initial management of puv ahmed al-sayyad md,frcsc
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Initial management of PUV
Ahmed Al-Sayyad MD,FRCSC
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Clinical Presentation
• Boys with PUV can present with a variety of symptoms and at various ages
• They range from newborns with life-threatening renal and pulmonary conditions to older children with minor voiding dysfunction
• In general, the symptoms are age dependent; the more severely affected boys present earlier in life
• Antenatal hydronephrosis diagnosed with prenatal ultrasonography is the most common presentation
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Clinical Presentation
• Obstruction leads to decreased fetal urine output and results in oligohydramnios
• The observation of marked hydro, a distended bladder, and a thickened bladder wall in utero strongly supports the diagnosis of valves
• Neonates with sever PUV can present with Pulmonary Hypoplasia , intrauterine growth retardation, failure to thrive, lethargy, and poor feeding
• Older children can present with urinary tract infection, voiding dysfunction or renal insufficiency
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Approach
• Hx :Pre and postnatal• Exam: Abdomen,genitalia and back• Blood work: CBC,lytes,Cr,?acid base• Bladder drainage• Abx prophylaxis• US• VCUG• Careful monitoring
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US
• Hydroureteronephrosis
• Increased echogenicity
• Peri-renal urinoma
• Thickened bladder
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VCUG
• Bladder is thickened and trabeculated, diverticula may be present, bladder neck is elevated and the proximal urethra is dilated, and the actual valve structure is often visible
• Vesicoureteral reflux is present in at least 50% of valve patients at the time of diagnosis
• The incidence of reflux has been found to be higher in
neonates than in older children
• There is an 80% incidence of reflux on the left side in patients with unilateral reflux for no apparent reason
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Investigations
• Initial laboratory evaluation of the newborn with valves is usually misleading because of the effects of maternal renal function mediated through the placenta
• It will take at least 48 hours for the serum levels of creatinine and blood urea nitrogen to accurately represent the child's intrinsic renal function
• Creatinine, blood urea nitrogen, and electrolyte values should be determined twice daily for the first few days of life until they plateau
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Bladder Drainage• Initial management of all patients with PUV requires immediate
bladder drainage
• This should be performed even if the diagnosis has not been confirmed by VCUG
• Neonates can be catheterized with a 3.5 or 5 French pediatric feeding tube
• Foley catheters have been used with success, but there have also been reports that the balloon causes irritation and resultant bladder spasms
• After successful initial bladder drainage and when the patient's medical condition has stabilized, the next step is to permanently destroy the valves
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Valve Ablation• Transurethral valve ablation is the 1st treatment choice
• A Bugbee electrode or a pediatric resectoscope with a hook or cold knife can be used to incise the valves
• A number of authors report use of a cystoscope and laser to disrupt valves
• Some surgeons prefer incision at 12-o'clock position; others prefer incisions at 4- and 8-o'clock, and others all three
• Although most valves are thin and do not bleed at surgery, it is preferable to leave a catheter in place for 24 hours after incision
• The valve remnants resolve after incision, and there is often no evidence of them on later cystoscopic examination
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Cutaneous Vesicostomy
• If the infant is too small for safe instrumentation for valve ablation, a cutaneous vesicostomy can be performed as a temporary measure
• The vesicostomy provides adequate drainage of the
upper tracts in more than 90% of cases
• There has been concern that vesicostomy would cause permanent loss of bladder volume, but this has not proved to be true, and vesicostomy does not significantly affect bladder capacity
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Upper Tract Diversion• There is controversy about the superiority of upper tract diversion vs.
vesicostomy regarding long-term results and measured renal function, bladder function, and somatic growth in each group
• the current consensus is that neither initial treatment is superior in promoting renal function and somatic growth
• The current consensus is that both approaches eventually yield similar results and that infants who undergo initial upper tract diversion are at the disadvantage of needing more surgical procedures
• Today, upper tract diversion is usually limited to those patients who fail to respond to bladder-level drainage
• Upper tract diversion Is considered if bladder-level drainage is insufficient to prevent infection or to drain the upper tracts adequately
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Upper Tract Diversion
• If the serum creatinine concentration drops below 2.0 mg/dL (150 μmol/L), it is safe to rely on improved bladder drainage for additional kidney improvement
• If the creatinine concentration remains above 2.0 mg/dL (150 μmol/L) after 10 days of adequate bladder decompression and if hydronephrosis is unimproved, upper tract diversion may be considered
• The type of diversion remains the surgeon's choice, options are high loop ureterostomy, ring ureterostomy, pyelostomy, and end ureterostomy
• If upper tract diversion is performed, reconstructive surgery to
internalize the urinary tract should be delayed until the bladder and upper tracts have improved as much as can be expected
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Management of VUR
• Reflux in PUV is considered secondary to bladder outlet obstruction
• the initial management of reflux is relief of obstruction
• Reflux resolves after valve ablation in between 20% and 32% of refluxing ureters
• Most reflux resolves within several months, but some can take as long as 3 years
• Reflux is more likely to resolve when it is associated with a better functioning kidney
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Management of VUR
• Children with initial bilateral reflux are more likely to have reflux resolve than are those with unilateral reflux
• As for any child with vesicoureteral reflux, they must be maintained on prophylactic antibiotics to prevent infection
• If persistent high-grade reflux is a clinical problem because of urinary tract infections or incontinence, bladder function and drainage must be reviewed
• Inadequate emptying and high storage pressures are the usual causes of persistent reflux
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Management of Hydronephrosis
• Nonrefluxing hydronephrosis resolves in 49% of patients and may do so rapidly after valve ablation
• This leaves a significant population of valve patients with persistent hydronephrosis for years despite adequate bladder emptying
• The majority of patients with persistent hydronephrosis do not have obstruction at either the bladder outlet or the ureterovesical junction
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Summary
• PUV is one of the trickiest conditions to treat
• It requires a very careful initial and long-term management
• Our goal is to preserve all remnant kidney function by relieving obstruction and preventing infection
• Special attention and long-term bladder management is a key in treating those patients