Posterior Urethral Valve-Let's Have Discussion-Past/Present/Future-A never ending story

• 09 Jun 2020 12:27:18 PM
• |Pediatic Urology

Dear All,

Comments(14)

• 

  Uday Sankar Chatterjee

  10 Jun 2020 05:04:53 PM

  This patient has got high creatinine and not coming down that much in spite of PUC. 

  VCUG showing bilat HUN.... Persisting .... It's due to UVJO... Due to detrusor hypertrophy 

  
  

  So bilat. Ureterostomy in necessary 

• 

  Tikenjit Mazumdar

  10 Jun 2020 06:44:54 PM

  If we consider this patient at this time...patients sepsis is settled...

    Creatine is still 2.1mg...if consider it to be nadir value...we needed some kind of diverse...

  1step...I would like to do is open vesicostomy... follow it up with creatine every 24-48 hrs...if it response...that's it...go for valve fulguration...

  If not... I would like to go for higher diverse...

  In this case...VCUG...show reflex...no VU obstruction...so 

• 

  Uday Sankar Chatterjee

  10 Jun 2020 06:56:20 PM

  In PUV, bladder pressure may be as high as 130 or more. So it's easy for contrast to go up... But would not come down as the ureteric peristaltic pressure would be around 15-30.

  So VCUG should have post void film to see, whether Ureters are empting or not.

• 

  shriram joshi

  11 Jun 2020 07:52:41 PM

  Dear anil, 

  This child has problems. His presentation is with urosepsis and electrolyte imbalance. Good you have been able to correct electrolytes and sepsis.

  All puv have a high detrusor pressure with an unstable bladder. It is unusual to have VUJ obstruction or any other mechanical obstruction. It is the pressure difference between ureter and bladder causes a physiological obstruction.

  The culprit is the bladder. So best solution is to do a Blockson cystostomy. Trick in such a cystostomy is to find the urachus. This will lead fundus of bladder. You anastomose opened fundus to skin.

  A fundic cystostomy achieves reduction in detrusor pressure and recycles the bladder. Any other cystostomy will not achieve this.

  To do bilateral ureterostmy in a sick child is not peice of cake. Quickest is a loop ureterostmy bilateral, but this may leave a drier bladder with poor recycling.

  So my advice is Blockson cystostomy.

  PUV fulguration when child has settled down. Closure of cystostomy when child is thriving well and parameters have touched nadir
  SSj
  
  
  
  
  
  

  
  

• 

  Dr. Anil Takvani

  11 Jun 2020 09:17:23 PM

  Attaching VCUG image provided by Dr. Udayshankar Chatterjee. 

  He will post his comments soon...thanks 

  

• 

  Uday Sankar Chatterjee

  12 Jun 2020 07:14:32 AM

  
  

  
  

       Combo of VUR & UVJO might be missed, if Post void residual in ureters is not sought for.

   In above VCUG plate, Residual contrast is staying >3.5 hours!

  Undiagnosed UVJO is one of the cause of upstaging of CKD. 

  All patients of PUV are in CKD in different stages. CKD is classified with GFR. So we have to monitor renal function with CCr not with Creatinine. Blame of ESRD due to missed  UVJO might be misfire on Renal Dysplasia!

  
  

• 

  Mallikarjuna Reddy N

  12 Jun 2020 09:04:24 AM

  I can't agree more  with Prof Joshi sir. I would also do a vesicostomy. wait for the cold to stabilise for an year or more and then reevaluate and proceed to further treatment. Fulguration at this time is not the option

  
  

• 

  Dr. Prasanna Venkatesh M K

  12 Jun 2020 09:06:04 AM

  Good morning,

  
  

  This child would benefit from a Blocksoms Vesicostomy 

  Just like what Dr S S Joshi, stated the technique is of paramount importance 

  Urachus to be identified and traced to the bladder and have a wide opening of the posterior wall of the bladder.

  Hopefully after the sepsis improves - the creatinine should settle down.

  The child will need long term follow up to monitor renal function and bladder definitely will need atleast a two decade follow up.

  
  

  Thank you 

• 

  Rahul Kapoor

  12 Jun 2020 10:02:28 AM

  Seeing this child presentation and emergency management. 

  I do agree that diversion is must and i will also choose vesicostomy.

  
  

  After vesicostomy, functioa obstruction at the level of VUJ should settle.  

• 

  Rahul Kapoor

  12 Jun 2020 10:06:51 AM

  I have a major question to ask now..

  How do we follow these babies

  Their r 2 scenarios

  1. Serum creatinine becomes normal (less than 0.7mg/dl)

  2. Serum creatinine still remain high

• 

  shriram joshi

  12 Jun 2020 05:34:29 PM

  Serum creatinine is an indicator of nephron damage. It won't rise till 25-30% function is lost. The damage to  nephron is intrauterine and often results in patchy dysplastic kidney. Hence creatinine may not come to normal. That is why nadir creatinine should be followed. This is the level of creatinine after diversion & fulguratioof valve

  SSJ
  

  
  

• 

  shriram joshi

  12 Jun 2020 05:34:30 PM

  Serum creatinine is an indicator of nephron damage. It won't rise till 25-30% function is lost. The damage to  nephron is intrauterine and often results in patchy dysplastic kidney. Hence creatinine may not come to normal. That is why nadir creatinine should be followed. This is the level of creatinine after diversion & fulguratioof valve

  SSJ
  

  
  

• 

  Dr. Isteaq Shameem

  13 Jun 2020 06:11:39 PM

  Isteaq Shameem

  Excellent opinions are already expressed, Shriram Joshi sir’s treatment is widely followed in these cases. Actually upper urinary diversion can be reserved for concomitant vujo. Vesicostomy will reduce bladder pressure preventing further upper tract damage. Valve fulguration can be undertaken taking into account of nadir creatinine as rightly pointed out by Joshi sir. Also bladder cycle has to be kept in mind.In practice these children require long term follow up

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  Dr. Anil Takvani

  20 Jun 2020 07:42:29 AM

  On behalf of Prof. S S Joshi Sir, I am posting images of Blocksome Vesicostomy.

  Sir will write details of procedure very soon...Thanks