What is the treatment for posterior urethral valves?

Treatment of Posterior Urethral Valves

Endoscopic ablation of the valve is the gold standard treatment for posterior urethral valves (PUV), with urinary drainage being the immediate priority regardless of the approach chosen. 1

Initial Management

1. Immediate urinary drainage

   • Obtain urinary drainage as soon as possible 2, 3
   • Options include:
     • Urethral catheterization (preferred if possible)
     • Suprapubic catheter placement if urethral catheterization is not feasible

2. Definitive treatment options

   • Primary endoscopic valve ablation (gold standard)

     • Techniques include:
       • Hot loop resectoscope
       • Cold knife urethrotome
       • Hook diathermy electrode
       • Diathermy coagulation bugbee electrode 4

   • Alternative approaches (when endoscopic facilities are limited)

     • Mohan's valvotome
     • Fogarty catheter stripping technique 1, 4

   • Temporary urinary diversion (when primary ablation is not feasible)

     • Vesicostomy - reserved for cases where:
       • Endoscopic equipment is unavailable
       • Patient is too small for endoscopic intervention
       • Persistent upper urinary tract dilatation despite valve ablation
       • Rising serum creatinine 1, 5

Complications and Follow-up

1. Early postoperative complications (occur in approximately 7.5% of cases)

   • Urinary retention (most common - 5.5%)
   • Urinary extravasation
   • Significant hematuria
   • Obstructive anuria 4

2. Late complications

   • Urethral strictures (2% of cases, more common with loop resection)
   • Bladder dysfunction
   • Progressive renal failure 4, 6

3. Follow-up protocol

   • Urethroscopy or urethrogram are the methods of choice for follow-up of urethral injuries 2
   • Monitor renal function regularly
   • Evaluate bladder function with urodynamic studies
   • Assess for proteinuria and hypertension, especially during teenage years 6
   • Consider anticholinergic therapy for bladder dysfunction 5

Special Considerations

• Bladder management is critical after valve ablation as bladder behavior may influence long-term renal outcomes 1

  • Some patients may require:
    • Double and triple voiding regimens
    • Intermittent catheterization
    • Anticholinergics
    • Alpha sympathomimetic blockers 6

• Upper tract management

  • Avoid ureteric reconstruction immediately after valve ablation due to hypertonic bladders 6
  • Persistent ureteral dilatation should be evaluated individually
  • Some patients may require reimplantation with or without tailoring, or augmentation cystoplasty 6

• Long-term monitoring

  • Despite successful treatment, approximately 25% of patients may develop chronic kidney disease (CKD) 5
  • Monitor for proteinuria and hypertension, which are hallmarks of progression to renal failure 6

The ultimate goal of PUV management should be to maximize renal function, maintain normal bladder function, minimize morbidity, and prevent iatrogenic problems through early diagnosis, appropriate surgical technique, and meticulous attention to neonatal care 1.