Introduction & Objective : Posterior urethral valves (PUVs) are found in 1 in 8000-25,000 male live births. Standard of care is to relieve obstruction and drain the bladder by either ablating the valve or performing vesicostomy within the first week of life. Treatment options vary widely and range from endoscopic fulguration (bugbee, hot-knife, and laser), and cold-knife incision to blind passage of a valvotome. Usage of a standard urethrotome requires 180-degree inversion of the scope to incise at 5- and 7-o’clock positions as the hook is inserted ventrally. This can prove technically difficult in small neonates. Barber et al. reported their experience with a modified urethrotome in which the hook is inserted dorsally. We report the efficacy and safety of using a 9 Fr Wolf resectoscope for cold-knife incision of PUV using a dorsally inserted hook.
Methods : We report our case series of 6 males who underwent this technique from May 2015 to February 2018. We collected pre- and postoperative serum creatinine (Cr), voiding cystourethrography (VCUG), and renal-bladder ultrasonography (RBUS) were obtained, when possible.
Results : Age at date of surgery ranged from 3 to 149 days-old (mean 41.5 days-old). Preoperatively, 6 patients had elevated Cr levels based on age (mean 1.62 mg/dL, range 0.57-4.5), and bilateral hydronephrosis was evident in all patients, with 5 patients having at least grade 3 hydronephrosis. Additionally, 5 patients had at least unilateral reflux with 3 patients having severe grade 5 reflux. Intraoperatively, no complications occurred. Postoperatively, Cr levels reflected improved renal function in all 6 patients (mean 0.9, range 0.39-2.67) with paired t-test showing a mean improvement in Cr within our cohort of 0.73, just outside significance (p=0.0514), likely the result of our study being under-powered. Four patients had their foley catheter removed within 48 hours while 2 patients required a foley catheter for 4 and 10 days. Of the 4 patients who underwent postoperative RBUS, 1 showed complete resolution, with the remainder showing improvement, and importantly, no worsening hydronephrosis. These same 4 patients underwent postoperative VCUG, with evidence of improvement in reflux in all and complete resolution of reflux in 2 patients.
While humble in its size, our case series sheds further light on the safety of cold-knife valvotomy as no morbidity was observed with marked improvements in serum Cr levels and, by correlation, renal improvement, bordering on significance.