Posterior urethral valves with persistent high serum creatinine: the value of percutaneous nephrostomy.
OBJECTIVE
In patients with posterior urethral valves and persistent high serum creatinine irrespective of vesical drainage proximal urinary diversion is done for presumed concomitant ureterovesical junction obstruction. We retrospectively evaluated whether such management is justified.


METHODS
Between 1982 and 1995 we reviewed the records of all patients with posterior urethral valves and serum creatinine persistently higher than 1.5 mg./dl. Patient characteristics, treatment method and eventual outcome were determined as well as the results of radiological and Whitaker pressure studies done to exclude obstruction at the ureterovesical junction.


RESULTS
Of the 48 patients evaluated 28 underwent primary valve ablation, 16 high loop ureterostomy and 4 vesicostomy. After an average of 78 months (range 37 to 135) chronic renal failure developed in 31% and 25% of those treated with and without high loop ureterostomy, respectively. However, in patients who underwent ureterostomy initially there was a significantly higher rate of decreased bladder capacity, urinary incontinence and augmentation cystoplasty. Obstruction at the ureterovesical junction was noted at surgery and after an average of 2 weeks of diversion in 7 (32%) and 1 (5%) of the 22 cases of percutaneous nephrostomy, respectively. However, after an average of 18 months of ureterostomy drainage we noted evidence of obstruction in 2 of the 27 ureterovesical units (7%). Early in our series 15 of 34 patients (44%) underwent ureterostomy. Subsequently, according to a treatment algorithm including percutaneous nephrostomy, only 1 of 14 boys (7%) underwent such diversion.


CONCLUSIONS
Based on our findings high loop ureterostomy does not prevent progression to renal insufficiency and is associated with more complications than primary valve ablation or vesicostomy. Unresolved ureterovesical junction obstruction is rare. Before performing formal supravesical diversion short-term percutaneous nephrostomy drainage helps to identify patients who require diversion.
Ghali
A M
AM
Urology and Nephrology Center, Mansoura University, Mansoura, Egypt, and College of Medicine, King Khalid University, Abha, Saudi Arabia.
El Malki
T
T
Sheir
K Z
KZ
Ashmallah
A
A
Mohsen
T
T
D003404:Creatinine / Q000097:blood*; D018450:Disease Progression; D006801:Humans; D007223:Infant; D009403:Nephrostomy, Percutaneous / Q000009:adverse effects; D051437:Renal Insufficiency / Q000209:etiology / Q000517:prevention & control; D012189:Retrospective Studies; D012307:Risk Factors; D014517:Ureteral Obstruction / Q000209:etiology / Q000601:surgery*; D014521:Urethra / Q000002:abnormalities*
D003404:Creatinine