2. First recognised in 1769, by morgagani,confirmed by
langenbeck in 1802.
First endosopic diagnosis of puv – hugh hampton
young.
First endoscopic resection of valves in 1920 – randall.
3. INTRODUCTION
Seen in 1.6 – 2.1 % in 10,000 births .
Most common pathology in LUTO in congenital
anomalies of the urinary tract.
8. UPPER URINARY TRACT
Increased pressure over prolonged intervals transmits
to ureter,renal pelvis and glomerular units -
architectural and functional changes of ascending
structure.
9. URETER
ureteral wall thickening
Loss of peristalsis
Loss of mucosal coapatation
Leading to urinary stasis, infection, increased pressures
in renal system .
11. Angiotensin II – renal damage – hemodynamic
changes in glomerular flow - induction of
transforming growth factor beta and tumour necrosis
factor alpha.
12. VURD
Hoover and duckett hypothesized that reflux served as
a pop off mechanism in which the dysplastic kidney
with reflux served as a pressure reservoir migitating
damage to the contralateral kidney.
Does not improve renal prognosis.
Contralateral ,nonrefluxing kidney – high risk of
congenital renal cortical damage
14. ULTRASONOGRAPHY
PUV – detected in 1 in 2,500.
Accounts for 10 % of screened antenatally
genitourinary disease, 1/3 rd of bilateral renal disease .
Fetal MRI – degree of obstruction based on urethral
dilatation ,distended bladder and reduced amniotic
fluids .
22. LABARATORY EVALUATION
After 48 hrs maternal blood mediated through
placenta should clear, base line labaratory values are
monitored.
Nadir Creatinine value – at 1 year of age is important
diagnostic tool .
23. RADIONUCLIDE RENAL
SCAN
Quantification of differential renal function and cortical
defects implying renal dysplasia in neonatal period .
Mercaptoacetyltriglycerine
24. CLINICAL PRESENTATION
Associated with pulmonary hypoplasia , physical
appaerence due to oligohydraminos such as potter
facies -clubfeet,deformed hands ,poor abdominal
muscle tone
Difficulty with voiding
Weak urinary stream
5 or 7 F feeding tube / coude tipped catheter, stylet to
curl tip of feeding tube
27. URINOMAS
Seen in 3% to 10 %
Forniceal rupture , distorted renal parenchyma,
contained with in renal capsule.
28. Transperitoneal transudation of fluid or bladder
rupture – neonatal ascitis .
Percutaneous drainage /tapping of ascitis – respiratory
distress .
29. DELAYED PRESENTATION
Postnatal period
UTI,ARF,voiding complaints .
HIGH DEGREE SUSPICION – presenting with lower
urinary tract symptoms especially with recurrent UTI,
gross hematuria,overflow incontinence,renal
dysfunction.
30. SURGICAL TREATMENT
VALVE ABLATION : cystoscopy and valve ablation
GOAL – to restore normal flow of urine through
urethra.
Crocket hook
7.5 F/ 9 F cystoscope with an offset lens, for passage of
ablating devices including bugbee electrodes.
32. MOHAN VALVOTOME
Hollow tube with ends shaped like hooks designed to
catch only a floating valve.
Does not use diathermy .
Set of two one 3 mm and 2mm diameter in size.
Handle is turned laterally,downward
Suprapubic pressure is applied while pulling valvotome
.
33. Lasers – ND : YAG , Holmium : YAG laser.
Whitaker and sherwood – modified the hook insulating
the wire except for the very distal portion of the hook
of 6/7 F, applying diathermy when ablating the valves.
43. CIRCUMCISION
Prophylactic measure for any boy + puv .
Reduces UTI by 83% to 92 %.
Overall risk of UTI – 50 to 60 %.
Assoc with upper tract dilatation , VUR ,incomplete
bladder emptying.
Progress to pyelonephritis,sepsis .
44. NEPHROURETECTOMY
Non functioning kidney with dilated urinary reflux
leading to infections and sepsis .
PUV + VURD .
Prevention – circumcision and proper bladder
emptying .
47. PATHOLOGY OF BLADDER
DYSFUNCTION
Detrusor hyperreflexia in infancy and early childhood
Decreased intravesical pressures and improved
compliance
Increased bladder capacity with hypocontractility
,atony in adolescence.
48. FOLLOW UP
Renal ultrasonography
Uroflow, PVR .
Toilet training ,adequate fluid intake ,practice double
voiding , pelvic floor muscle excercises,biofeed back
therapy.
Alphablockers /anticholinergics
49. CONTD….
Routine – height ,weight ,blood pressure, serum
creatinine and elecrolytes .
Indicated – isotope renography ( MAGE 3 or DMSA ),
Formal estimate of GFR .
50. VALVE BLADDER
SYNDROME
Polyuria
Poor bladder compliance with high pressure voiding
and elevated wall tension bladder .
Residual urine volume
54. ANTENATAL MANAGEMENT
Antenatal scan – oligohydraminos ,dilated
bladder,severe HUN with out renal cortical cystic
lesions in a fetus with a normal karyotype.
55.
56. FETAL URINE SAMPLING –
FAVOURABLE PROGNOSIS
Fetal urine sample – 20 weeks of gestational age
Urinary sodium less than 100 meq/L.
Chloride less than 90 meq/L
Osmolarity less than 200 meq/L
Beta microglobulin less than 6 mg/L
57. PROGNOSTIC INDICATORS
FOR RENAL FUNCTION
ESRD + PUV – 20 to 50 %.
Serum creatinine at one year of age – 0.8 mg/dl –
minimal risk
>1.2 mg/dl – high risk .
58. PREDICTORS OF POOR
PROGNOSIS FOR RENAL
FUNCTION
PRENATAL – history of maternal
oligohydraminos,regardless of gestational age at
onset,early detection of prenatal u/s and other
prognostic features of fetal urinary tract.
POST NATAL – clinical presentation in the first 6
months of life,proteinuria,bilateral VUR,impaired
continence at 5 yrs of age.
59. TRANSPLANTATION IN PUV
Prevalence of ESRD + PUV – 50 % .
Second most CC – obstructive uropathy .
PUV – VUR + NFK + Bladder valve syndrome ( thick
walled, poorly contractile or hypercontractile bladder )
Pretransplant evaluation – throughly
60. CAUSE – thickened bladder wall may increase
incidence of ureteral obstruction .
Video urodynamics
Overnight bladder drainage / CIC .
Pretransplant augmentation – rare, done in
immunocomprimised child.
61. LONG TERM RESULTS
LUTS
Bladder dysfunction
UTI
Renal dysfunction
Erectile dysfunction
Infertility .
62. POP OFF VALVES
A mechanism by which high intravesical or intrapelvic
presure is dissipated.
Allows for normal development of one or both kidneys
by one of three mechanisms
1) urinary ascitis – urine leaks from the fornices of the
kidney or from a bladder rupture
63. 2) VURD syndrome – massive unilateral reflux into a
non functioning kidney
3) large bladder diverticulum – causing aberrant
micturation into diverticulum there by taking pressure
off the developing renal units .
64. FAVOURABLE PROGNOSTIC
FACTORS
Creatinine falling below 1.0 one month after treatment
initiated
Absence of VUR
Preservation of the corticomedullary junction of the
kidneys by renal U/S .
Radiologic evidence of a pop off valve
65. ADVERSE PROGNOSTIC
FACTORS
Prsentation after the age of 1 year
Failure of cr to fall below 1.0 1 month following
initiation of therapy/drainage
Bilateral VUR
Diurnal incontinence beyond 5 yrs of age
Prenatal diagnosis in the second trimester
