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


METHODS
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).


RESULTS

Of the 133 patients, 131 had normal urinary stream and 4 (3%) had nocturnal enuresis. Vesicoureteral reflux (VUR), initially seen in 83 units (31% units), regressed completely at a mean duration of 6 months in 41 units (49%). Of the 152 non-VUR, hydroureteronephrosis (HUN) units, 11 were poorly functioning kidneys. Persistent slow but unobstructed drainage was seen in 23 units (16%) 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%) had daytime frequency for a mean duration of 1 year and one (9%) 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%). In the non-VUR, HUN patients, slow (but unobstructed) drainage was persistent in two units (14%) at 3 years. Group C: Of the 16 patients, only 5 (31.3%) were asymptomatic. Six patients (nine units) had persistent VUR for 6 months to 3 years. Of the 20 units with HUN, 17 (85%) were persistent at 1-4 years (mean 2 years). Eight patients (50%) required a second fulguration while 3 (18.7%) required urethral dilatation for stricture following which all parameters improved.


CONCLUSIONS
Adequacy of fulguration should be assessed by a properly performed MCUG. A postop PU/BU ratio >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.
Department of Pediatric Surgery, Advanced Pediatric Center, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
Prema
P
Menon
K L N
KL
Rao
S
S
Vijaymahantesh
R P
RP
Kanojia
R
R
Samujh
Y K
YK
Batra
K S
KS
Sodhi
A K
AK
Saxena
A
A
Bhattacharya
B R
BR
Mittal