1. 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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. Urology & Nephrology Center, Mansoura, EGYPT
Results
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

11. Urology & Nephrology Center, Mansoura, EGYPT
Results
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

12. Urology & Nephrology Center, Mansoura, EGYPT
Results
Urodynamics:
Mean age at time of exam.: 8.04 years
Mean capacity: 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: ml
Percent PVR (PVR / PVR as 15% of capacity) 1.44.
Detrusor overactivity:13 (56.6%).
5/16/2018
Urology & Nephrology Center, Mansoura, EGYPT

13. Urology & Nephrology Center, Mansoura, EGYPT
Results
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

14. Urology & Nephrology Center, Mansoura, EGYPT
Results
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

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

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

17. Urology & Nephrology Center, Mansoura, EGYPT
Results
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

18. 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

19. 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

20. 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

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