Surgical Management of Lower
Urinary Tract Obstruction.
Prof. O.B. SHITTU.
CONSULTANT UROLOGIST.
Pre- Test
•
a.
b.
c.
d.
e.
‘Gold standard’ investigation for the
diagnosis of Posterior urethral valves
Isotope renal Scintigraphy
Urethrocystoscopy
Retrograde urethrogram (RUG)
Voiding cystourethrography (VCUG)
Cystometrograph.
• Answer True or False
Pre-natal diagnosis and treatment of
Posterior urethral valves make the long
term outcome better
•
a.
b.
c.
d.
e.
In a child with posterior urethral valves,
initial catheterisation is best done with
Foley catheter
Infant feeding tube
Coude catheter
De Peezer catheter
Malecot catheter
•
a.
b.
c.
d.
e.
Which of the following is not part of the
lower urinary tract
Fossa navicularis
Prostatic urethra
Pelvi-ureteric junction
Bladder
Bulbar urethra.
Aetiological Factors.
•
a.
b.
c.
d.
e.
Congenital causes
Bladder neck stenosis
Posterior urethral polyp
Posterior urethral valves
Congenital urethral stricture
Meatal stenosis/stricture
Aetiological Factors.
• Acquired causes
a. post-traumatic strictures
Fall-astride/pelvic fracture
b. Catheter induced stricture
c. Stones
d. Phimosis/Para-phimosis
Posterior Urethral Valves.
• POSTERIOR URETHRAL VALVES ARE
OBSTRUCTING MEMBRANES WITHIN
THE LUMEN OF THE URETHRA,
EXTENDING FROM THE
VERUMONTANUM DISTALLY.
• OCCUR ONLY IN BOYS.
• COMMONEST CAUSE OF BLADDER
OUTLET OBSTRUCTION AT UCH,
IBADAN.
Posterior Urethral valves.
Posterior Urethral Valves:
Epidemiology.
• INCIDENCE: 1/ 5000 – 8,000 male infants.
1/1,250 by recent foetal Uss.
• GENETICS: debatable, but have been
seen in siblings.
Posterior Urethral Valves:
Clinical presentation.
• PRE-NATAL PRESENTATION:
Distended, thick walled foetal bladder.
Hydronephrosis.
Oligohydramnios. Most of the amniotic fluid
after the 16th/52 of gestation depend on
the foetal urine. Oligohydramnios would
suggest primary renal impairment or
obstruction.
Posterior Urethral Valves:
Clinical presentation.
•
POST- NATAL DIAGNOSIS:
TIME AND MODE OF PRESENTATION
WOULD DEPEND ON THE SEVERITY
OF THE CONDITION.
1. RESPIRATORY DISTRESS.
2. URAEMIA AND SEPSIS.
3. ABDOMINAL DISTENTION.
4. DIFFICULTY WITH MICTURITION.
Posterior Urethral Valves:
Clinical presentation.
• TREAT ACUTE, ASSOCIATED
PROBLEMS.
• RELIEVE UPPER TRACT
OBSTRUCTION.
• INVESTIGATE TO ESTABLISH
DIAGNOSIS. VCUG- ‘Gold standard’
Poterior Urethral Valves:
Clinical presentation.
• Features that can be seen on VCUG.
1. Dilated,thick walled, trabeculated bladder
2. Elongated and dilated prostatic urethra with
narrow bladder neck.
3. Folds of valves could be seen as filling defects
from the area of the verumontanum.
4. VUR, diverticula, pseudoresidual, etc.
5. Valves unilateral reflux and renal dysplasia
syndrome. (VURD)
MCUG in a Child.
Posterior Urethral Valves:
Treatment.
• PRIMARY VALVES ABLATION.
• VESICOSTOMY AND DELAYED VALVES
ABLATION.
• TEMPORARY UPPER TRACT
DIVERSION.
Posterior Urethral Valves:
Long term management.
• VESICO URETERIC REFLUX.
1.
Prophylactic antibiotic cover.
2.
Ureteric re-implantation.
Posterior Urethral Valves:
Long term Management.
1.
2.
3.
4.
URINARY INCONTINENCE:
INCOMPLETE VALVE ABLATION.
URETHRAL STRICTURE.
NON-COMPLIANT BLADDER.
RENAL INSUFFICIENCY.
Posterior Urethral Valves:
Long-term renal insufficiency.
1.
2.
3.
4.
5.
POLYURIA
SALT-LOSING NEPHROPATHY
METABOLIC ACIDOSIS
RENAL OSTEODYSTROPHY
GROWTH RETARDATION