Posterior urethral valves are congenital anomalies that can cause obstruction of urine flow from the bladder. If not treated, they can lead to damage of the lower and upper urinary tract, including renal dysfunction. Early diagnosis through antenatal ultrasound and treatment after birth through valve ablation or vesicostomy can help prevent long term complications. Prognosis depends on factors like age of presentation, presence of reflux, and renal function as assessed by creatinine levels.

1. POSTERIOR
URETHRA
L VALVES
DR.LEELAKRISHNA

2. First recognised in 1769, by morgagani,confirmed by
langenbeck in 1802.
First endosopic diagnosis of puv – hugh hampton
young.
First endoscopic resection of valves in 1920 – randall.

3. INTRODUCTION
Seen in 1.6 – 2.1 %in 10,000 births .
Most common pathology in LUTO in congenital
anomalies of the urinary tract.

4. TYPESOFPUV

5. PATHOLOGY

6. DAMAGE CAUSEDBUPUV

7. LOWERURINARYTRACT
Bladder dysfunction – urinary reflux,renal dysfunction
,worsening hydronephrosis.
Valve bladder syndrome – voiding dysfunction ,urinary
reflux, renal dysplasia ,obstructive uropathy.

8. UPPERURINARYTRACT
Increased pressure over prolonged intervals transmits
to ureter,renal pelvis and glomerular units -
architectural and functional changes of ascending
structure.

9. URETER
ureteral wall thickening
Loss of peristalsis
Loss of mucosal coapatation
Leading to urinary stasis, infection, increased pressures
in renal system .

10. RENAL DYSFUNCTION
Renal dysplasia
Obstructive uropathy

11. Angiotensin II – renal damage – hemodynamic
changes in glomerular flow - induction of
transforming growth factor beta and tumour necrosis
factor alpha.

12. VURD
Hoover and duckett hypothesized that reflux servedas
a pop off mechanism in which the dysplastic kidney
with reflux served asa pressure reservoir migitating
damage to the contralateral kidney.
Does not improve renal prognosis.
Contralateral ,nonrefluxing kidney – high risk of
congenital renal cortical damage

13. CYSTOSCOPIC FINDINGS

14. ULTRASONOGRAPHY
PUV– detected in 1 in 2,500.
Accounts for 10 % of screened antenatally
genitourinary disease, 1/3 rd of bilateral renal disease.
Fetal MRI – degree of obstruction based on urethral
dilatation ,distended bladder and reduced amniotic
fluids .

15. ULTRASOUND

16. CONTD…

17. KEYHOLESIGN–
ANTENATAL SCAN

18. FETAL MRI

19. VOIDING
CYSTOURETHROGRAM

20. VURD IN VCUG

21. VCUG

22. LABARATORY EVALUATION
After 48 hrs maternal blood mediated through
placenta should clear, base line labaratory values are
monitored.
Nadir Creatinine value – at 1 year of age is important
diagnostic tool .

23. RADIONUCLIDE RENAL
SCAN
Quantification of differential renal function and cortical
defects implying renal dysplasia in neonatal period .
Mercaptoacetyltriglycerine

24. CLINICAL PRESENTATION
Associated with pulmonary hypoplasia ,physical
appaerence due to oligohydraminos such as potter
facies -clubfeet,deformed hands ,poor abdominal
muscle tone
Difficulty with voiding
Weak urinary stream
5 or 7 F feeding tube / coude tipped catheter, stylet to
curl tip of feeding tube

25. PULMONARY HYPOPLASIA
Perinatal mortality
Ventilator support,delays attention away from PUV
Etiology – unclear, multifactorial.
Reduced expansion of alveoli
Renal growth factor .

27. URINOMAS
Seen in 3% to 10 %
Forniceal rupture ,distorted renal parenchyma,
contained with in renal capsule.

28. Transperitoneal transudation of fluid or bladder
rupture – neonatal ascitis .
Percutaneous drainage /tapping of ascitis – respiratory
distress .

29. DELAYED PRESENTATION
Postnatal period
UTI,ARF,voiding complaints .
HIGH DEGREESUSPICION– presenting with lower
urinary tract symptoms especially with recurrent UTI,
gross hematuria,overflow incontinence,renal
dysfunction.

30. SURGICAL TREATMENT
VALVEABLATION : cystoscopy and valve ablation
GOAL– to restore normal flow of urine through
urethra.
Crocket hook
7.5 F/ 9 Fcystoscope with an offset lens, for passage of
ablating devices including bugbee electrodes.

31. CYSTOSCOPY– INCISION OF
PUV

32. MOHAN VALVOTOME
Hollow tube with ends shaped like hooks designed to
catch only a floating valve.
Does not use diathermy .
Set of two one 3 mm and 2mm diameter in size.
Handle is turned laterally,downward
Suprapubic pressure is applied while pulling valvotome
.

33. Lasers – ND :YAG,Holmium :YAGlaser.
Whitaker and sherwood – modified the hook insulating
the wire except for the very distal portion of the hook
of 6/7 F,applying diathermy when ablating the valves.

34. CYSTOSCOPY

35. Thin ,associated with minimal vascularity and
aggressive resection should be avoided .
Cold knife and cutting resectoscope loop .
Hot loop resectoscope – urethral stricture
Urethral catheter – 24 hrs
VCUG– repat after 1 month.

36. VESICOSTOMY
INDICATIONS : LBWinfant whose urethra cannot
accomadate an endocope
Impaired renal function
High bladder volumes
Upper tract detoriation after valve ablation or urethral
catherization .

41. UPPERTRACTDIVERSIONS-
INDICATIONS
Direct compression of the kidney will produce low
pressure urinary drainage ,allowing optimization of
renal function.
Complete decompression of the lower urinary tract
Sepsis
Increasing upper tract dilatation
Worsening renal function.

42. UPPERTRACTDIVERSIONS

43. CIRCUMCISION
Prophylactic measure for any boy + puv.
Reduces UTI by 83% to 92 %.
Overall risk of UTI – 50 to 60 %.
Assoc with upper tract dilatation ,VUR ,incomplete
bladder emptying.
Progress to pyelonephritis,sepsis .

44. NEPHROURETECTOMY
Non functioning kidney with dilated urinary reflux
leading to infections and sepsis.
PUV+ VURD .
Prevention – circumcision and proper bladder
emptying .

45. VUR
recurrent UTI + reflux - elevated bladder pressures
Conservatively – anticholinergic agents .
Treating underlying bladder dysfunction.
Requires Ureteric reimplantation.
Complications – stricture, persistent reflux.
Endoscopic > open – low risk.

46. BLADDER DYSFUNCTION
Voiding dysfunction
urinary reflux
worsening of renal dysplasia
obstructive uropathy .

47. PATHOLOGY OF BLADDER
DYSFUNCTION
Detrusor hyperreflexia in infancy and early childhood
Decreased intravesical pressures and improved
compliance
Increased bladder capacity with hypocontractility
,atony in adolescence.

48. FOLLOW UP
Renal ultrasonography
Uroflow, PVR .
Toilet training ,adequate fluid intake ,practice double
voiding ,pelvic floor muscle excercises,biofeed back
therapy.
Alphablockers /anticholinergics

49. CONTD….
Routine – height ,weight ,blood pressure, serum
creatinine and elecrolytes .
Indicated – isotope renography ( MAGE 3 or DMSA ),
Formal estimate of GFR.

50. VALVE BLADDER
SYNDROME
Polyuria
Poor bladder compliance with high pressure voiding
and elevated wall tension bladder .
Residual urine volume

51. VICIOUS CYCLE

52. TREATMENT
CIC
Overnight bladder drainage .
Appendicovesicostomy
Augmentation cystoplastly

53. VESICOAMNIOTIC
SHUNTING

54. ANTENATAL MANAGEMENT
Antenatal scan – oligohydraminos ,dilated
bladder,severe HUN with out renal cortical cystic
lesions in a fetus with a normal karyotype.

56. FETALURINESAMPLING –
FAVOURABLE PROGNOSIS
Fetal urine sample – 20 weeks of gestational age
Urinary sodium less than 100 meq/L.
Chloride less than 90 meq/L
Osmolarity less than 200 meq/L
Beta microglobulin less than 6 mg/L

57. PROGNOSTIC INDICATORS
FORRENALFUNCTION
ESRD + PUV– 20 to 50 %.
Serum creatinine at one year of age – 0.8 mg/dl –
minimal risk
>1.2 mg/dl – high risk .

58. PREDICTORSOFPOOR
PROGNOSISFOR RENAL
FUN
PR
C
EN
T
AT
IA
O
L–
N
history of maternal
oligohydraminos,regardless of gestational age at
onset,early detection of prenatal u/s and other
prognostic features of fetal urinary tract.
POST NATAL – clinical presentation in the first 6
months of life,proteinuria,bilateral VUR,impaired
continence at 5 yrs of age.

59. TRANSPLANTATION IN PUV
Prevalence of ESRD+ PUV– 50 %.
Second most CC– obstructive uropathy .
PUV– VUR+ NFK + Bladder valve syndrome ( thick
walled, poorly contractile or hypercontractile bladder )
Pretransplant evaluation – throughly

60. CAUSE– thickened bladder wall may increase
incidence of ureteral obstruction .
Video urodynamics
Overnight bladder drainage / CIC.
Pretransplant augmentation – rare, done in
immunocomprimised child.

61. LONG TERM RESULTS
LUTS
Bladder dysfunction
UTI
Renal dysfunction
Erectile dysfunction
Infertility .

62. POPOFFVALVES
A mechanism by which high intravesical or intrapelvic
presure is dissipated.
Allows for normal development of one or both kidneys
by one of three mechanisms
1) urinary ascitis – urine leaks from the fornices of the
kidney or from a bladder rupture

63. 2) VURD syndrome – massive unilateral reflux into a
non functioning kidney
3) large bladder diverticulum – causing aberrant
micturation into diverticulum there by taking pressure
off the developing renal units .

64. FAVOURABLE PROGNOSTIC
FACTORS
Creatinine falling below 1.0 one month after treatment
initiated
Absence of VUR
Preservation of the corticomedullary junction of the
kidneys by renal U/S .
Radiologic evidence of a pop off valve

65. ADVERSE PROGNOSTIC
FACTORS
Prsentation after the age of 1year
Failure of cr to fall below 1.0 1 month following
initiation of therapy/drainage
Bilateral VUR
Diurnal incontinence beyond 5 yrs of age
Prenatal diagnosis in the second trimester