Postablation followup of PUV Patients

1. PUV follow up; Post fulguration
Dr. Faheem Ul Hassan
Fellow Pediatric Urology
IGICH Banglore
Dr. Vinay Jadhav
Associate Professor
Pediatric Surgery & Pediatric Urology
IGICH Banglore

2. VBD
despite successful valve ablation, intrinsic bladder
dysfunction leads to deterioration of them upper urinary
tracts and incontinence.

3. Causes of VBD
1. Detrusor abnormalities
poor compliance, and
myogenic failure
2. High-pressure voiding secondary to
incomplete valve ablation
Bladder neck hypertrophy
3. Detrusor-sphincter dyssynergia in which the sphincter muscle
fails to relax during Voiding

4. VBD- Causes
4. Polyuria secondary to a concentrating defect
5. Thimble Bladder, which is a bladder with poor
compliance resulting from fibrosis secondary to long-
standing obstruction.

5. VBD- Molecular Level
There is hypertrophy of smooth muscles
increase in the deposition of extracellular matrix (ECM)
Alteration in the detrusor blood flow resulting in ischemia
and decreased perfusion
There is a shift to anerobic metabolism and the nerves
within the bladder wall are damaged.

8. Prognosis
At follow-up after 18 years of age,
CRF was detected in 54%,
hypertension in 37.5%
presence of lower urinary tract symptoms in 29%.
In India, medicolegal termination in view of bad prognosis for a fetal
condition is permitted as per law

9. Prognostic factors
Poor prognostic factors
prenatal detection at <24 weeks gestation,
respiratory distress at birth,
Urinary sepsis,
dyselectrolytemia,
nadir serum creatinine >0.8 mg/dL,
bilateral VUR,
hyperechoic kidneys,
and absence of pop-off mechanism.

10. VUR in PUV
VUR is present in about ⅓ to ½ of the patients of PUV.
Half of these will have U/L and the other half would have
B/L
VUR will resolve in at least 1/3rd of the patients
Remaining 2/3rd would require deflux injection or surgery.
Resolution of reflux has also been seen with addition of
alpha-blockers.
The incidence of ESRD before 16 years was highest in a
patient with bilateral VUR (25% ), unilateral VUR (7% )

11. PUV and Bladder dysfunction
 1/3rd of the patients have persistent bladder dysfunction after PUV
ablation,
 50%– 70% have high PVRU due to bladder neck hypertrophy.
 Radiological indicators of dysfunction
 persistent UTD,
 posterior urethral dilatation,
 VUR,
 trabeculation and diverticula in bladder,
 and significant postvoid residual urine.

12. Goals of Follow up
The principles of follow-up for PUV are to:
1. Maximize renal function
2. Minimize urinary infections
3. Minimize renal scarring
4. Assess voiding dysfunction
5. Attaining urinary continence
6. Assess bladder growth
7. Assess need for renal replacement therapy

13. Follow up
3m, 6m, 9m, 1y, 3y, 5y, 10y, 13y, 15y
RFT, CBC, electrolytes,
midstream urine for analysis,
USG with with BC and PVRU,
uroflowmetry were noted.
More than 10% of the prevoid volume is abnormal and
described as significant postvoid residue

14. Indications for MCU
Check MCU at 3 months postfulguration (optional)
If HUN is present postfulguration on USG, repeat VCUG at 2,
5, and 10 years
If deflux/ureteral reimplantation planned
To study the bladder anatomy before bladder augmentation
or renal transplant.

15. UDS
1. Persistent daytime urinary incontinence beyond the age
of 5 years
2. Deterioration in RFT (rising creatinine or dropin GFR)
with no obvious cause such as growth spurt
3. Increase in upper tract dilatation in the absence of
ongoing outflow obstruction
4. Before renal transplantation to ensure a safe, compliant
low-pressure urinary tract

16. UDS
7. Functional problems – detrusor-sphincter
discoordination or suspected dyssynergia
8. Increased PVRU.

17. Drug Treatment- Anticholinergics

18. Casey et al
3 abnormal urodynamic patterns on UDS
of myogenic failure,
Detrusor hyperreflexia and
decreased compliance/ small capacity may develop
The type of bladder dysfunction that develops after PUV
ablation can be unpredictable.

19. Casey et al
Initial urodynamics were performed at approximately 3
months after PUV ablation.
High voiding was defined as pressure greater than 60 cm
H2O),
small bladder capacity was defined as less than 70% of EBC
oxybutynin (0.1 mg/kg twice daily).
This low dose was chosen given the young age of the
patients.

20. Casey et al
UDM was performed six monthly upto toilet training
Oxybutinin was stopped at toilet training
Mean age for PUV fulguration was 17 days
Oxybutinin was started on mean age of 3 months

21. Casey et al
Initial voiding pressures were high (defined as greater than
60 cm H2O) in 17 of 18
Among the 17 patients with initially high voiding pressures
15 demonstrated improvement to a mean voiding pressure
of 49.9 cm after 12 months

22. Casey et al
Poor bladder compliance was defined as a PSBV at 25 cm
H2O of less than 90% bladder capacity
all demonstrated improvements in bladder compliance
while on oxybutynin,

23. Casey et al
Low bladder capacity was defined as less than 70% EBC,
normal bladder capacity as 75% to 200% EBC and high
bladder capacity as greater than 200% EBC.
All the patients experienced significant improvement in
capacity with OXB
However 2 patients out of 7 had abnormal increase in
bladder capacity (MF)

24. Casey et al
4 patients out of 17 needed discontinuation of OXB due to
Inappropriate increase in BC
MF
Increased PVRU

25. M K Abraham

26. Abraham et al
Forty-two children with significant PVRU after valves
ablation were studied
placed on Terazosin ranging from 0.25 to 2 mg.
Post void urine at follow up was monitored with abdominal
ultrasound

27. Abraham et al
PVRU significantly reduced in 95% who were put on
Terazosin.
Mean pretreatment PVR was 15.7 ml and mean PVR at the
last follow up was 2.4 ml (P = 0.000).
Mean follow up was 17 months

28. Abraham et al

29. PUV-Role of Nephrologist
The nephrologist should be involved earlier in cases of
deranged renal parameter.
They take care of timely institution of renal replacement
therapy including Vitamin D, soda bicarbonate, calcium,
erythropoietin,
Proteinuria depicts early renal damage.

30. PUV-Timed Voiding
The children with dilated upper tracts should be
encouraged to do double or triple voiding.
Constipation should be avoided.
Adequate bladder emptying can be achieved by timed
voiding

31. PUV- CIC
Bladder may not be able to empty completely due to
Myogenic failure
Overdose of OXB
Hyperactive sphincter (DSD)
CIC should be instituted with raised PVR
It increases bladder complicance
Improves renal function and GFR
Decreases the grades of reflux

32. CUA

33. CUA
CIC was instituted in < 4 year children when indicated

34. CUA

35. PUV-NTD

36. PUV-NTD
Overnight drainage in conjunction with daytime CIC can be appropriate
management in children with poorly compliant bladders, especially in
the early stages of renal compromise

37. `PUV-Biofeedback Therapy
Children with urinary tract dysfunction
biofeedback therapy and
Home pelvic floor exercises, with an overall consistent good
response in 70%.
Ansari MS, Srivastava A, Kapoor R, Dubey D, Mandani A, Kumar A. Biofeedback therapy and home pelvic floor exercises for
lower urinary tract dysfunction after posterior urethral valve ablation. The Journal of urology. 2008 Feb 1;179(2):708-11

38. PUV-Bladder neck ablation
Secondary bladder neck obstruction has been over
diagnosed in patients with PUV
The practice has not been adopted universally

39. PUV-Bladder neck ablation
No Improvement was found

40. PUV-Bladder Augmentation
Augmentation may be required in
valve bladder when medical management fails
to prevent the deterioration of renal function or
the bladder is very small with thickened wall and
High Grade VUR with recurrent UTI
Renal transplant has been planned.

41. PUV-Bladder Augmentation

42. PUV-Bladder Augmentation
Treatment of VBD with clean CIC and NTD via a Mitrofanoff stoma can
achieve significant improvements in hydronephrosis and bladder
dysfunction urodynamic parameters.
However, it does not prevent renal deterioration.

43. Renal transplantation
As up to 50% of PUV patients can end in ESRD, renal
transplantation may be required.
This may require bladder augmentation to increase the
bladder capacity

44. Controversy about pretransplant augmentation
Pretransplant augmentation raises the risk of febrile UTIs
significantly and may lead to malfunction of the graft

45. Controversy about pretransplant augmentation

46. Controversy about pretransplant augmentation

47. PUV-VUR

48. PUV-VUR
The incidence of VUR at diagnosis of PUV is 64%
Spontaneous resolution of reflux is seen in 50% of ureters
within 2 years (67% within 3 years) after valve ablation,
occurring more rapidly in unilateral than bilateral
Kidneys with refluxing ureters have worse primary function
VUR is frequently bilateral

49. PUV-VUR
The refluxing nonfunctioning kidney was removed in
18% of our patients, although the possible benefit
remains undetermined

50. PUV- Minivesicostomy

51. PUV- Minivesicostomy

52. Minivesicostomy
The mini-vesicostomy allows
bladder cycling as the stoma is very small and
keeps the storage function of the bladder intact,
provides an access for CIC.
This may decrease the need for future bladder
augmentation in these patients

53. Urethral Index

54. Urethral Index
MCU to be done at 3 months post ablation

55. SWRD Score
Incontinence is found in 20% of patients with treated PUV
on longterm follow-up
It is caused by sphincter weakness postablation
Interestingly, most patients (up to 90%) will have
spontaneous improvement by puberty
OXB, CIC and AC are the treatment options

56. SWRD Score
Compliant bladder Score 1, Non Compliant bladder Score 3

57. Thank you