THE MANAGEMENT OF UNILATERAL POORLY FUNCTIONING KIDNEYS IN PATIENTS WITH POSTERIOR URETHRAL VALVES

Purpose: There is no uniform agreement on how to manage the unilateral nonfunctioning or poorly functioning kidney associated with posterior urethral valves. We studied the results of treatment of our patients to make recommendations regarding management of these kidneys. Materia ls and Methods: We reviewed the records of 13 boys with a history of p osterior urethral valves and a unilateral nonfunctioning or poorly fun ctioning kidney, defined as less than 10% of total renal function on ( 99m)technetium dimercapto-succinic acid renal scans. Variables investi gated included pyelonephritis, hypertension, vesicoureteral reflux, ne phroureterectomy, ureteral reimplantation and spontaneous cessation of reflux. We also evaluated how the management of abnormal urodynamic p arameters influenced the results of reimplantation or medically induce d cessation of reflux. Results: Three of the 6 boys with grade 5 reflu x ipsilateral to the poorly functioning kidney required nephroureterec tomy at a mean age of 21 months because of recurrent urinary tract inf ections. Another 4 boys underwent successful ureteral reimplantation, including 2 who had bilateral grade 5 reflux, and 2 who had ipsilatera l grade 4 reflux, and grade 3 (1) and grade 2 (1) contralateral reflux . Of 4 boys ipsilateral grade 3 reflux in 3 and bilateral grade 5 refl ux in 1 disappeared without surgery after treatment of urodynamic abno rmalities. Two patients with poorly functioning kidneys and no reflux did not undergo surgery. Overall 10 of the 13 poorly functioning renal units were not removed, and these patients were free of pyelonephriti s and hypertension. Ureteral reimplantation (4 ipsilateral and 3 contr alateral) was performed only after urodynamic abnormalities were addre ssed. All reimplantations were successful. Conclusions: Based on our r esults we believe that unilateral poorly functioning kidneys in patien ts with posterior urethral valves can be safely preserved in select pa tients without hypertension and pyelonephritis. Reimplantation to corr ect reflux may be preferable to nephroureterectomy in specific situati ons, such as when contralateral function is suboptimal and the contral ateral ureter needs reimplantation. When indicated, reimplantation can be performed successfully if abnormal urodynamic parameters are addre ssed preoperatively. In fact, treating abnormal urodynamic findings ma y lead to spontaneous reflux resolution.