2. Professors:
Prof. Dr. G. Sivasankar, M.S., M.Ch.,
Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
Dr. J. Sivabalan, M.S., M.Ch.,
Dr. R. Bhargavi, M.S., M.Ch.,
Dr. S. Raju, M.S., M.Ch.,
Dr. K. Muthurathinam, M.S., M.Ch.,
Dr. D. Tamilselvan, M.S., M.Ch.,
Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH and KMC, Chennai. 2
3. • This obstructive membrane has no active
function,simply a passive barrier to urine
flow
• DR.HAMPTON YOUNG -described and
classified in 1919 .
• Incidence -1 in 25,000 live births
• 10% of urinary obstruction in utero
3
Dept of Urology, GRH and KMC, Chennai.
4. Posterior urethral valves
Young’s classification system
Type I valves:
Most common type -95%
Ridge lying in floor of urethra continuous with veru .
Takes anterior course and divides into two fork like processes
In the bulbomembranous jn and is directed upwards and
forward attached to the urethra throughout its entire
circumference.
Two leaflets Type Ia or as a unicuspid leaflet Type Ib
4
Dept of Urology, GRH and KMC, Chennai.
7. Abnormal insertion of the mesonephric
duct into the uro genital sinus
7
Dept of Urology, GRH and KMC, Chennai.
8. Arises from veru and extending along
posterior urethral wall towards bladder
neck
-Non obstructing
-Due to hypertrophy of muscles of
superficial trigone and prostatic urethra
due to distal obstruction.
8
Dept of Urology, GRH and KMC, Chennai.
9. Can be seen in many obstructive
conditions such as urethral strictures
,posterior urethral valves ,anterior
urethral valves,detrusor-sphincter
dyssynergia.
Type 2 folds are no longer referred to as
valves.
9
Dept of Urology, GRH and KMC, Chennai.
11. -5%
-Membrane lying transversely across
urethra with a small perforation near its
center
-Distal or proximal to veru.
- Distal Type IIIa or Proximal Type IIIb
11
Dept of Urology, GRH and KMC, Chennai.
14. Embryology
-Persistence of the urogenital membrane
-Type 3 valves present in the same manner
and are managed in the same way as
type 1.
Type 3 valves have a worse prognosis.
14
Dept of Urology, GRH and KMC, Chennai.
15. PUV damage the entire urinary tract
above the valves.
Reduced Glomerular function
Abnormal renal tubular function
Hydronephrosis
Vesico ureteral reflux
Vesical dysfunction
15
Dept of Urology, GRH and KMC, Chennai.
16. Bladder
-hypertrophy and hyperplasia of the detrusor
muscle with increased connective tissue.
- The bladder neck is rigid and hypertrophied .
Bladder neck appearance and function improve
after ablating valves
Prostatic urethra
-High voiding pressures distend and thins.
The storage capacity sometimes exceeds that of
the bladder
Verumontanum -distorted
Ejaculatory ducts - dilated due to refluxing urine.
16
Dept of Urology, GRH and KMC, Chennai.
17. Upper Urinary Tract
Ureter –severe damage.
- direct transmission of pressure from the dysfunctional
bladder
- VUR seen in 70%
Chronicity of ureteral dilatation leads to
Ureteral wall thickening
Loss of peristalsis
Loss of mucosal coaptation
Increasing the risk of urine stasis
17
Dept of Urology, GRH and KMC, Chennai.
18. Two distinct components.
1) Obstructive uropathy - by persistent high
pressure.
reversible with relief obstruction.
2) Renal dysplasia-
-Increased pressure during the
development of the kidney
- Abnormal embryologic development.
- Not reversible.
18
Dept of Urology, GRH and KMC, Chennai.
19. Hoover and duckett hypothesized that
the reflux served a pop-off mechanism in
which the dysplastic kidney with reflux
served as a pressure reservoir mitigating
damage to the contralateral kidney
VURD found in 13 % of valve patients .
Refluxing kidney is on the left side in 92 %.
No protective effect on long term renal
prognosis
19
Dept of Urology, GRH and KMC, Chennai.
20. Prenatal usg
oligohydramnios , Hydroureteronephrosis,
distended bladder, thickened bladder wall .
Neonates - Pulmonary Hypoplasia
most common cause of mortality in valve patients.
etiology – distended bladder & gross HUN along
with increased uterine pressure reduces
diaphragmatic expansion and affects lung volume
& growth
20
Dept of Urology, GRH and KMC, Chennai.
21. signs of severe systemic illness
Intrauterine growth retardation, failure
to thrive, lethargy, and poor feeding
Classic signs of oligohydramnios: Potter
facies, bowed and deformed limbs, with
pressure dimples over knees and elbows
from intrauterine pressure
21
Dept of Urology, GRH and KMC, Chennai.
22. 40% of neonatal ascites- PUV.
High intraluminal pressure forces urine to
extravasate usually across a renal fornix, enters the
retroperitoneum and travels across the peritoneum
as a transudate
The urine within the peritoneum is subject to the
large absorptive mesothelial surface that quickly
normalizes the creatinine and electrolyte values,
masking the identity of ascitic fluid as urine.
Lowers urinary pressure and offer protection to the
developing kidneys but urinary ascites alone has a
poorer prognosis.
22
Dept of Urology, GRH and KMC, Chennai.
23. Urinary tract infection
Voiding dysfunction
35 % of Patient presenting at school
age -renal insufficiency.
23
Dept of Urology, GRH and KMC, Chennai.
25. 10% of all fetal uropathy
Highly sensitive –fetal Hydronephrosis but
specific diagnosis of PUV is more difficult
Timing of screening for PUV is after 24
weeks
Renal echogenicity important
parameter
- increased echogenicity
25
Dept of Urology, GRH and KMC, Chennai.
28. Defines the anatomy and gross function of the
bladder, bladder neck, and urethra.
On Imaging the bladder and upper tracts of
children with neuropathic bladder, urethral
stricture, anterior urethral obstruction, and posterior
urethral valves are identical
Images during voiding are necessary to make
correct diagnosis
Bladder is thickened , trabeculated, bladder
diverticula and severe vesicoureteral reflux.
28
Dept of Urology, GRH and KMC, Chennai.
29. • Lateral projection- bladder neck is elevated
, proximal urethra is dilated, and actual
valve structure is often visible
• Crescentic radiolucent defect bulges out
into the contrast column below the veru the
SPINNAKER SAIL appearance-type 1 valve
• Type III valves when they prolapse into the
bulbous portion of urethra gives wind sock
appearance
29
Dept of Urology, GRH and KMC, Chennai.
31. MAG-3 (mercaptoacetyltriglycine)-most
useful agent
functional data ,adequate imaging
of both parenchyma and collecting
system
Provides differential renal function
Photopenic area -scarring
-Dysplasia
Bladder must be emptied during the entire
study with a catheter- AVOID reflux.
31
Dept of Urology, GRH and KMC, Chennai.
32. Bladder storage and capacity
HIGH FILLING /VOIDING PRESSURE
3 Types of Detrusor dysfunction
MYOGENIC FAILURE :Weak bladder
contraction
PVR :Large
HYPERREFLEXIA : Unstable bladder
contraction
POOR COMPLIANT : Reduced capacity
32
Dept of Urology, GRH and KMC, Chennai.
34. Initial creatinine and blood urea niteogen
are low due to effects of maternal renal
function mediated through the placenta.
- Test urea and creatinine after 48 hrs -
represent the child's intrinsic renal function.
-Creatinine, blood urea nitrogen, and
electrolyte values- Twice daily for the first
few days of life until they plateau.
- Serum bicarbonate, sodium, and
potassium concentrations are critical
factors
34
Dept of Urology, GRH and KMC, Chennai.
35. • Initial management
- Catheterisation with 3.5fr to 5fr infant feeding
tube/foleys catheter-difficult due to bladder
neck elevation
To avoid placing catheter in the dilated
prostatic urethra- Confirm position with bladder
imaging and one shot cystogram is often
advisable.
-Pulmonary hypoplasia and renal insufficiency:
ventilatory Support,extracorporeal membrane
oxygenation,dialysis,parenteral nutrition,control
of hypertension
35
Dept of Urology, GRH and KMC, Chennai.
37. Ind - sr creat < 1.5 mgs
No urosepsis
Urethra admits scope
No other co morbid factors
37
Dept of Urology, GRH and KMC, Chennai.
38. • permanently destroy the valves
• To destroy PUV
-Hooks, balloon catheter and valvulotomes
• Bugbee electrode or pediatric resectoscope with a hook or cold
knife used to incise the valves
• Retrograde –viewed through urethra
• antegrade approach-through vesicostomy or supra pubic puncture
of the bladder.
38
Dept of Urology, GRH and KMC, Chennai.
41. Complete resection of valves –stricture
urethra due to electrosurgical and
instrument damage .
The goal is not to remove the valves but to
incise them so that they are not suspended
across the urethra obstructing urine flow.
Point of incision-12 O’ clock or some prefer
4 and 8
Valves are thin ,do not bleed,preferable to
keep the catheter in place for 24 hrs
41
Dept of Urology, GRH and KMC, Chennai.
42. Post PUV ablation
• signs of successful relief of obstruction:
Decreased trabeculation, resolution of
reflux, uniform urethral diameter
• Ratio of diameter of the posterior urethra to
anterior urethra as an indicator of obstruction.
post ablation urethral ratio of 2.5 to 3.0 at 12
weeks is acceptable
• transurethral incision of bladder neck at the
time of valve ablation improve the bladder
performance
42
Dept of Urology, GRH and KMC, Chennai.
45. INDICATIONS
- Sr creatinine > 1.8 mgs
-Urosepsis
- pt is not responding to catheter
drainage
- infant too small for safe instrumentation
- infants too ill for valve ablation
-Better decompression of kidneys
45
Dept of Urology, GRH and KMC, Chennai.
46. Cutaneous VESICOSTOMY –
Safe and efficient for preserving renal
function
Adequate upper tract drainage in 90%.
No permanent loss of bladder volume.
Technique –BLOCKSOM method.
46
Dept of Urology, GRH and KMC, Chennai.
49. Adv -
• Quick & prompt renal decompression
Improve renal function , Reduce infection
Disadvantage-
• Difficult reconstruction later in life as an
additional procedure.
49
Dept of Urology, GRH and KMC, Chennai.
50. INDICATIONS -Persistant upper tract dilation
after vesicostomy
Scr->2 mg% after 10 days of bladder
decompression.
OPTIONS : Pyelostomy
Pyelo ureterostomy
Ureterostomy- Distal, Proximal
loop, Ring, Sober y ureterostomy
50
Dept of Urology, GRH and KMC, Chennai.
52. assess renal function-aspirate fetal
bladder urine-sodium-high-poor function.
-vescicoamniotic shunt
-restoration of amniotic fluid-bet 20-32
weeks
-oligohydramnios earlier than 20 weeks –
incompatible with life
-latter than 32 weeks early delivery is
preferable for fetal intervention
52
Dept of Urology, GRH and KMC, Chennai.
53. 50-70% of PUV have reflux
32% is bilateral
Secondary to bladder outlet obstruction
Most reflux resolve within several months,
some can take as long as 3 years.
B/L reflux are more likely to resolve than
unilateral reflux
High grade reflux have renal dysplasia
53
Dept of Urology, GRH and KMC, Chennai.
54. INVESTIGATIONS :
VCUG-residual valves and grade of reflux
UDE- evaluate bladder function
Management
Low grade reflux- Antibiotics
High grade-Surgery – Reimplantation
Higher failure and complication rate.
54
Dept of Urology, GRH and KMC, Chennai.
55. Valve bladder syndrome - coined by Mitchell
Three process contributes to the devolution of
bladder into a valve bladder
1. Polyuria
2. Poor bladder compliance with high pressure
voiding & elevated wall tension
3. Residual urine volume
55
Dept of Urology, GRH and KMC, Chennai.
57. Management-
Timed voiding
Alpha blockers- reduces post void
residual urine and improving the
urinary stream .
Clean intermittent catheterisation
The mean reduction of residual volume
was 85%
57
Dept of Urology, GRH and KMC, Chennai.
58. Bladder dysfunction-
Peters –three urodynamic patterns
1.Myogenic failure-older children –leads to
over flow incontinence and incomplete
emptying
Management; timed voiding,double
voiding,alpha blockers,and intermittent
catheterisation
58
Dept of Urology, GRH and KMC, Chennai.
59. 2.Detrusor hyperrefexia-urinary
frequency,urge incontinence managed
with anticholinergics
3.Decreased compliance/small capacity
Boys with puv if bladder function is not
adequate to protect the upper tracts
CIC,anticholinergics
augmentation cystoplasty
59
Dept of Urology, GRH and KMC, Chennai.
60. Ileal augmentation-disadvantage
mucous production,risk of rupture,stone
,bladder cancer
Ureteral augmentation-advantage
Leaving the bladder lined only with the
native urothelium and avoiding
mucous,stone and cancer
60
Dept of Urology, GRH and KMC, Chennai.
61. 1) Age at diagnosis- poor <1 yr
2) Presence of reflux- poor
3) USG-amount of Dysplasia
4) Serum bio chemistry-Scr-0.8 mg% at 1st yr
-good
61
Dept of Urology, GRH and KMC, Chennai.