Does mode of treatment affect the outcome of neonatal posterior urethral valves?

A prospective study on the outcome of posterior urethral valves (PUV) was performed. The data analyzed were whether the modality of treatment (fulguration vs vesicostomy) affected renal function and somatic growth, and whether the presence of vesicoureteral reflux (VUR) and abnormal serum creatinine levels affected somatic growth.

A total of 45 consecutive neonates were diagnosed and treated for PUV with fulguration (24) or vesicostomy (21) between 1997 and 2003. Postoperative stable creatinine values, renal function and somatic growth were recorded. Well tempered renal scans using diethylenetetraminepentaacetic acid were performed during the first and second years of life at followup. Standard anthropometric techniques and statistical methods were used to compute distance statistics for body weight and crown-heel length at age intervals of 3 months for year 1 and 6 months for year 2.

Of the patients 9 were lost to followup and 6 died in the first year of life due to renal failure. Preoperative and postoperative mean serum creatinine was 1.6 +/- 1.5 and 0.7 +/- 0.2 mg/dl, for the fulguration group and 1.7 +/- 1.5 and 0.9 +/- 0.7 mg/dl, respectively, for the vesicostomy group. In 10 patients renal function deteriorated or there was no improvement after treatment. With the advancement of age neonates with PUV showed normal increase in body weight and crown-heel length. Those with VUR were significantly shorter compared to neonates with no VUR at the end of year 2 of life (p <0.05). Patients with creatinine less than 1 mg/dl had significantly greater increase in body weight (at 3 and 6 months) as well as crown-heel length (at 3 and 9 months), respectively (p <0.05). Physical growth of the fulguration and vesicostomy groups remained substantially lower than that of their normal healthy counterparts. Newborns treated with vesicostomy did not have any breakthrough urinary tract infections. Although patients treated with vesicostomy were lighter and smaller initially (p <0.05), they were comparable to those treated with fulguration at the end of 2 years, thus demonstrating catch-up growth.

Our prospective study demonstrated that transurethral fulguration and vesicostomy are equally effective for neonatal valves and achieve similar renal function. Both groups showed retarded growth compared to healthy counterparts. Somatic growth was delayed by serum creatinine greater than 1.0 mg/dl and the presence of VUR. Vesicostomy seemed to help neonates catch-up the growth deficit in the first 2 years of life.