renal function showed statistically significant overall improvement, which was more evident in patients diagnosed and treated in the 1st month of life (P = 0.000) than in those treated between 1 and 12 months (P = 0.004) or after 1 year of age (P = 0.025). Renal function considerably improved in the vesicostomy group (P = 0.000). Thirteen patients (12.4%) are now either dead (2) or have end-stage renal disease (6) or chronic renal insufficiency evolving toward end-stage renal disease (5); 5 of these 13 were treated by vesicostomy in the first days or months of life, and at presentation the glomerular filtration rate (GFR) was less than 25 ml/min . 1.73 m². Determination of basic GFR and, even more, functional renal reserve is relevant in predicting the long-term evolution. In the author's opinion, vesicostomy is the procedure of choice in very ill newborns or infants. Aggressive management with early surgical reconstruction is rarely justified, because frequently UUT complications resolve spontaneously or clearly improve, and their surgical treatment has limited and very precise indications.