الفهرس 
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Abstract
Posterior urethral valve (PUV) is the most common cause of urinary
outflow obstruction in pediatric practice. PUV is estimated to occur in 1 of
every 5000 to 8000 male births and constitutes about 10% of prenatally
diagnosed hydronephrosis.
Children with congenital posterior urethral obstruction present in a
variety of ways, depending primarily on the degree of obstruction. They
ranged from newborns with life threatening renal insufficiency and
pulmonary hypoplasia to older children with minor voiding dysfunction or
urinary tract infection. Today, most patients with posterior urethral valves
are diagnosed with prenatal ultrasonography.
Management of posterior urethral valves depends on the degree of
renal function. Currently, many patients with posterior urethral valves are
diagnosed by prenatal ultrasound. After birth, a urethral catheter is placed;
further management is dictated by the level of renal function. In the
presence of satisfactory renal function, transurethral valve ablation is
performed. In the unusual situation in which the newborn urethra seems too
small to accommodate the available endoscopes, an elective vesicostomy is
appropriate and safe. The major area of continuing controversy involves the
most appropriate approach for management of the infant who has significant
renal insufficiency that persists after a satisfactory period of transurethral
drainage. The options for managing this group of children include
endoscopic destruction of the urethral valves only, elective vesicostomy, or
high-loop ureterostomy.
The aim of the work to determine which method achieves the current
posterior urethral valve management goals of preserving renal function and
functional integrity of the lower urinary tract
To accomplish this aim, the records of 30 consecutive patients with
posterior urethral valves of different age were reviewed. At hospital
admission a clinical examination was done for all patients. Serum creatinine
was measured. Abdominal & pelvic ultrasound and voiding
cystourethrogram (VCUG) were done for all patients. Urodynamic studies
were carried out only for patients who were toilet trained after at least one
year of the management. Patients were divided into 2 groups according to
primary surgical management. Group 1 includes (15) patients managed by
endoscopic valve ablation, group 2 includes (15) patients managed by
vesicostomy with delayed valve ablation
Both groups were subjected to follow up, 3months, 6 months & one
year after management. During follow up the children were subjected to:
clinical assessment, laboratory assessment, radiological assessment, and
urodynamic studies were carried out only for patients who were toilet
trained.
The most common presentation in group 1 managed by valve ablation
was difficult micturition (60%). While, in group 2 managed by initial
vesicostomy the most common presentation was febrile urinary tract
infection (66.67%). While the preoperative presentations have significantly
improved during the postoperative follow up in both groups, the
incontinence was not improved, which may be due to irreversible detrusor
dysfunction.
In both groups of our study the preoperative serum creatinine is
significantly improved during follow up after 1 year of the management.
Postoperative serum creatinine is significantly lower in group 1 than group
2. Preoperative mean serum creatinine levels for groups 1 and 2 were 1.16
± 0.32 mg/dl and 1.529 ± 0.622 mg/dl, respectively. At the end of 1 year the
serum creatinine decreased to 0.55 ± 0.22and 0.8 ± 0.39 mg/dl, in groups 1
and 2, respectively.
In our study, the improvement of postoperative hydronephrosis grade
in both groups is not significantly different. In group 1, backpressure
changes improved in 70.0% of affected renal units. In group 2, backpressure
changes improved in 63.3% affected renal units
In our study, the incidence of VUR is 63.3%. In group 1 after surgical
correction of urethral obstruction, VUR improved in 77.78% of affected
renal units. In group 2 VUR improved in 65% of affected renal units. The
improvement of postoperative hydronephrosis grade in both groups is not
significantly different.
The improvement of postoperative bladder score in both groups is not
significantly different. The mean postoperative bladder score in group 1 was
2.13± 1.45. The mean postoperative bladder score in group 2 was 2.40±
1.12.
Our cases who had urodynamic studies demonstrate higher incidence
of hypocompliant bladder in group 2 managed by initial vesicostomy (75%)
than patients managed by valve ablation (33.3%).