Management of posterior urethral valves
- Nicholas Holmes, MD
Nicholas Holmes, MD
- Clinical Professor of Surgery
- University of California, San Diego
Posterior urethral valves (PUV) are obstructing membranous folds within the lumen of the posterior urethra (figure 1). PUV is the most common etiology of urinary tract obstruction in the newborn male, occurring in 1 in 5000 to 8000 pregnancies . PUV are also the most common cause of chronic kidney disease (CKD) due to urinary tract obstruction in children .
The management of PUV will be reviewed here. The clinical presentation and diagnosis of PUV are discussed separately. (See "Clinical presentation and diagnosis of posterior urethral valves".)
With prenatal detection of posterior urethral valves (PUV) and technological advances in surgical equipment, the management of PUV has evolved to include prenatal surgical intervention. However, this remains investigational, and the vast majority of affected infants should be treated soon after birth [3,4].
The first case of prenatal surgery to relieve obstructive uropathy was performed in 1981 [5,6]. Surgical intervention, primarily vesicoamniotic shunt placement, was based upon the rationale that restoring amniotic fluid to normal levels by shunting fetal urine from the obstructed urinary system to the amniotic space would prevent lung hypoplasia and, thus, improve neonatal survival. In addition, relief of the obstruction would also reduce back pressure and reduce injury to the developing nephron, thus improving long-term renal function postnatally. (See "Clinical presentation and diagnosis of posterior urethral valves", section on 'Renal and urologic manifestations' and "Overview of fetal hydronephrosis", section on 'Management'.)
However, over the past three decades since the introduction of fetal intervention for obstructive uropathy, data on outcome of fetal surgery for PUV suggest that it is associated with a risk of fetal and maternal morbidity without proven benefit for long-term renal outcome.
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