7 years old male child presented with vesicostomy, done when child was 4 days old for urinary retention.
Urethroscopy could not be done due to very narrow calibre, SPC Scopy veru was seen and a pinpoint hole. Glide wire could be passed as seen.
I think, VCUG can give us some more insight... Thanks
Dear Dr Sham Joshi
Unfortunately i lost follow up with this patient.
If confirmed no Urethral duplication then
Thanks to all stalwarts for their very much valuable comments and suggestions.
This post may not be as a reply to the discussions hitherto made.
Antenatally, 2 types of Lower Urinary Tract Obstructions (LUTO) can be discerned. Of which we discuss PUV quite frequently and hence no further discussion on PUV is made. The other two types though uncommon are Urethral Stenosis and Urethral Atresia. Among these two Urethral Stenosis is rarer than Urethral Atresia. Those who practice Foetal Cystoscopy mention that a catheter could be passed down the urethra and out of external Urethral meatus in Urethral stenosis and PUV but not in Urethral Atresia.
In the presentation that we are discussing, we have been using the term Urethral Atresia rather loosely.
I am providing few Images of these conditions as observed with Foetal cystoscope (PDF).
The term Urethral Atresia should be limited to a situation where the child even prenatally has not voided through the urethra. Urethral Atresia is usually fatal unless there is some other egress for the urine to escape the bladder, such as patent urachus or an Uro-Rectal communication, and these lesions are not compatible with renal development. The point regarding Uro-Rectal communication has been raised by Amilal Bhat. This child presented did not have any such communications. Atresia of urethra often presents on routine antenatal ultrasound with Oligohydramnios or Anhydramnios which in turn affects the development of the lungs and causes features of Potter sequence.
The other condition that we have to understand is Urethral Stenosis. The urethra is often stenosed at the Bladder neck region or rarely at the prostato-membranous region and could be short segment stenosis or the entire urethra could be narrow. As mentioned earlier there is usually a communication between External meatus and Bladder. This could be hypoplastic. Such a scenario of hypoplastic urethra could be observed in Prune belly syndrome as well. But the case provided does not suggest this.
Extensive surgeries have been recommended by Sanjay and others. But the saving grace is an attempt at a Urethroscopy s prior to planning surgery.
Abdol-Mohammad Kajbafzadeh et al (2010, he has described various types of PUV that can be observed) has suggested Hydrodistension of Urethra in such hypoplastic Urethra prior to decision of surgical interventions. Five milliliters of normal saline was pushed via a 22-gauge plastic angio catheter into the Urethra and this was repeated with higher volumes of the solution (up to 20 mL). The procedure was continued until a 6F or 8F feeding tube catheter confirmed the urethral patency. Hydrodistension was repeated in 3-month intervals till complete patency was confirmed by imaging. It usually takes few sittings to achieve success.
May be this could be performed for this child though the child is now seven and needs higher volumes for hydrodistension. This is only a suggestion.
Anil and others have suggested VCUG, a procedure that could be performed by occluding the vesicostomy. But can a child who has never voided per urethra be able to void per urethra when attempt at VCUG is made. I do not know.
With warm regards,
Thanks for concluding remarks Sir.
Thanks for wonderful inputs.