Management of Posterior Urethral Valves in Rural Kenya
Nyagetuba M, Mugo R, Hansen E.
AIC Kijabe Hospital
Correspondence to: Dr. Muma Nyagetuba, P.O. Box 20-00220 Kijabe.
Background: Posterior Urethral Valves (PUV) are the most common cause of bladder outlet obstruction in children. Early detection is necessary to prevent potentially irreversible sequel. We conducted a study to determine the presentation, interventions and outcome of patients with PUV.
Methods: A retrospective study was conducted over a six year period with an average of two years follow-up.
Results: The commonest presenting symptoms were dysuria (55%), poor urinary stream(67%)and straining (39%). Malnutrition was present in 36%. Four patients developed chronic renal failure. There were four mortalities due to urosepsis, acute renal failure, and complications of Mainz-II ureterosigmoidostomy. 40% of patients developed valve bladder syndrome.
Conclusion: The high incidence of valve bladder indicates delayed intervention even when addressed in the early postnatal period. This, coupled with malnutrition call for a multidisciplinary approach and long term follow up of these patients.
Keywords: Posterior Urethral Valves, Valve Bladder Syndrome, LMICs
Ann Afr Surg. 2016;13(1):12-14
Posterior Urethral Valves (PUV) are a common cause of bladder outlet obstruction in boys. In countries where health care is optimum, the poverty rate low and the literacy rate high, the detection rate is high and early; the converse is seen in Africa (1).The incidence of chronic renal failure (CRF) is 34% and end stage renal disease (ESRD) is 10% at the end of 10 years (2). Early detection and intervention are necessary to prevent potentially irreversible sequelae. Though most men with a past history of PUV will be continent, 40% will have signs of bladder dysfunction (3). This study examines the presentation, intervention and outcomes of patients with PUVs who were seen at AIC Kijabe hospital.
A retrospective chart review of patients diagnosed with PUVs was conducted and corroborated with information from an electronic database at our hospital with is rural and has a countrywide catchment. The study period was from January 2009 to February 2015. The mean follow up period was two years.
Thirty three patients were treated during the study period. The median age was 50 months (11days – 12 years). Of the children who presented below the age of 36 months, 6 (20%) presented in the neonatal period. Of those who presented above the age of 60 months, majority (9/12) were older than 10 years. Thirteen patients (39%) had persistent urinary symptoms and were managed as having valve bladder syndrome (Table 1).
Nine of the thirteen patients with valve bladders were diagnosed pre or intra-operatively on the basis of a severely trabeculated bladder. The remaining four were detected on subsequent clinical follow up on the basis of persistent urinary symptoms and/or deteriorating kidney function in the absence of residual valves. One patient had residual valves confirmed by VCUG necessitating repeat procedure to relieve the symptoms. The urinary obstructive symptoms reported were poor stream (67%), straining (39%), acute retention (27%) and dribbling (24%). The irritative symptoms reported were dysuria (55%), frequency (15%), urgency (15%) and hematuria (9%). More than 40% of children had been treated for recurrent urinary tract infections (UTI) in peripheral health facilities. Only two patients were suspected to have PUVs during the first episode of UTI. Malnutrition was present in 36% of patients, with 20% being severely undernourished with a greater than –3 Z score weight for age. Voiding cystourethrogram documented reflux uropathy in 52% of the patients.
Trans Urethral Resection of Valves (TURV) was carried out in all patients. Four patients presented with vesicostomy already fashioned. Circumcision was conducted in six patients as part of a newly developed prophylactic protocol. One patient underwent urinary diversion (Mainz II – ureterosigmoidostomy) due to severe valve bladder disease with deteriorating kidney function.
Acute kidney injury (AKI) was diagnosed in 2 patients, both presenting in the neonatal period. Two other patients developed chronic renal failure. There were 3 mortalities, one patient died from renal failure and urosepsis and two died of ESRD.
Although the incidence of PUV has remained stable, the widespread use of prenatal ultrasound evaluation has significantly increased its early diagnosis and management. Most patients in developed countries are now diagnosed by the postnatal evaluation after a diagnosis of prenatal hydronephrosis (4). In contrast however, in most low and middle income countries (LMICs) this is not the case (1,2,5,6). The results of this study demonstrate a similar pattern where the mean age was 60.8 months and all were diagnosed postnatally. Factors that may contribute to this are, p