We have limited facilities for valve ablation in small child & also lack of expertise in neonate,infants valae ablation.We usually do vesicostomy in neonates but our experience is very bad in future management of associated megaureter(VUR,UVJ obst.),bladder dysfunction.
if the patient diagnosed to have puj obstruction the obstruction should be relived as soon as possible ,it’s too late by the age of 2 month because of the back pressure to the kidney will damage the if the patient diagnosed to have puj obstruction the obstruction should be relived as soon as possible ,it’s too late by the age of 2 month because of the back pressure to the kidney will damage the kidney.
Regarding management of the patients with PUV±VUR, first step should be cystoscopic valve ablation to protect both bladder and kidney functions. If it is not feasible, vesicostomy is a reasonable alternative. Close follow-up with serial clinical and radiologic examinations are needed. Ureteric reimplantation should be avoided, especially in the first year of life. Yes, bladder dysfunction after vesicostomy and, more importantly, the valve bladder are demoralizing conditions for the surgeons, requiring multidisciplinary approach in an experienced center.
Hi, in our experience, vesicostomy and antibiotics as an initial procedure have been helpful. This vesicostomy helps to relieve the reflux and allow kidney function to improve. We do not have facilities for renal scan, but the renal function in respect to electrolytes usually improves. We have not had affectation of bladder following this procedure. Caution, the vesicostomy should be well located and should be adequately decompressing. In our experience , we have not managed any patient with associated grade 5 reflux that did not resolve with the vesicostomy and antibiotics. We have had cause to do vesicostomy in those greater than 2 months with good outcome.
By 2 months old Baby we go for cystoskopy and Fulguration of the Valves. Then close follow-up. Reflux Op must avoided at least in the first year of life.
We havent done in the last 10 y any Vesicostomy.
By bad functioning Kidney mit severe Reflux we did Ureterostomy ( Soaber ).
The first thing really is to relieve the obstruction by the posterior urethral valves. Since you have limited options for ablation, I would suggest the Mohan's valvotome if you have it and are experienced in its use. We have used it successfully in LMIC where we are challenged by lack of appropriate paediatric scopes for endoscopic ablation. Also, the parents cope better than when the baby has a vesicostomy. Culture specific antibiotics to treat the UTI, then maintain on prophylactic antibiotics (I use amoxicillin) while monitoring for improvements in the VUR. In the abscence of DMSA, then serial serum electrolytes&creatinine, IVUs may help in planning further mangement of a persistent VUR and bladder dysfunction. Please include paediatric surgeons, urologists and paediatric nephrologists in the multidisciplinary care of this child right from the onset.
The first and the foremost step is Valve ablation and then to see the effects on the effected kidney and VUR. Get a Mag3 scan done to get the baseline and then follow the child of the effects of decompression done by valve ablation. If the VUR does not improve the address it accordingly looking at the functions of the kidneys and avoiding Valve bladder syndrome.
Vesicostomy is an aggressive and devastating procedure that should be better avoided. PUV ablation is the best way followed by MCUG and and IVU's if renal isotopes studies are not available.
I agree, avoid a vesicostomy. Valve ablation via cystoscope is the gold standard. Alternatively can be done with a Fogarty catheter in radiology. Sounds like there has been a pop-off effect on left side which will preserve function on right
Dear Dr. Roy,
You mention something about the use of a Fogarty catheter in radiology.
Can you explain it as I am not familiar with. Thanks
The original concept was from Prof Prem Puri's work in Dublin (J Urology, 168, 1841-3, 2002). Under fluoroscopy a Fogarty balloon is pulled through the valve, thus destroying it. It is a very effective technique, I have performed it several times in the neonatal nursery under ultrasound guidance.
Thank you Roy for this comment.
This is a very less cost effectiveness that needs to be investigated with more evidence as it may solve a problem especially in low resource settings.
I agree. It avoids a general anaesthetic, and can be performed without the need for expensive urological instruments. Diagnosis and follow-up will need retrograde urethrograms by fluoroscopy.
Sorry very late to add my comments. The best way to manage PUV is ablation by endoscopic means(if available) where the surgeon has a good control of what he is doing. Follow up is the most important aspect in managing PUV. Reflux revolves in more than 50 % of cases by 2 years as per long term studies for VUR in PUV more often in lower grades. Oxybutynin or other anticholinergics along with timed/double voids helps. If persisting UTI or sonological evidence of worsening dilatation a repeat MCU to assess reflux and R/O distal obstruction(residual valves) is needed. If higher grade reflux is persisting and the child has stable bladder a reimplant may be done.
Vesicostomy gives a good result, then to be reassessed after a 6-12 months
actually there was an old method to destroy the PUV which is no more used. they inflate a balloon of the Foley's catheter by 0.5cc of NS, and pull it out, and repeat it with 1ml.
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