ORIGINAL ARTICLE

Vesicoureteral Reflux – Severe Associated Factor of Posterior Urethral Valves in ChildrenAurelia Masca1, Klara Branzaniuc2

1 Municipal Hospital of Sighisoara, Pediatrics Ward 2 University of Medicine and Pharmacy Tg.Mures, Anatomy Department

Introduction: Posterior urethral valves represent a congenital barrier at the level of the posterior urethra, which opposes miction . They are located near the prostatic urethra, originating at the verumontanum level, affecting the male sex. The obstruction determines dilation of the prostatic urethra upstream, hypertrophy of the bladder detrusor which obstructs the urethrobladder junction. The ureters are inconstantly dilated, the vesicoureteral reflux is met in 2/3 cases, half of these being bilateral. The presence of the reflux is interpreted as a severe associated factor. Semiology is pretty unspecific: unremitting fever, sepsis, dehydration syndrome, urinary infections, dysuria, reduction of urinary jet, urinary incontinence, vesical globe, haematuria, ureterohydronephrosis. Positive diagnosis is based on early discovery, antenatally, of the impairment, by fetal echography starting from the 28th week of pregnancy. Postnatal echography followed by miction cystography and retrograde urethrography, creatinine dosage completes the diagnosis. The treat-ment is surgical: endoscopic ablation of the valves (in the absence of renal failure, percutaneous pyelostomy, high lateral ureterostomy, and in severe cases vesicostomy, renal transplant. Prognosis depends on how early the impairment is detected, on the degree of pulmonary hypoplasia, on the presence of the vesicoureteral reflux and the possibility of recovering renal function; Material and method: Study lot: Children diagnosed with vezicouretral reflux between the ages of 0-18 years, of male sex,interned in the II Pediatric Clinic in Tg.Mures in the last 10 years. Type of study: transversal, used method: retrospective study.Results: Out of 170 children with vesicoureteral refflux,four children were diagnosed with posterior urethral valve.Conclusions: The presence of the vesicoureteral reflux represents an unfavourable prognosis regarding the degree of renal function impairment.

Keywords: antenatal echography, ureterohydronephrosis, urethral valve ablation

IntroductionPosterior urethral valves (PUV) represent a congenital bar-rier at the level of the posterior urethra which opposes mic-tion. These are the most frequent obstructive congenital urethral lesions and affect only boys, being located in the distal section of the prostatic urethra [1]. The incidence of posterior urethral valves is estimated to be 1:5.000-8.000 of male newborns [2] and represents about 10% of prenatally diagnosed hydronephroses.The obstruction determines dilation of the prostatic ure-thra upstream, hypertrophy of the bladder detrusor which obstructs the urethrobladder junction.The vesicoureteral reflux (VUR) is met in 2/3 cases, half of these being bilateral. The reflux can be secondary to the sub-bladder barrier, but it can also be considered primitive, determined by the intra-bladder ectopy of the ureter. The presence of the reflux is interpreted as a severe associated factor [3].Semiology is pretty unspecific: unremitting fever, haema-turia, sepsis, dehydration syndrome, urinary infections, dy-suria, reduction of urinary jet, urinary incontinence,vesical globe, ureterohydronephrosis,renal failure [4].Positive diagnosis conducts two aspects: antenatally dia-gnosis and postnatally diagnosis. Antenatally diagnosis is based on detection of the disease by fetal echography star-ting from the 28th week of pregnancy, when it only highli-ghts the high attractiveness: ureterohydronephrosis [5, 6].The postnatal diagnosis is based on the echographical exa-mination during the neonatally or nurseling child, which

highlights bilateral hydronephrosis with the narrowing of the parenchyma, associated with renal dysplasia and mega-ureter due to uni- or bilateral reflux, relaxed urinary blad-der with thick wall and dilated prostatic urethra [7].The postnatally echography is used especially to evaluate the effect of the urethral valves on the urinary tract and also to diagnose the diseas [8].Miction cystography, retrograde urethrography, dosing se-ric creatinine completes the diagnosis[9,10] and are consi-dered to be the most important means of diagnosis.The treatment is surgical, from endoscopic ablation of the valves in the absence of chronic renal failure, to per-cutaneous pyelostomy, high lateral ureterostomy, and in severe cases vesicostomy [11], renal transplant [12,13]. Early and correct treatment will avoid renal failure, growth stopping and the impairment of sexual function and fertility.The prognosis depends on how early the impairment is de-tected, on the presence of the VUR, of chronic renal failure (CRF) which is present in 1/3 of cases [14].

Purpose of the paperTo highlight how many children diagnosed ante- or post-natally with ureterohydronephrosis and VUR have as cause a sub-bladder obstruction, namely the presence of posteri-or urethral valves.The main purpose of this paper is to analyze the degree of the renal function impairment in the case of vesicoureteral reflux associated or determined by PUV.

570 Aurelia Masca and Klara Branzaniuc

Material and method Study lot:Children diagnosed with vesicoureteral reflux between the ages of 0-18 years, of male sex, interned in the II Pediatric Clinic in Tg. Mures in the last 10 years.Means of gathering data:Data has been gathered by analyzing Observation sheets of children diagnosed with ureterohydronephrosis, vesico-ureteral reflux, posterior urethral valves at the II Pediatric Clinic – Nephrology Department.Criteria for inclusion:

children aged between 0-18 years –

sure diagnosis of VUR and PUV –

Criteria for exclusion: children aged between 0-18 years with medical history –

of renal impairmentmistakes in urodynamic studies –

children aged between 0-18 years with sepsis, acute –

dehydration syndrome, unremitting fever having an etiology different than the renal one.

Target population: 170 patients with VUR and possible PUV diagnosis –

Available population: research will begin with all children having VUR, ure- –

terohydronephrosis discovered ante- and postnatally, associated or determined by posterior urethral valves.

Type of study: transversal, analytical, experimental. –

Used method: retrospective study –

picked cases –

statistical method used – descriptive statistics –

Since no figures were used which could lead to the identifi-cation of a patient, there is no informed consent.

ResultsOut of 170 children with vesicoureteral reflux, four chil-dren were diagnosed with posterior urethral valve.

1st case 3-year old child with diagnosis:

Bilateral ureterohydronephrosis –

Operated posterior urethral valve –

Relapsing high type urinary tract infection –

Deficient anemia –

Discovered postnatally at the age of 4 months. Treatment:

valve ablation when he was 5 months old. –

Evolution: favourable with repeated urinary infections and defici- –

ent anemia (Figure 1.).

2nd case1-year and 4-month old child with diagnosis:

Bilateral ureterohydronephrosis –

1st degree left vesicoureteral reflux –

Posterior urethral valve –

Deficient anemia –

Diagnosed antenatally – fetal echography at 30 weeks hi-ghlighted bilateral hydronephrosis, then exploratory cys-tography highlighted urethral stenosis, posterior urethral valve and left vesicoureteral reflux. Treatment:

percutaneous cystostomy then valve ablation –

Evolution: favourable –

3rd case 9-year old child with diagnosis:

5th degree ureterohydronephrosis by sub-bladder bar- –

rierPosterior urethral valve –

5th degree right vesicoureteral reflux –

Chronic renal failure –

Bilateral cutaneous ureterostomy –

Repeated urinary tract infections –

Fig. 1. Case 1 – Ureterohydronephrosis

571Vesicoureteral Reflux – Severe Associated Factor of Posterior Urethral Valves in Children

Detected antenatally at 32 weeks of pregnancy, fetal echo-graphy visualizing bilateral ureterohydronephrosis.

Treatment: bilateral cutaneous ureterostomy, then bilateral ureteral reimplantation and valve resection.Evolution with 5th degree vesicoureteral reflux and chronic renal failure presently with peritoneal dialysis (Figure 2).

4th case 3-year old child with diagnosis:

Bilateral megadolicoureter –

5th degree bilateral vesicoureteral reflux –

Posterior urethral valve –

3rd degree chronic renal failure –

Bilateral cutaneous ureterostomy –

Vesical residuum 13,5 ml RS - Hidronephrosis

Ureter proximal right Ureter proximal left

RD - HidronephrosisFig. 2. Case 3 – Ureterohydronephrosis

572

Detected postnatally at 5 weeks beginning with signs of 3rd degree ADS, urinary tract infection, the echography highlighted renal dysplasia; cystography and urography highlighted massive bilateral vesicoureteral reflux.Treatment: bilateral ureterostomy at the age of 10 monthsEvolution: unfavourable with 3rd degree chronic renal fai-lure, peritoneal dialysis (Figure 3 - Caz IV).

Discussions:Out of the four children with PUV, three cases were dia-gnosed with VUR, one bilateral there is a similitudine with the studied bibliography dates.In all the four cases the treatment was done surgically, from the ablation valves to cutanated bilateral ureterosto-mia, two of the patients evolving propitiously with repeted urinal infections, although one of the children presented VUR. This congenital malformation culminates in its evolution with renal failure, observed fact at cases III and IV, where installation of VURuni or bilatheral, repeated urinal infec-tions, relatively aggravated the diseas.RVU may be considered as an associated gravity factor, the two children needing peritoneal dialysis, being candidates in the future to renal transplant [15].The urinal infection, obstruction, presional reflux and hyperfiltration, will exercitate a big pression at the growing child and will have a semnificative impact on the final pro-gnostic [16].PUV are rare malformations of the posterior urethra, but their existence can lead to serious changes in the upper uri-nary system, culminating with cronical renal failure, des-pite the early surgical solving of the obstructed urethral, thus lowering the quality of life for children sufferin from this diseas.

Conclusions:Posterior urethral diagnosis represents a challenge in the 1. sense of detecting the impairment as early as possible

(antenatally) and choosing the right therapeutic proce-dure in accordance with the degree of the renal impair-ment.Vesicoureteral reflux, which can be secondary to the bar-2. rier, is interpreted as a severe associated factor.Surgical treatment consists of endoscopic ablation of 3. valves and ureterostomy. In the studied cases it lead to a favourable evolution in two cases and to chronic renal failure in the other two, requiring dialysis and finally a renal transplant.

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RDRD Ureter proximal dilatat

Fig. 3. Case 4 – Ureterohydronephrosis

Aurelia Masca and Klara Branzaniuc