Urology & Nephrology Center, Mansoura, EGYPT Antenatal versus postnatal diagnosis of posterior urethral valve, does it affect bladder function? Bassem S. Wadie*, Osama Sarhan*, Ahmed El Hefnawy*, Alaa El ghoneimi§ Urology and Nephrology Center (UNC), Mansoura, EGYPT*, Robert Debre for children (RDCH), Paris, France §. 5/16/2018 Urology & Nephrology Center, Mansoura, EGYPT

Urology & Nephrology Center, Mansoura, EGYPT Introduction 1 Morbidity of PUV: Incontinence: seen in over 20% of children 1 year after valve ablation1 Bladder dysfunction: in 75% 2 starting in utero and progresses later, even after valve ablation 3,4 Renal impairment: Sometimes despite successful valve treatment. Almost a third of cases ends up by renal failure 2. 1 Churchill, B M , et al : Emergency treatment and long term follow up of posterior urethral valves. Urol. Clin.N Am., 17: 343, 1990 2 Parkhouse, H. F. et al: Long –term outcome of boys with posterior urethral valves. Br. J. Urol. 62: 59,1988. 3 Peters, C.A., et al: The urodynamics consequences of posterior urethral valves. J Urol. 144: 122, 1990. 4 Peters, C. A. et al: The effect of obstruction on the developing bladder. J. Urol. 148: 491,1992. 5/16/2018 Urology & Nephrology Center, Mansoura, EGYPT

Urology & Nephrology Center, Mansoura, EGYPT Introduction 2 Primary valve ablation is the gold standard for early postnatal management of PUV * * Podesta, M., et al: Bladder function associated with posterior urethral valves after primary valve ablation or proximal urinary diversion in children and adolescents. J Urol. 168: 1830, 2002. 5/16/2018 Urology & Nephrology Center, Mansoura, EGYPT

Urology & Nephrology Center, Mansoura, EGYPT Introduction 3 The value of urodynamic in valve management has been repeatedly emphasized: “valve ablation alone without urodynamic follow up is not appropriate” * *Glassberg, K. I.: The valve bladder syndrome: 20 years later. J. Urol. , 166: 1406, 2001. 5/16/2018 Urology & Nephrology Center, Mansoura, EGYPT

Urology & Nephrology Center, Mansoura, EGYPT Introduction 4 Aim of the study: whether antenatal diagnosis and early valve ablation better serve bladder function in boys with PUV. 5/16/2018 Urology & Nephrology Center, Mansoura, EGYPT

Urology & Nephrology Center, Mansoura, EGYPT Patients & Methods 1 Retrospective, multi center study of 2 groups of children from 2 different centers: one with antenatal diagnosis and early ablation (group 1) and another with postnatal diagnosis (symptomatic disease) (group 2). 5/16/2018 Urology & Nephrology Center, Mansoura, EGYPT

Urology & Nephrology Center, Mansoura, EGYPT Patients & Methods 2 In group 1,diagnosis was based on antenatal US and confirmed by postnatal SPVCUG. children having persistent symptoms, evidence of incomplete voiding were scheduled for urodynamics. In group 2, all children had preoperative VCUG, renal US and radiouclide scan of the kidney ( MAG 3). 5/16/2018 Urology & Nephrology Center, Mansoura, EGYPT

Urology & Nephrology Center, Mansoura, EGYPT Patients & Methods 3 Urodynamics: 6 F catheter was used for measuring bladder pressure and infusion of distilled water at room temperature. A rectal catheter was used for abdominal pressure recording. PVR was measured once the catheter is inserted within 5 minutes of the child’s last void. Rate of infusion was adjusted at 10th the expected capacity for the age. Voiding was allowed in the urodynamic sitting. For those who could not void beside a catheter, free uroflowmetry was allowed, using a weight transducer flowmeter 5/16/2018 Urology & Nephrology Center, Mansoura, EGYPT

Urology & Nephrology Center, Mansoura, EGYPT Patients & Methods 4 Statistical analysis was carried out using SPSS (14). Levene’s test for independent variables was used for inter-groups comparison. 5/16/2018 Urology & Nephrology Center, Mansoura, EGYPT

Urology & Nephrology Center, Mansoura, EGYPT Results 1 Group 1 23 children. Antenatal ultrasound, between 21 and 37 weeks of gestation (median: 32 weeks). All had ablation of their valves within the first week after birth. 5/16/2018 Urology & Nephrology Center, Mansoura, EGYPT

Urology & Nephrology Center, Mansoura, EGYPT Results 2 21 (91.3%) had vesicoureteric reflux 12 unilateral. 9 bilateral 2 (8.7%) had hydronephrosis without reflux. 5/16/2018 Urology & Nephrology Center, Mansoura, EGYPT

Urology & Nephrology Center, Mansoura, EGYPT Results 3 Urodynamics: Mean age at time of exam.: 8.04 years Mean capacity: 280.43 ml. Mean percent capacity (ratio of the actual capacity /expected capacity for age ) : 1.01 Mean compliance (full capacity) :17.87 ml/cmH2O. Mean PVR: 64.13 ml Percent PVR (PVR / PVR as 15% of capacity) 1.44. Detrusor overactivity:13 (56.6%). 5/16/2018 Urology & Nephrology Center, Mansoura, EGYPT

Urology & Nephrology Center, Mansoura, EGYPT Results 4 Group 2: 30 children Age at time of valve ablation ranged from 1 month to 16 years (Median: 2 years). Major presentation was retention of urine in almost half the cases, while difficulty on micturition, recurrent UTI and nocturnal enuresis accounted for the other half 5/16/2018 Urology & Nephrology Center, Mansoura, EGYPT

Urology & Nephrology Center, Mansoura, EGYPT Results 5 Post natal clinical presentation of children with PUV: Frequency Percent Retention 14 46.7 Difficulty 8 26.7 Infection 6 20 Enuresis 2 6.6 Total 30 100 5/16/2018 Urology & Nephrology Center, Mansoura, EGYPT

Urology & Nephrology Center, Mansoura, EGYPT Results 6 10 (33.33%) had reflux: 2 unilateral 8 bilateral 14 (46.66%) had hydronephrosis without reflux 5/16/2018 Urology & Nephrology Center, Mansoura, EGYPT

Urology & Nephrology Center, Mansoura, EGYPT Results 7 Urodynamics: Mean age at time of exam.: 7.46 years Mean capacity: 274.17 ml. Mean percent capacity (ratio of the actual capacity /expected capacity for age ) : 1.004 Mean compliance (full capacity) : 16.23 ml/cmH2O. Mean PVR: 99.33 ml. Percent PVR (PVR / PVR as 15% of capacity) 3.27 . Detrusor overactivity: 18 (60%) 5/16/2018 Urology & Nephrology Center, Mansoura, EGYPT

Urology & Nephrology Center, Mansoura, EGYPT Results 8 Upper tract in both groups Group 1 N= 23 Group 2 N= 30 Reflux: Unilateral Bilateral 21 (91.3%) 10 (33.33%) 12 2 9 8 Hydronephrosis 2 (8.7%) 14 (46.66%) 5/16/2018 Urology & Nephrology Center, Mansoura, EGYPT

Results 9 Urodynamic parameters in both groups Group 1 (n=23) P value Actual capacity 280.43 274.17 0.87 Capacity for age 301.3 284.0 0.52 Percent capacity 1.010 1.004 0.96 Compliance 17.87 16.23 0.45 PVR 64.13 99.33 0.21 Overactivity 13 18 0.04 Percent PVR 1.44 3.27 0.001 Q max 13.08 11.58 0.24 5/16/2018 Urology & Nephrology Center, Mansoura, EGYPT

Urology & Nephrology Center, Mansoura, EGYPT Conclusion 1 Antenatal diagnosis and earlier valve ablation was associated with larger bladders with better compliance, less PVR, less frequency of overactivity and slightly better flow. Incidence of overactivity and percent PVR varied significantly. 5/16/2018 Urology & Nephrology Center, Mansoura, EGYPT

Urology & Nephrology Center, Mansoura, EGYPT Conclusion 2 These findings support the benefit of antenatal diagnosis and early valve ablation. 5/16/2018 Urology & Nephrology Center, Mansoura, EGYPT

Urology & Nephrology Center, Mansoura, EGYPT 5/16/2018 Urology & Nephrology Center, Mansoura, EGYPT