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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
LETTER TO THE EDITOR  
Year : 2012  |  Volume : 23  |  Issue : 2  |  Page : 355-357
Management of obstructive uropathy with cutaneous ureterostomy in posterior urethral valve


Department of Urology, King Abdulaziz University Hospital, Jeddah, Saudi Arabia

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Date of Web Publication28-Feb-2012
 

How to cite this article:
Tayib AM, Alsayyad AJ. Management of obstructive uropathy with cutaneous ureterostomy in posterior urethral valve. Saudi J Kidney Dis Transpl 2012;23:355-7

How to cite this URL:
Tayib AM, Alsayyad AJ. Management of obstructive uropathy with cutaneous ureterostomy in posterior urethral valve. Saudi J Kidney Dis Transpl [serial online] 2012 [cited 2014 Oct 24];23:355-7. Available from: http://www.sjkdt.org/text.asp?2012/23/2/355/93177
To the Editor,

The incidence of chronic renal failure (CRF) in children up to 18 years of age in Saudi Arabia is 20.4 per million for age adjusted population. [1] This is higher than that reported from some western countries. [2] Kari J, in a study involving 66 Saudi children with CRF, reported that 17% of them had posterior urethral valve (PUV) as a causative etiology. [3] Primary valve ablation followed by close monitoring of the bladder and kidney function is considered as the first line and the most efficacious way of managing PUV. [4] However, many children do not improve with this tech­nique as one would expect. In many cases, obstruction caused by posterior urethral valves is found to be associated with profound dys­function of the entire proximal urinary tract. The functionality of the ureterovesical junction will affect the ureteric function and conse­quently, the upper tract. For this reason, many of them probably require upper tract surgery.

We undertook a study to find out the efficacy of cutaneous end-ureterostomy as a valid method in the management of complicated cases with PUV. Inclusion criteria for the study included bilateral hydroureters and hydronephrosis, renal function deterioration following valve ablation, Foley's catheter and adequate bladder emptying. Twenty children seen in the Department of Urology between May 2002 and November 2009 at King Abdulaziz University in Jeddah, who met inclusion criteria, were included into this retrospective study. Routine laboratory tests and scans including a complete blood count (CBC), electrolytes, serum creatinine, blood urea nitrogen (BUN), voiding cystourethro-gram (VCUG), DTPA renal scan and uro-dynamic studies were performed preoperatively. The mean age of all 20 children met inclusion criteria and were included in the study at time of presentation was 4.2 years (range: 2-8 years). Eight (40%) children presented with an incidental finding of bilateral hydronephrosis detected by ultrasound of the kidneys, five (25%) children had recurrent attacks of symp­tomatic urinary tract infection, two (10%) chil­dren presented with elevated blood pressure, and four (20%) children presented with dimi­nished urine output or a voiding disorder such as dribbling urination. All patients included in our study were diagnosed primarily from other hospitals and they were not properly diagnosed or adequately managed. Ultrasound (US) showed severe bilateral hydronephrosis and hydro-ureters in all cases, while VCUG confirmed the diagnosis of posterior urethral valve. Grade 5 vesicoureteral reflux (VUR) was documented bilaterally in nine (45%) cases and unilaterally in six (30%) cases while no reflux was seen in five (25%) cases. DTPA renal nuclear scan still showed obstructive pattern in children who had undergone valve ablation and vesical diversion elsewhere. End-ureterostomy with a ureteral stoma using the nipple technique was performed on all patients.

Follow-up included US of the kidneys, DTPA renal scan, serum creatinine, and electrolytes every 3 months for the first year and yearly thereafter.

The mean glomerular filtration rate (GFR) prior to cutaneous ureterostomy was 49.8 mL/min/ 1.73 m² (range: 30-67 mL/min/1.73 m²). Mean serum creatinine for all patients was 93 mmol/L (range 87-104 mmol/L). The GFR improvement, evaluated 1 month after cuta­neous ureterostomy, varied between 7 and 13 mL/min/1.73 m² (mean 7.2 mL/min/1.73 m²). Likewise serum creatinine level improved to between 23 and 38 mmol/L. Three patients who presented with hypertension were able to discontinue antihypertensive drug treatment 6 weeks after cutaneous ureterostomy. One child had to continue on one antihypertensive drug. All patients stopped developing symptomatic urinary tract infections, Ureteral stoma ste­nosis occurred in one patient postoperatively and this required revision seven weeks into the postoperative period. All patients included in the study continued to have stable renal func­tion and underwent augmentation ileocysto-plasty by the Studor technique at the age of 7- 8 years.

In patients with posteror urethral valve, be­nefit from supravesical diversion is an area of debate among authors. It is a well-known fact that, despite adequate bladder drainage, persis­tent deterioration of renal function occurs as a consequence of posterior urethral valve. This is often due to coexisting renal dysplasia or persistent upper tract anatomic or functional obstruction or combination of both factors Careful assessment of these patients is crucial where some would truly benefit from supra-vesical diversion although contraversial views do exist about the benefit of such a procedure.

Ghali et al [5] concluded that high loop urete-rostomy does not improve renal insufficiency and recommended short-term nephrostomy tube insertion before supravesical diversion, How­ever, Podesta and colleagues in their series with 19 children with posterior urethral valve found that long-term bladder function of patients with posterior urethral valves treated with temporary supravesical diversion was inferior to those treated with valve ablation alone. [6] On the other hand in 1989, Gutierrez and associates in a study of 32 children with posterior urethral valves concluded that renal function improved in patients with early upper urinary tract diversion. Recently, Kitchens et al concluded that cutaneous ureterostomy is a time-tested diversion method and that its effec­tiveness has never been questioned. [7],[8] In our series only one child developed stomal steno­sis which required revision. Stomal stenosis is the most common complication of cutaneous ureterostomy where modifications such as the Toyoda method can be employed to avoid or minimize the risk of stomal stenosis. [9],[10],[11]

The goal of this study was to evaluate cuta­neous ureterostomy as a valid method of ma­nagement for patients with complicated PUVs and that it may be an important step in sta­bilizing and improving renal function prior to definitive management of the child. Our study on the selected 20 children clearly shows the efficacy of cutaneous ureterostomy drainage of the upper tract. Additionally, we demonstrated an improvement in the quality of life as some children were able to discontinue antihyper-tensive medications and all had fewer symp­tomatic urinary tract infections, less voiding dysfunction and decreased interference with overall growth.

 
   References Top

1.Aldress A, Kurpad RP, Alsabban E , Ikram M, Abu-Aisha H. Chronic renal failure in children in 36 Saudi Arabian hospitals. Saudi Kidney Dis Transplant Bul 1991;2(3):134-8.  Back to cited text no. 1
    
2.Esbjorner E, Berg U, Hansson S. Epidemiology of chronic renal failure in children: a report from Sweden 1986-1994. Seweden Pediatric Nephrology Association. Pediatr Nephrol 1997; 11(4):438-42.  Back to cited text no. 2
    
3.Kari JA. Chronic renal failure in children in the western area of Saudi Arabia. Saudi J Kidney Dis Transpl 2006;17(1):19-24.  Back to cited text no. 3
    
4.Carr MC, Snyder HM, Urethral valves fate of the bladder and upper urinary tract. Urologe A 2004;43(4):408-13.  Back to cited text no. 4
    
5.Ghali AM, Elmalki T. Sheir KZ, Ashmallah A, Mohsen T. Posterior urethral valve with persis­tent high serum creatinine: the value of percu­taneous nephrostomy. J Urol 2000;163(4)1340-4.  Back to cited text no. 5
    
6.Podesta M, Ruarta AC, Gargiulo C, et al. Bladder function associated with posterior ure-thral valves after primary valve ablation or proxi­mal urinary diversion in children and adolescents, J Urol 2002;168:1830-5.   Back to cited text no. 6
    
7.Kitchens DM, Defoor W, Minevich E, et al. End Cutaneous Ureterostomy for the manage­ment of severe hydronephrosis. J Urol 2007; 177:1501-4.  Back to cited text no. 7
[PUBMED]  [FULLTEXT]  
8.Gutierrez JM, Jaurequizar E, Murcia J, Espinosa L, Navarro M, Valdes R. Posterior Urethral valves: prognosis related to the initial surgical treatment. Cir Pediatr 1989;2(3):133-6.  Back to cited text no. 8
    
9.Terai A, Yoshimura K, Ueda N, Utssunomiya N, Kohei N, Arai Y. Clinical outcome of tube-less Cutaneous Ureterostomy by the Toyoda method. Int J Urol 2006;13(7):891-5.  Back to cited text no. 9
    
10.Kim CJ, Takimoto K, Tomita K, Osafune T, Nishikawa N. Clinical study of tubeless Cuta­neous Ureterostomy. Hinyokika kiyo 2009;55 (7):385-7.  Back to cited text no. 10
    
11.Kim CJ, Wakabayashi Y, Sakano Y, Johnin K, Yoshiki T, Okada Y. Simple technique for improving tubeless Cutaneous Ureterostomy. Urology 2005;65(6):1221-5.  Back to cited text no. 11
    

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Correspondence Address:
Abdulmalik M.S. Tayib
Department of Urology, King Abdulaziz University Hospital, Jeddah
Saudi Arabia
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PMID: 22382237

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