C E Close1, M E Mitchell. 1. División de Urología, Facultad de Medicina, Universidad de Nevada, Las Vegas, USA.
Abstract
OBJECTIVE: The basic question proposed in this article is whether early diagnosis and treatment of children with posterior urethral valves can prevent bladder and upper tract deterioration. If so, which is the best treatment? METHODS/ RESULTS: Results with temporary urinary diversion for children with posterior urethral valves and renal insufficiency have not fulfilled expectations of an improved long-term outcome. Furthermore, there is mounting evidence that proximal urinary diversion with complete early bladder defunctionalization may result in reduced bladder capacity and compliance. In our experience early bladder cycling following valve ablation in the neonatal period is critical for the initiation of the healing process. Regardless of the initial appearance of the bladder and the status of the upper tract, early valve ablation may offer the best chance at functional recovery of normal bladder function, and restoration of upper tract function and anatomy without reconstructive surgery. In our series of 23 boys whose valves were resected at a mean of 21 days, bladder trabeculation resolved in 85% at one year. Follow up varied between 1 and 9 years. When compared to infants treated with urinary diversion, these children achieved superior potty training results. CONCLUSION: Bladder healing with early ablation seems to be dependent on bladder filling and emptying (cycling) with low outflow resistance. Ultimately, maximum recovery of renal function will depend on preventing the development of a hostile bladder. Early valve ablation may best achieve both goals of maximum bladder and renal functional recovery.
OBJECTIVE: The basic question proposed in this article is whether early diagnosis and treatment of children with posterior urethral valves can prevent bladder and upper tract deterioration. If so, which is the best treatment? METHODS/ RESULTS: Results with temporary urinary diversion for children with posterior urethral valves and renal insufficiency have not fulfilled expectations of an improved long-term outcome. Furthermore, there is mounting evidence that proximal urinary diversion with complete early bladder defunctionalization may result in reduced bladder capacity and compliance. In our experience early bladder cycling following valve ablation in the neonatal period is critical for the initiation of the healing process. Regardless of the initial appearance of the bladder and the status of the upper tract, early valve ablation may offer the best chance at functional recovery of normal bladder function, and restoration of upper tract function and anatomy without reconstructive surgery. In our series of 23 boys whose valves were resected at a mean of 21 days, bladder trabeculation resolved in 85% at one year. Follow up varied between 1 and 9 years. When compared to infants treated with urinary diversion, these children achieved superior potty training results. CONCLUSION: Bladder healing with early ablation seems to be dependent on bladder filling and emptying (cycling) with low outflow resistance. Ultimately, maximum recovery of renal function will depend on preventing the development of a hostile bladder. Early valve ablation may best achieve both goals of maximum bladder and renal functional recovery.