LOWER URINARY-TRACT CHANGES AFTER EARLY VALVE ABLATION IN NEONATES AND INFANTS - IS EARLY DIVERSION WARRANTED

Purpose: Severe hydronephrosis, high grade reflux and/or renal insuffi ciency often leads to proximal urinary tract diversion in male infants with posterior urethral valves. Even with this treatment progressive loss of renal function often occurs. Unfortunately with early diversio n the bladder, already damaged by in utero obstruction, is also defunc tionalized. Alternative treatment with valve ablation in the newborn p eriod and without diversion may facilitate recovery of normal bladder function. Materials and Methods: We retrospectively reviewed the recor ds of infants treated for posterior urethral valves before age 1 year at our institution in the last 8 years. Treatment comprised primary va lve ablation in 23 patients and urinary diversion in 8. Preoperative a nd serial postoperative voiding cystourethrograms were scored for degr ee of trabeculation, bladder neck hypertrophy and prostatic urethral d ilatation in all patients undergoing primary valve ablation. Recovery of bladder and renal function after primary valve ablation was compare d to that of patients treated with urinary diversion. Results: All pat ients treated with primary valve ablation demonstrated marked improvem ent or resolution of bladder abnormalities on voiding cystourethrograp hy by 1 year postoperatively. Bladder compliance and volume were stati stically better than in patients treated with primary diversion. Upper tract diversion failed to halt progressive renal failure in 5 of the 6 patients who underwent diversion. Similarly primary valve ablation d id not stop progressive renal failure in a matched group of patients. Conclusions: Early ablation of posterior urethral valves results in th e recovery of normal bladder appearance and function when performed in the first months of life. Severe renal insufficiency tends to progres s even with upper tract diversion. Furthermore, this treatment prevent s normal bladder cycling, which may inhibit bladder recovery in the pa tient with posterior urethral valves.